‘That Dude’ Strikes Again

That Dude has struck again. A second review of another of my books appeared on Amazon on 14 April 2021.

On this second strike, this author is making a little progress: ‘That Dude’ actually awarded my book 2.0 out of 5 stars instead of just one!

I graciously accept this 100% increase in my book’s star award. I detect a possible trend here.

Here I print the review [with annotations] to correct ‘That Dude’s’ many, many errors.

People should know something before buying this book.

The Author is universally acknowledged as being the foremost critic of Remote Viewing.

‘That Dude’ starts with an accolade. But it’s all downhill from here on however. ‘That Dude’ continues:

The pilot Remote Viewing experiment was published in 1974. The way it worked is that a demarcation team would go to a randomly chosen location and the psychic would have to get information on this location without any foreknowledge. After this was done several times a group of independent judges attempted to match the psychic’s descriptions to the locations. They achieved a statistically significant score.
Marks found out that the judges were handed the target locations in order of visitation and that there were cues that could allow a judge to get perfect matchings without ever using the legitimate data.
Upon this criticism, Charles Tart took the transcripts, covered all the extraneous cues, found another independent judge and had him match the transcripts to the locations with appropriate randomisation of the order of locations. They were still able to achieve a statistically significant score.
Marks looked at this work again and “discovered” more cues that talk about a shielded room, a park and an office locations. The problem with this is that these aren’t the locations of the demarcation team which the psychic was trying to describe, these are the locations where the psychic was viewing from (This can be confirmed by comparing the 1974 Vol. 251 and 1986 Vol. 319 articles of Nature together).

[ The above statement is False. The ‘psychic’ was always located at the same place, the SRI laboratory. Please see here for details].

What this means is that there is literally no logical way for the judge to be cued in on the target locations unless he actively cheats.

[Again, false. The judge can always tell which place a transcript does not belong with when it mentions a place already visited.]

This makes the whole argument a baseless ad hominem attack which, when left unsubstantiated, has no place in the realm of science as the same strategy could be used to invalidate literally anything.

[Again, false. The judge did actively cheat. I proved that by re-judging them all again, with and without the cues. ].

When I first spotted this issue I bought Marks’ book ‘psychology of the psychic’ to see if there were any more details or if this was indeed an empty argument on his part. Not only does he never explain how the cues from Vol. 319 of Nature can be used to invalidate the Pat Price series of remote viewing experiments, he literally never even outlines what those cues actually were. [False.]

This heavily signifies to me that his alleged cues were nothing more than a red herring. [False.]

And, if you don’t believe me, you can indeed confirm this yourself by using the ‘sci-hub’ website to access the relevant nature publications and check for yourself:

1974 – Nature Vol. 251 – Information transmission under conditions of sensory shielding – Harold Puthoff, Russell Targ
1978 – Nature Vol. 274 – Information transmission in remote viewing experiments – David Marks, Richard Kammann
1980 – Nature Vol. 284 – Information transmission in remote viewing experiments – Charles T. Tart
1983 – BBC Documentary – The Case of ESP
1986 – Nature Vol. 319 – Remote Viewing Exposed – David Marks

I bought this book thinking that David Marks would finally, after more than 30 years, reveal this as a “mistake” since he is actively trying to take a more open-minded approach here. He does not. [Because it isn’t a mistake.]

He explains the entire Pat Price series and then claims there are more ‘cues’ while again, never mentioning what they were or how they can be used to invalidate the experiment. [False. I describe all of the cues.].

This was probably his last chance this mistake. He blew it. After reading this book, it’s clear he has nothing on the Pat Price series and he probably knows it. [All false.]

That said, I actually don’t hate the book. It’s still proven immensely useful [Thank you, ‘That Dude’] despite some of the misinformation.

In each chapter Marks, for the most part, will berate parapsychology with whatever tools he can. [i.e. scientific tools]

Wether [sic] it’s speculation or ad hominem attacks, skeptics will be pleased to know their champion pulls no punches here. However, he includes towards the end of each chapter an opportunity for parapsychologists to defend their work. Skeptics will overall be confronted with quite compelling arguments both for and against psi phenomena and will be able to make a much more educated decision on how to direct their beliefs as a result.[Thank you again, ‘That Dude’, you are beginning to get the message.]

I also highly rate Marks’ on the fact he has learned the basic tenets for proper skepticism by engaging in and encouraging probabilistic thinking. However, despite being confronted with compelling arguments from parapsychologists that clearly warrant at least SOME ambiguity on position, Marks’ rates his belief in phenomena quite often too low at 0.001%, meaning he clearly doesn’t understand how probabilistic thinking or even proper skepticism is supposed to work as he has already taken a firm position prior. [Funny that I clearly don’t “understand how probabilistic thinking works”, because my PhD dissertation in 1969 was concerned with subjective probability judgements and the Bayesian approach .]

The phenomena that he rates particularly harshly just so happen to be the ones he thinks he’s debunked in Psychology of the Psychic. Be honest Marks, can you really say you have anything on Daryl Bem? [I have an awful lot to say on Daryl Bem and so does Bem himself. It’s all in the Psychology and the Paranormal. Please read the book before you review it next time around.]

Although I don’t fully agree with most of his conclusions (I doubt many readers will for different reasons) it’s a hell of a lot better and more open minded than his work in Psychology of the Psychic. [Thank you again ‘That Dude’.]

Whether you are a skeptic or a parapsychology enthusiast, this book has something for you. Read on as a war of the sciences between psychology and parapsychology clash against each other in it’s most up to date form. [Thank you again ‘That Dude’.]

‘That Dude’ is finally getting somewhere in their appreciation level. A 100% improvement no less. Let’s keep this trend going.

Happy to receive the endorsement of my most extreme critic on Amazon!


An Anomaly of Ceaseless Wonder

Psi is an anomaly of ceaseless wonder and mystery. The psi hypothesis remains neither confirmed nor disconfirmed but it connects us to our fellow beings, to nature and the cosmos at large.

David F Marks, Psychology and the Paranormal, 2020, p. 313.

A recent post featuring Adrian Parker shows the openness of a thought leader to a new scientific idea. The new scientific idea is that psi is an unpredictable anomaly of human experience that occurs spontaneously and cannot be controlled inside the laboratory. The view runs counter to the tradition of experimental research in parapsychology, founded by Joseph Banks Rhine, and does not rest easily with those who have invested in this tradition – i.e. the mainstream Parapsychology community. The epitome of that mainstream is the Society of Psychical Research founded in 1882.

Resistance to New Ideas

Resistance to new ideas seems to be an enduring human characteristic, and scientists –despite extolling the virtues of objectivity– have often proved themselves very human in this respect. Many of the great breakthroughs of modern science were initially rejected or ignored, sometimes for decades, and mainly because of bias. It is instructive to consider a few examples of scientific advances that were originally rejected.

Science for the Public 2022

Either the resistance to the ideas in my latest book is too strong or, I fear, I have failed to get my point across. In either case, there is a lot more work to be done.

In the Journal of the Society for Psychical Research, Volume 85, Number 3, Issue 944, July 2021, p. 159 this review by Mr Chris Little is long (4600 words) and tedious. Sadly, it reveals major misreadings of my book and the zetetic position it offers. I do not mince words. I refer to the review as a “distorted carbuncle that does a disservice”. I believe these words are a valid description of Mr Little’s expatiations about my book.

The book review editor, Mr Nemo Mörck, sent along a draft version of Mr Little’s piece in March 2021 and I submitted a response the following month. Because of “a few behind the scenes problems”, the JSPR publication was held up for 18 months.

To continue our fruitful dialogue, I have accepted the invitation of the SPR President, Professor Adrian Parker, to give an address at the SPR’s next conference.

Below I reproduce my letter to the JSPR.

Review of a Review

by Little, C. (2020). Review of PSYCHOLOGY AND THE PARANORMAL by David F. Marks. London: Sage. 2020. 402 pp. £29.99. ISBN 9781526491053.

Dear Editor,

Thank you for this opportunity to respond to the JSPR review (Little, 2020) of ‘Psychology and the Paranormal: Exploring Anomalous Experience’ (Marks, 2020). I explain here why I consider Chris Little’s review to be distorted carbuncle that does a disservice to your readership and to this author. Your reviewer appears to have read a different book to the one that I wrote.

Your  reviewer begins by misdescribing the title and author. The title is: ‘Psychology and the Paranormal. Exploring Anomalous Experience’ (PPEAE ) not as stated in the copy sent to me by your Book Review Editor, Mr Nemo Mörck: ‘Psychology and the Paranormal’. The missing words, ‘Exploring Anomalous Experience’ are essential to the book’s purpose and, by this omission, your reviewer reveals precisely how he could so misunderstand the book’s message. I asked Mr Mörck to restore the full title to the review before publication and hope he managed to do so.

In the first sentence, your reviewer characterises me as “a retired academic psychologist who has been a prominent sceptic regarding parapsychology”.  If I am indeed retired, nobody has informed me.  From 2015-2020 I have published six books, two editions of an 800-page textbook on Health Psychology (Marks, Murray & Estacio, 2018, 2020), multiple peer-reviewed journal articles and served as Editor-in-Chief of the Journal of Health Psychology, which receives more than 1000 submissions per year. I can see that in the world inhabited by Mr Little, every living person must be categorised either ‘believer’ or ‘sceptic’.  I respectfully disagree. As a personal descriptor, the term ‘sceptic’ is at odds with my long-held conviction in the significance of subjective experience, including imagery, the hypnotic trance state, and altered states of consciousness more generally, as evidenced by the bibliography printed in PPEAE.  

Your somewhat myopic reviewer gets it grossly wrong when he describes the book as “a further shift in emphasis towards experimental parapsychology”.   On the contrary, the main point of my book is to show that the ‘emphasis towards experimental parapsychology’ may well be entirely misplaced.  My book proposes to investigate psi as an anomalistic experience that occurs most readily and prevalently outside of the experimental laboratory. As the Preface states: “The goal here is …to dig below the surface of anomalistic experience, to take a close look at the psychology of the paranormal, to put psi ‘under the microscope’. One should not be surprised if all is not as it seems and we can expect surprises aplenty here…I last visited this field 20 years ago. Now, with ‘new eyes’ and new evidence, one’s understanding could be significantly different compared to 20 years ago. Unlike previous visits, I am giving the psi hypothesis an initial probability of being a real, authentic and valid experience of 50%” (PPEAE, p. x).  In his review, among its many faults, Mr Little: i) did not attempt to engage with any of the new theoretical ideas presented in PPEAE, ii) ignores my discussion of five different theories of anomalous experience, iii) ignores my review of neuroscientific studies, iv) fails to accept the zetetic approach and so refers to my conclusions as ‘paradoxical’, v) confesses to not seeing why a new general psychological theory is included in the book at all.  There is not space in this letter to address all of these points, which would require an entire journal article.

In advocating the zetetic approach à la Marcello Truzzi (1987) – to whom PPEAE is dedicated –  PPEAE does not present the fixed point of view desired by readers such as  your reviewer. One’s point of view is not paradoxical either; it is conditional upon differing levels of supportive evidence: “With each new claim, one must read, reflect, question, reflect some more, and ultimately decide at one particular moment the degree of plausibility that any specific claim possesses.” A Bayesian ‘Belief Barometer’ indicates one’s degree of belief for any particular claim in light of one’s understanding of the evidence. The expected variation in one’s degree of belief for different claims is showing one’s sensitivity to evidence. When a person’s belief is habitually set at ‘0%’ or ‘100%’ for absolutely everything, that surely indicates intransigence and intolerance of ambiguity. In  PPEAE  I assert that: “In any science, all ideas are provisional, pending further investigation. Those who assert a fixed point of view before looking at the evidence break the ‘Golden Rule of Science’, which is to let conclusions follow the evidence” (p. xii).

The zetetic approach is an authentic and legitimate response in any scientific domain.  For example, consider the current scientific interest in Mars. One might give a .5 probability to the proposition that a human will visit Mars by 2030, a .01 probability to the proposition that the visitor will find water there, and a 10-100 probability that they will meet another being already inhabiting the planet. Naturally, different propositions about Mars have different probabilities. The same must surely be true for different propositions about psi as one kind of anomalous experience. I started my book with a ‘Personal Belief Barometer reading’ (PBBR) of 50% for ‘Lab ESP’. After reviewing the evidence, my PBBR for ‘Lab ESP’ had declined to 10-9.  However, my PBBRs for five other propositions ranged from 75-100%: ‘Coincidences as Paranormal’ (75%), ‘Trance Logic’ (100%), ‘OBE’ (,100%) ‘NDE’ (100%) and ‘Spontaneous ESP’ (75%). Entering into the spirit of the approach, on page 136 of PPEAE, Professor Adrian Parker states a PBBR of 60-90%.

The take-home messages from PPEAE can be stated as follows:

  1. PPEAE offers a new paradigm for the study of the paranormal reformulated as one major part of a new Science of Anomalous Experience.
  2.  Psi is a spontaneous process that cannot be summoned at will in a laboratory experiment.
  3. There is a spectrum of consciousness showing a multiplicity of states. The psi experience is one of those states.

I look forward to continuing discussions of psi theory with the Society for Psychical Research.


Little, C. (2020). Review of PSYCHOLOGY AND THE PARANORMAL by David F. Marks. London: Sage. 2020. 402 pp. £29.99. ISBN 9781526491053. JSPR vol xx, pp yy-zz.

Marks, D. F. (2020). Psychology and the Paranormal: Exploring Anomalous Experience. London: SAGE Publications Ltd.

Marks, D.F., Murray, M.  & Estacio, E.V. (2018, 5th ed.). Health Psychology. Theory, Research & Practice. London: SAGE Publications Ltd.

Marks, D.F., Murray, M.  & Estacio, E.V. (2020, 6th ed.). Health Psychology. Theory, Research & Practice. London: SAGE Publications Ltd.

Truzzi, M. (1987). On pseudo-skepticism. Zetetic Scholar, 12/13, 3-4.


Psi as a Spontaneous Phenomenon

Originally published by leading parapsychologist ADRIAN PARKER as ‘Informal Psi Tests’ in the Paranormal Review. Adrian is President of the Society of Psychical Research, London, and Professor Emeritus, Department of Psychology, University of Gothenburg, Sweden.

The veteran psi-critic David Marks has recently published a book Psychology and the Paranormal in which he has taken a softer position concerning the paranormal. He argues that the phenomena may occur, but that they are inherently spontaneous and elusive, and because of this they cannot be captured in the lab. According to Marks, parapsychologists and their critics should resolve their differences and accept this. Such a challenge obviously goes against all the ethos and efforts of academic parapsychology at UK Universities, such as Northampton. which follow the basic belief of Rhine that by piecing together numerous factors and personality- traits, a degree of control over psi can eventually be achieved. This is the successful working model used throughout applied psychology where psvchological testing predicts job performance and is used even to some extent for diagnostics in clinical psychology. Marks’s challenge also goes against my own efforts to show that altered states of consciousness are the royal road to reliably reproducing lifting psi-in-the-wild to psi-in- the-lab. In particular, we developed a version of the ganzfeld using real-time recordings that could actually catch the sender’s experiences of target film clips in the form of the receiver’s imagery, since these ganzfeld images are often shown to follow in real time the changing scenes being watched in the target clip.

Nevertheless, there may be some truth in Marks’s assertion. Some of the best cases of ESP seem to occur before controls can be brought in, only to disappear when they are brought in. The critic would of course say that this is because ESP is ‘error some place’, but those directly involved are left with some scepticism as to the plausibility of normal explanations. The late Donald West experienced exactly this when he tested what seemed to be his own ESP ability in 1941 (as reported in the JSPE of that year). The same thing occurred when he tested groups of others two years later. Such was also the case of what I witnessed during an informal demonstration by a six-year-old Chinese girl at our conference hotel in Ha Long Bay, Vietnam. This was the second conference organized by Bingo Wu whom those attending our recent SPR conferences will recall is a teacher of blind children and who claims to have taught them to use their ESP ability to reach such a high level where they can use this to negotiate their environment. We were never able to access these claims directly because the Chinese government had prohibited access to the school. This year the conference
could not be held in Hong Konq because of the political situation.

[Section here has been cut]

…In our hotel room, our translator showed how she could reproduce the number he had written and hidden in folded paper. She succeeded with this, but the symbols in this case were a triangle and a square, which are those most commonly thought of in such tasks, so this was not so impressive. When I took over, I drew the number 9 (7 or 5 had been commonly guessed at), while apparently obscured from her normal field of vision even given the blindfold, which she then correctly reproducFor the next attempt, I drew an S and then as an afterthought added a line like a dollar sign to make the design more specific. She succeeded even with this as is shown in the photograph. It was late in the evening, our translator had her ‘on loan’ from her mother for this demonstration and I thought that there would be plenty of opportunity to work with her later. It was not to be. Wu involved the children in a long series of competitive tests that were intended to show their psi-ability. These took place in a group situation and although all the children received certificates celebrating their successes, it appeared to be highly demanding and stressful for those taking part. I was told that the six- year-old girl was disappointed with her performance and would not agree to be tested further. In the photograph, the target symbols are on the folded paper on the right and the child’s attempts are on the left.

Naturally, normal explanations abound: the child might have had hypersensitive hearing and followed the sound of the drawing, or maybe she was able to peek through the mask. However, in my opinion these are, not only unconstructive speculations, but are wrong questions.

As with spontaneous phenomena, one turns first to the lab and if one is satisfied that the basic phenomena have been established there, then the most useful question is: does this case
tell us anything that can be learned about the phenomena? In this case, it may be a confirmation of David Marks’s contribution in emphasizing the roles of spontaneity and elusiveness.


‘That Dude’: An Alien to the Truth

Psi is an anomaly of ceaseless wonder and mystery. The psi hypothesis remains neither confirmed nor disconfirmed but it connects us to our fellow beings, to nature and the cosmos at large.

David F Marks, Psychology and the Paranormal, 2020, p. 313.

Normally, one does not reply to book reviews, especially one-starred reviews. Yet, on this occasion, needs must.

Sometimes a reviewer goes so far beyond the bounds of reasonable criticism and fair comment, passing a red line and one cannot let it pass. That red line is slander.

Hiding behind the safety of a nom-de-plume, ‘That Dude’ slates my book for entirely spurious reasons and he lies in the process. I consider here the Review of my book ‘The Psychology of the Psychic’ posted by

That Dude

under the title: ‘A Fairy Tale for Skeptics’ on March 18, 2021.

‘That Dude’ has also posted another review of my 2020 book, Psychology and the Paranormal. I deal with that here – it makes similar false arguments and so falls at the same hurdle: The Truth.

‘That Dude’s’ Review

‘That Dude’ states:

I’ve analysed the Nature publications between Puthoff, Targ, Tart and Marks. When you compare the original Pat Price remote viewing experiment published in 1974 against Marks’ cues in 1986, they actually pertain to the Psychics location, not that of the demarcation team. Put simply, they logically cannot be used to match the location to the transcripts despite Marks implying it can. [1]

This means the original SRI Remote Viewing experiments can still be considered scientifically valid despite what Marks would have you believe.[2]

I bought this book to get Marks’ complete side of the story and to see if he really had any more damning evidence. He actually omits the cues from Tarts re-judging… he had nothing. He’s effectively pretended to have debunked Remote Viewing for 20 years (40 years if you include ‘Psychology and the Paranormal’).[3]

It’s a shame. He genuinely was open minded towards psi and actually made a decent replication experiment. The likely problem was the locations didn’t contrast highly enough. The result is this completely biased one-sided hit piece against parapsychology as revenge for his failure. He is far more concerned with finding pedantic reasons to discount experiments than actually learn the truth.[4]

He mentions accurate transcripts where there should be none, he mentions Joe McMoneagle getting commended for intelligence gathering. He mentions spoons bending across the Nation from Geller’s audience. Does he explore these anomalies further? No… that’s not his goal. He only cares about invalidating evidence for Psi as quickly as possible by any means necessary, no matter how weak or speculative the arguments are.[5]

For all his talk on subjective validation, he fails to realise it works both ways. The irony is extreme here.[6]


Other reviewers do not agree with ‘That Dude’s’ one-star review, and typically give the book five stars. The average score being 4.2, pulled down thanks to ‘That Dude’s bomb attack.

My response to the reviewer’s paragraphs follows.

1)The cues pertain to the Psychic’s location

This statement is false. The cues do not refer to the psychic’s location, which was the same on every occasion. The ‘Psychic’ remained at SRI. I reproduce here the original description published in Nature in 1974.

‘That Dude’ falls at the very first hurdle: the Simple Truth. Either ‘That Dude’ did not read the investigators’ description of the SRI study or did not understand it or deliberately falsified it, making her/him/them/? an alien to the truth.

2) “This means the original SRI Remote Viewing experiments can still be considered scientifically valid”

My criticisms of the SRI remote viewing experiments are published in chapters within three books here, here, and here. Many other topics are also covered.

Three books on claims of the paranormal published in 1980, 2000 and 2020

The evidence in these three books proves beyond any reasonable doubt that the SRI RV experiments were methodologically unsound and that the findings are unsafe. In the most recent book, Dr. Hal Puthoff, principal investigator of the SRI studies, was given the opportunity to defend the SRI studies. Dr. Puthoff declined to do so.

3) “He’s effectively pretended to have debunked Remote Viewing for 20 years (40 years if you include ‘Psychology and the Paranormal’)”

This statement is slanderous. I have pretended no such thing. My publications have demonstrated that the remote viewing research in the scientific literature is quite generally poorly done and the findings are unsafe.

4) “this completely biased one-sided hit piece against parapsychology as revenge for his failure”.

This ad hominem attack does little to advance the discussion. There is nothing to avenge. I have published three well-received books on the Parapsychology field. The only “completely biased one-sided hit piece” is the Dude’s vitriolic book reviews.

5) “He only cares about invalidating evidence for Psi as quickly as possible by any means necessary, no matter how weak or speculative the arguments are.”

Pure ad hominem. Pure slander. Pure gobshite.

How consistent is ‘That Dude’s’ statement with my 40-year period of researching claims of the paranormal?

How well does his statement align with the following conclusion on the very last page of the last book in the series?

Psi is an anomaly of ceaseless wonder and mystery. The psi hypothesis remains neither confirmed nor disconfirmed but it connects us to our fellow beings, to nature and the cosmos at large.

David F Marks, Psychology and the Paranormal, 2020, p. 313.

6) “For all his talk on subjective validation, he fails to realise it works both ways. The irony is extreme here”

The irony would indeed be extreme if ‘That Dude’ was telling the truth. Sadly for his case, he is not. I fully acknowledge my personal susceptibility to subjective validation. For example, see the concluding sentence of Chapter 4 in Psychology and the Paranormal, analysing a personally experienced anomalous event:

In spite of everything, the entire episode could be nothing more than subjective validation.

Psychology and the Paranormal, p. 88.

Again, here’s what I say on page 299 of The Psychology of the Psychic (2nd Edition):

Subjective validation is not unique to psychic belief, but is a regular part of human life and thought.

The Psychology of the Psychic (2nd edition), p. 299

As a human being, I am of course willing to admit to the power of subjective validation in making up one’s mind, making choices and taking decisions about the truth.

My version of the truth is not That Dude’s version. My version of the truth follows what the SRI investigators actually stated in multiple original published reports. ‘That Dude’s’ version of the truth is based on a false description of the original SRI investigators statements.

‘That Dude’ is an alien to the truth, the author of a fairy tale all of his own making.


A book reviewer using the pen name ‘That Dude’ has written a scurrilous piece, which is planted at the top of my Amazon book website. ‘That Dude’ needs to remove the review ASAP because any loss of sales could be associated with the slander that is committed there.


Nature Restores

We all tend to feel good when we go outdoors among nature. Alone, with others, or walking the dog. And more so in rural areas than urban ones.


A recent study by Migle Baceviciene, Rasa Jankauskiene and Viren Swami helps to explain why this might be the case. Feeling good is partly to do with feeling better about our bodies. According to the authors:

research shows that nature exposure is directly and indirectly associated with more positive body image, an important facet of mental health more generally. Positive body image refers to a love and respect for the body, appreciation of the uniqueness of one’s body, acceptance of the body including those aspects that do not meet stereotypical beauty ideals, appreciation of the body’s functionality, and acceptance of body-protective behaviors.


This study aimed to test the mediating effects of nature restorativeness, stress, and nature connectedness in the association between nature exposure and quality of life (QoL). Urban and rural Lithuanian inhabitants (n = 924; 73.6% were women), mean age of 40.0 ± 12.4 years (age range of 18–79) participated in the study. In total, 31% of the respondents lived in rural areas. Study participants completed an online survey form with measures on sociodemographic factors, nature proximity, nature exposure, nature connectedness, and nature restorativeness, stress, and QoL assessed by the abbreviated version of the World Health Organization’s Quality of Life Questionnaire’s (WHOQOL-BREF). Path analysis was conducted to test the mediating effects of nature restorativeness, stress, and nature connectedness in the model of nature exposure and QoL. Nature exposure was directly associated with a greater QoL (β = 0.14; B = 2.60; SE = 0.57; p < 0.001) and mediated the association between nature proximity and QoL. Nature restorativeness and lower stress levels were mediators between nature exposure and QoL. Nature connectedness was a mediator between nature exposure and QoL. A path model was invariant across genders and the urban and rural place of residence groups: patterns of loadings of the pathways were found to be similar. Nature restorativeness (β = 0.10–0.12; p < 0.01) had a positive effect on the psychological, physical, social, and environmental domains of QoL. Connectedness to nature positively predicted psychological (β = 0.079; p < 0.05) and environmental (β = 0.082; p < 0.05) domains of QoL. Enhancing nature exposure and nature connectedness might help strengthen QoL in urban and rural inhabitants.

Model of Findings


  1. Getting out and about in Nature is associated with connectedness to nature.
  2. Nature connectedness is associated with feelings of being restored, both physically and mentally.
  3. These results are consistent with the General Theory of Behaviour regarding conscious and unconscious actions of homeostasis.
  4. These findings were obtained in a cross-sectional study and no causal inferences can be drawn.
  5. Causal relationships could be obtained from future prospective studies.

More Screen Time, More Sugar and Caffeine

Young teens who spend more time with TV and electronic devices drink more sugared or caffeinated drinks than others according to a study of U.S. teens led by McMaster University researchers. It is a concern because many exceed recommended levels of both sugar and caffeine. The study was published in 2019 by Kelly M. Bradbury, Ofir Turel and Katherine M. Morrison (pictured) of the Department of Pediatrics, Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, Ontario, Canada. My post follows an earlier theme of Food, diets and dieting.

Here is the Abstract


Despite recent declines in consumption of sugary beverages, energy drinks (ED) and sodas continue to contribute a substantial amount of sugar and caffeine to the diet of youth. Consumption of these beverages has been linked with electronic device use, however in-depth associations between sugar and caffeine intake from energy drinks and sodas with various electronic devices are not clear.


Describe the relationship of soda and energy drink consumption and associated added sugar and caffeine intake with electronic device use among adolescents.


Secondary data from the 2013–2016 cycles of Monitoring the Future Survey, a national, repeated, cross-sectional study, were analyzed. Information on energy drink and soda consumption by students in grades 8 and 10 (n = 32,418) from 252–263 schools randomly sampled from all US states was used.


Soda and energy drink consumption decreased each year from 2013–2016 while daily use of electronic devices remained stable. An additional hour/day of TV was linked to a 6.92g (6.31,7.48; p<0.001) increase in sugar intake and a 32% (OR = 1.32; 1.29,1.35; p < .001) higher risk of exceeding World Health Organization (WHO) recommended sugar intakes. Further, each hour/day of TV was linked to a 28% increased risk of exceeding caffeine recommendations (OR = 1.25–1.31; p<0.001). Each hour per day talking on a cellphone was associated with an increased risk of exceeding WHO sugar and caffeine intakes by 14% (OR = 1.11–1.16; p<0.001) and 18% (OR = 1.15–1.21; p<0.001) respectively. Video game use was only weakly linked to caffeine intake. Computer use for school was associated with lower likelihood of exceeding sugar intake cut-offs.


While a trend towards reduced energy drink and soda intake from 2013–2016 was evident, greater electronic device use, especially TV time, was linked to higher intake of beverage-derived added sugar and caffeine amongst adolescents. Addressing these behaviours through counselling or health promotion could potentially help to reduce excess sugar and caffeine intake from sodas and energy drinks among this population.

To this conclusion, one might add:

Upstream prevention is more effective than downstream. Legislation is necessary to remove the images from screens and to remove sugar and caffeine from the drinks.


A Mysterious Tower in Vincent van Gogh’s Painting of Langlois Bridge, 1888

In an earlier post, I discussed Vincent van Gogh’s works at Langlois Bridge, Arles. Of particular interest is the painting F400 that includes an as-yet unidentified tower ‘T’ on the right hand side of the painting. The illustration below shows a photograph taken in 1902, which does not show the tower ‘T’, together with the relevant section of the painting.

What and where was tower T?

In an interesting comment, Yves Klein suggests two hypotheses to explain the building marked ‘T’. Yves Klein comments:

“1) VvG painted St. Trophime but overestimated its appearance because painting F400 was not accomplished outdoor with a permanent view of the object, but in his studio, using memory and imagination. We know from letter 589 that it was the second attempt after a failure. This time, VvG turned the perspective about 30° anti-clockwise. He gave the black building a size and a shape that he *imagined* to appear if he were on-site. The grey second edge on the left of the building may stand for the north tower of the amphitheatre in the background. The oblique black brush stroke may stand for the main nave of the church. Maybe even the whole is exceptionally meant as a symbolic placeholder for the vaguely imagined buildings.”

In my opinion, tower T is not St Trophime. If VvG had wanted to paint St Trophime he would have done so with precision and exactitude. Turning to the second hypothesis:

“2) VvG painted a building with the correct size and shape, as he usually strived to do, but it was not St. Trophime. “[Agree].
“a. It could be the municipal theatre (though its shape is rather unsimilar)” [Agreed – too unsimilar to receive serious attention.] “or a windmill (though no city map from 1848 to 1914 shows one).” [I return to this idea below].
“b. Or it could be a building that existed at VvG‘s time but has now disappeared: Ste. Croix.”

Yves Klein says: “Seen from VvG’s position in the south, it had a zagged silhouette like the black building in the painting. ..In this scenario, we would identify
B = St. Césaire, J = St. Laurent, T = Ste. Croix.

An engraving of St Croix from 1683:

In my opinion, tower T is unlikely to have been Saint Croix. If VvG had wanted to paint St Croix, I think that he would have painted it much more exactly. But he did not. What VvG seems to have painted is a rough sketch of a building that itself appears unfinished.

Was Tower T a Windmill?

Wooden and stone windmills were a common site around Arles in the late 19th century. Only stone mills survived more than several decades and wooden windmills were not always depicted on maps. We can find clues about the structures in and around Arles in other paintings produced by VvG. The painting ‘Snowy Landscape with Arles in the Background’ (1888) shows almost every tall building in Arles in the early Spring of 1888, just a few weeks before he painted Langlois Bridge.

Snowy Landscape with Arles in the Background (1888)

Many of the structures shown here are possible candidates for tower T. Of particular interest are the three towers on the far right hand side of the painting. These are enlarged and labelled ‘A’, ‘B’ and ‘C’ in the detail below.

Notice that both B and C show an oblique chute-like structure going down from the right side of each building. These are reminiscent of tower T at Langlois Bridge. The prominence of structure A also cannot be ignored.

One problem with this hypothesis that we do not know from which direction VvG painted this scene.

A map of Arles from 1892 shows the location of the ‘Langlois Bridge’ and the surrounding area, which remained agricultural. No large buildings that could have been candidates for tower T existed near the bridge, only fields.

Le port d’Arles, 1892. Atlas des ports de France. Imprimerie Sarasin, Paris.


Unless a high definition map can be found showing every mill and tower in Arles of 1888, the identity of tower T must forever remain a mystery.


Vividness of Movement Imagery Questionnaire (VMIQ)

The VMIQ is a widely used self-report measure of movement imagery. Originally published in 1986, it uses the same conceptual framework as the VVIQ. The VMIQ was constructed together with my PhD student, Anne Isaac, at the University of Otago, New Zealand, in collaboration with David G Russell.

I post here the first page of the publication in the Journal of Mental Imagery, 1986, followed by the two pages of the VMIQ. The VMIQ has been validated and used in approximately 500 peer-reviewed studies.

The VMIQ is free for research use without any need to seek permission from the authors. The author will be pleased to answer questions in the Comments space below.

Original publication


VMIQ, page 1

Filtering Data in Evidence-Based Practice

A recent post described the evidence pyramid. Like anything else in science, there have been criticisms. Here I liken evidence-based practice to filtering coffee. Evidence needs filtering to remove the coffee grain and any impurities. The trouble is, if one filters a lot of times, there may be nothing left that’s worth drinking.

Box 6.1 is from a textbook available here.


Yellow Journalism

Once the preserve of the red tops, the use of fake science and fake news stories is spreading to the broadsheets such as The Times. A recent example is the positing of positive thinking by Professor Paul Garner as a cure for Long-Covid, something of a medical scandal.

See the illustration above. It uses a scary headline designed to evoke anxiety and a sense of hopelessness with a set of brain images combined with a cartoon of a coronavirus to give some pretension of scientific authenticity. The dirty yellow tinge on the bottom is all that you need to know.

What a disgrace.

It is what our American friends used to call yellow journalism.

It plays on people’s fears of the unknown.

It creates false hope.

It is an anecdote that carries no weight as scientific evidence.

The article can be fairly labelled as pseudoscientific trash.

Any thinking reader will dismiss the story as nothing more than dangerous and misleadng.

Shame on The Times for publishing this story.


The Origins of Subjective Anomalous Experience

Text and Figures 2.1 -2.4 © David F Marks, 2022

Reproduced from Chapter 2 of Psychology and the Paranormal by David F Marks (2020), Sage, London.

In any developed science, there is, of necessity, a wide gap between the diverse facts of observation and those few types of observed fact which form the basis of important generalizations and from which a body of theory is then derived. For the very act of reducing observation to order involves the neglect of many pertinent facts; a theory which attempted to take account of everything would be smothered by its own complexity. Thus all generalizations and theories necessarily refer to artificially simplified situations.

Alfred North Whitehead (1938, p. 171)


The process of theory construction in science means solving a scientific jigsaw puzzle: from the multiple pieces emerges one coherent picture. The puzzle here is why one large group of individuals have subjective paranormal experiences (SPEs) and an almost equal number do not. The jigsaw becomes a theory of SPE which highlights factors in childhood, notably trauma. The ‘Trauma + Dissociation’ Theory links childhood trauma with dissociation, fantasy, coping and SPE into one causal chain. The theory holds that childhood trauma causes depersonalization, compartmentalization and defensive fantasy to regain feelings of safety and control. The ‘Trauma + Dissociation’ theory  fits a large body of findings from multiple studies that are reviewed in this chapter.[1]


Why do so many people experience anomalous paranormal experiences while others do not?  Like all natural phenomena, variation in SPE follow a normal distribution.  Genetic and epigenetic variations are almost certainly part of the answer, as all human traits are heritable to a certain extent. Yet, an environmental theory is necessary to explain the non-genetic part of the variation.  What differentiates people with paranormal experience from the others?  To date, there have been three main theories:

1)Socialization to a Cultural Source, absorbing paranormal beliefs and experiences through exposure to family members and close friends with a shared culture of paranormal belief, e.g. joining religious, cultist groups, reading astrology columns or New Age literature, watching paranormal-themed entertainment on television (Sparks and Miller, 2001), YouTube, games and social media that promote paranormal content. The Cultural Source theory points to the relevance of the cultural context of paranormal experience, but this theory does not adequately explain the huge variations that exist between people in the number and intensity of their paranormal beliefs and experiences.

2)The Social Marginality Theory suggests that paranormal experiences are more likely in socially marginal people with limited education, low income, low social status, ethnic minorities, unstable sexual relationships and few friendships (Bainbridge, 1978). The world of the paranormal is said to provide compensation for the pressures arising from ‘structured social marginality’. However, this theory is inconsistent with the observation that a widely diverse population reports paranormal experiences, not only people who can be categorized as socially marginal (Emmons and Sobal, 1981; Carsto et al., 2014).

3)The Experiential Source Theory of McCLenon (1994) suggests that anomalous experiences have a universal physiological basis, which acts as a source of recurring beliefs in spirits, souls, life after death, and magical abilities. McClenon’s (2000)content analysis of a collection of 1215 accounts of anomalous experiences indicated to him that experiences of apparitions, paranormal dreams, and waking extrasensory perceptions have uniform structures and that these experiences coincide with recurring ideas within folk traditions.  However, McClenon’s Source Theory is speculative and, to date, it has not received the attention it deserves; the theoretical predictions require testing by independent researchers.  At this point, it is impossible to say whether the theory is correct or incorrect, or correct for some people and incorrect for others.

In outlining the case I am presenting here, it is necessary to review the complex literature about a topic of great social relevance and sensitivity: the incidence of childhood trauma and abuse, and the associated processes of dissociation, fantasy proneness and SPE. Thousands of relevant studies have been conducted and it is necessary to pinpoint the ones that provide key pieces in the puzzle.  One by one, the jiggled up pieces of a large theoretical jigsaw are unscrambled and fitted into a single picture of the origin of SPEs. Please bear with me, because it is a puzzle that takes time and patience to solve.


Over the past decade, ‘celebrity’ child abuse cases have brought the issue into a spotlight of public attention: in 2012, the Jimmy Savile scandal hit the headlines in the UK; in 2019, the Michael Jackson scandal created a storm of controversy in the US. Also in 2019,  the conviction of the Pope’s closest advisor, Cardinal George Pell in Australia for sexual abuse, led Pope Benedict XVI to apologize for many cases of proven child sexual abuse involving priests. This issue is far larger than the metaphorical ‘elephant in the room’, it is a Blue Whale.

David Finkelhor (1994, 2008; Finkelhor et al., 2014) at the University of New Hampshire

suggests that 20% of  girls and 5% of boys in the US fall victim of child sexual abuse. Furthermore, during a one-year period, 16% of youth ages 14 to 17 had been sexually victimized, and, over the course of their lifetime, 28% of youth aged 14 to 17 had been sexually victimized. The late 1980s and early 1990s saw an increase in the reporting of childhood sexual abuse in the US. The US Department of Health and Human Services’ Children’s Bureau (2010) reported that the vast majority of victimized children,78.3%, suffer neglect, 17.6% suffer physical abuse and 9.2% are sexually assaulted, yet the impact can be equally profound across all categories. The National Institute of Justice (2003) suggested that 3 out of 4 sexually assaulted adolescents were victimized by someone they knew well. More than 25% of children and adolescents in the US  are exposed to a traumatic event by the age of 16, and many are exposed to repeated events (Costello, Erkanli, Fairbank, & Angold, 2002).

Since the late 1980s, the detrimental effects of child sexual abuse (CSA) on the well-being of victims has been systematically researched. A child victim of prolonged sexual abuse usually develops low self-esteem, a feeling of worthlessness, an abnormal or distorted view of sex, becomes withdrawn and mistrustful of adults, or even suicidal (Cohen, Deblinger, Mannarino & Steer, 2004; Davis & Petretic-Jackson, 2000;  Finkelhor, 1987; Marshall, Marshall, Serran & O’Brien, 2009; Paolucci, Genuis, & Violato, 2001; Münzer, Fegert & Goldbeck, 2016; Putnam & Trickett, 1993; Romano & De Luca, 2001). The psychological understanding of childhood trauma draws on the clinical theorizing of the French psychologist, Pierre Janet (1859 – 1947; Ellenberger, 1970; Van der Hart and Horst, 1989).  Pierre Janet is credited as being of three ‘founding fathers’ of Psychology along with Wilhelm Wundt and William James, both of whom also makes appearances in this book. Janet was interested in the integration of experiences associated with trauma which he found associated with “vehement emotion and a destruction of the psychological system”, a process that he called “dissociation” (Van der Kolk and van der Hart, 1989, p. 1532).  Dissociation is a process that may be crucial to our understanding of anomalous experience and is a core construct of this field.  Dissociation occurs when mental functions are alleged to split into different systems or ‘compartments’. The splitting is uncontrolled and unpredictable and can create multiple difficulties and complexities for the individual’s stream of consciousness.  ‘Compartmentalized’ or automatic parts can exist outside of conscious awareness or memory recall (Ludwig, 1983, p. 93; Ellenberger, 1970; Van der Kolk and van der Hart, 1989). Janet’s dissociation theory focused on the role of dissociation, and especially compartmentalization, in conditions induced by trauma and is relevant for research into traumatic stress and posttraumatic ‘hysteria’ (Van der Hart and Horst, 1989).

Dissociation has been defined as: “an experienced loss of information or control over mental processes that, under normal circumstances, are available to conscious awareness, self-attribution, or control, in relation to the individual’s age and cognitive development” (Cardeña & Carlson, 2011, p.246). The most extreme form of dissociation occurs in dissociative identity disorder (DID), a psychiatric condition with two or more distinct personality states, including memory gaps and discontinuity in sense of agency and selfhood.  The evidence suggests that DID is most prevalent in emergency psychiatric settings in approximately 1% of the general population (Dorahy, et al., 2014).  Hence the vast majority of people experiencing dissociation do not suffer from the extreme symptoms of DID. Typically, sufferers of DID display alterations known as “alters” whereby their mental functions are changed unpredictably (American Psychiatric Association, 2013).  DID was popularized in books The Three Faces of Eve (Thigpen & Cleckley, 1957) and Sybil (Schreiber, 1973) and also adapted into films. Alters are often depicted with disturbed or violent behaviours such as occurs in Stevenson’s (1886/1924), The Strange Case of Dr. Jekyll and Mr. Hyde. Santoro, Costanzo and Schimmenti (2019) review the prominence and misrepresentation of DID in popular culture, films, games and videos.  Research indicates that DID frequently originates in repeated episodes of abuse and neglect in a child’s relationship with attachment figures (Dorahy et al., 2014; Schimmenti, 2017; 2018).

Meta-analysis of research on dissociation in psychiatric disorders using the Dissociative Experiences Scale (Lyssenko et al., 2017) finds that the largest dissociation scores occur in DID, followed by PTSD, borderline personality disorder, and conversion disorder. Patients with somatic symptom disorder, substance-related and addictive disorders, feeding and eating disorders, schizophrenia, anxiety disorder, OCD, and most affective disorders also show raised dissociation scores. Dissociation can also be benign, without ill effects or disturbances to everyday behaviour or conscious experience, beyond perhaps some limited impact on dreaming (Giesbrecht & Merckelbach, 2006).

In dissociation there is a dichotomy between two qualitatively different phenomena, ‘detachment’ and ‘compartmentalization’ (Holmes et al., 2005).  Detachment incorporates depersonalization, derealization and similar phenomena such as out-of-body experiences, all of which can occur in combination (Sierra & Berrios, 1998). Detachment involves feelings of being ‘spaced out’, ‘unreal’ or ‘in a dream’. Patients may have SPEs in which events seem as though they are not really happening, with the external world seeming pallid and two-dimensional. ‘Peri-traumatic dissociation’ involves a sense of detachment at the moment a traumatic event occurs and can be evaluated with ‘The Peritraumatic Dissociative Experiences Questionnaire’ (Marmar, Weiss, & Metzler, 1997).  It is thought that in peri-traumatic detachment, the encoding of information is disrupted so that memories of the traumatic event may be incomplete.  Such fragmented memories can trigger intrusive images and flashbacks (Brewin, Dalgleish, & Joseph, 1996). Peri-traumatically encoded feelings of detachment may be a part of the intrusive memory that is re-experienced, or perhaps the process of re-experiencing itself generates feelings of detachment. Becoming totally immersed in a traumatic memory to the point of believing that the event is actually happening again (‘flashbacks’) seems to be relatively rarely.

Compartmentalization is the inability to deliberately control processes or actions or information in memory that would normally be amenable to self-control (Brown 2002a, 2004; Cardena, 1994; Holmes et al., 2005).  Compartmentalization incorporates an inability to bring normally accessible information into conscious awareness (e.g. dissociative amnesia). The functions that are no longer amenable to deliberate control, and the information associated with them, are said to be ‘compartmentalized’. One of the defining features of this phenomenon is that the compartmentalized processes continue to operate  (Janet, 1907; Hilgard, 1977; Kihlstrom, 1992; Oakley, 1999; Brown (2004). Dissociation is viewed as an adaptive strategy to intense stress or trauma that leads to conditioned dissociative reactions, which can prevent adequate processing and integration of information (Koopman, Classen, & Spiegel, 1994; Lynn & Rue, 1994; Putnam, 1997; Eisen, Goodman & Davis, 2002). Repeated trauma can sensitize a child to hyper-arousal leading to dissociative responding under stress (Perry, Pollard, Blakley, Baker, & Vigilante, 1995). It must be acknowledged that many abused people do not evidence having dissociative experiences (Hall, 2003). However, the theory to be presented applies to the sizable proportion of cases where trauma triggers dissociation. Dissociation is an adaptive mechanism which aids survival in the following situations: 1) direct and close encounter with a dangerous perpetrator using force or having malevolent intent, e.g., when skin contact occurs; 2) in the presence of body fluids with danger of contamination, e.g. blood or sperm; 3) when bodily integrity is already injured, e.g. invasion, penetration, sharp objects (e.g., teeth and knife) at the skin (Schauer and Elbert, 2015). 

The Trauma + Dissociation Theory holds that SPEs are one of the more frequent consequence of childhood trauma.  There is a large literature of supportive evidence. Ellason and Ross (1997) found ESP experiences correlated .45 and .44 respectively with the level of childhood physical and sexual abuse.  Ross and Joshi (1992) obtained similar findings with a random sample of 502 Canadian adults. Reports of paranormal or extrasensory experiences were common and linked to a history of childhood trauma and dissociation. Ross and Joshi conceptualized SPE as one aspect of dissociation triggered by child abuse. SPEs discriminated between individuals with childhood trauma histories and those without trauma histories. Perkins and Allen (2006) compared paranormal belief systems in individuals with and without childhood physical abuse histories using the Tobacyk Revised Paranormal Belief Scale and a SPE questionnaire with 107 students. They found that psi and spiritualism beliefs were among the most strongly held among abused students and these were at a significantly higher level in abused vs. non-abused participants. Perkins and Allen (2006) concluded: “by providing a sense of control, certain paranormal beliefs may offer a powerful emotional refuge to individuals who endured the stress of physical abuse in childhood” (p. 349).

In the context of both detachment and compartmentalization, it has been proposed that ideas and fantasies of the paranormal serve a restorative function, aimed at resetting the psychological system. In an earlier book, we stated a general hypothesis that humans: “have a profound yearning for a magic formula that will free us from our ponderous and fragile human bodies, from realities that will not obey our wishes, from loneliness or unhappiness, and from death itself” (Marks and Kammann, 1980, p. 156).  It is suggested that individuals are able to use paranormal ideation as a coping strategy for past traumas in a search for stability, restorative justice, compensation or even revenge (Wuthnow, 1976). If emotional security and psychological adjustment depend upon the conviction that the physical and social worlds are orderly and meaningful, then a paranormal worldview provides an adaptive framework for structuring otherwise chaotic, unpredictable or unfair experiences that can make them more comprehensible and controlled (Irwin, 1993).


Trauma in childhood evokes an instinctive need to regain a sense of control, which increases the appeal of paranormal abilities to provide mastery over threats to safety and other incomprehensible events. When children experience persistent terror without escape, as in neglect, attachment disruptions, incest or other sexual trauma, dissociation is protective against emotional distress (Bailey and Brand, 2017). Repetitive childhood physical or sexual abuse, or other forms of trauma such as neglect, are all found to be associated with the development of dissociative states and disorders (Putnam, 1985). Dissociation, detachment and compartmentalization can be considered adaptive to childhood trauma because they can reduce the degree to which the distress is overwhelming.  However, if detachment and compartmentalization continue in adulthood, they tend to be maladaptive. The dissociative adult may automatically disconnect from any situations that are perceived to be unsafe or threatening, without taking time to determine whether there is any real danger. This tends to leave the person “spaced out” or “dreamy” and unable to protect themselves in conditions of real danger making them vulnerable. In the following sections, different strands of research about childhood trauma, dissociation, fantasy and paranormal ideation are integrated into a single, coherent theory.

This Dissociation Theory of SPE hypothesizes a need for power and control in the face of adversity (Bandura, 1989; Taylor & Armor, 1996; Prilleltensky, Nelson & Peirson, 2001). It incorporates neurobiological evidence from the Polyvagal Theory (Porges, 2017) and the principles of homeostasis from the General Theory of Behaviour (Marks, 2018) to explain one origin of paranormal ideation. The central plank of the theory is the neurobiological evidence concerning the changes that accompany repeated childhood neglect and abuse which are thought to permanently alter developmental processes of adaptation in producing a “use-dependent” brain:

Childhood trauma has profound impact on the emotional, behavioural, cognitive, social, and physical functioning of children. Developmental experiences determine the organizational and functional status of the mature brain…There are various adaptive mental and physical responses to trauma, including physiological hyperarousal and dissociation. Because the developing brain organizes and internalizes new information in a use-dependent fashion, the more a child is in a state of hyperarousal or dissociation, the more likely they are to have neuropsychiatric symptoms following trauma. The acute adaptive states, when they persist, can become maladaptive traits.” (Perry et al., 1990, p. 271).

 In addition to the neurobiological changes, child abuse and neglect are associated with increased risk for psychiatric disorders including depression, bipolar disorder, post-traumatic stress disorder (PTSD), substance and alcohol abuse, and also medical disorders such as cardiovascular disease, diabetes, irritable bowel syndrome, asthma, and others (Nemeroff, 2016). Persistent biological alterations associated with childhood maltreatment include changes in neuroendocrine and neurotransmitter systems and pro-inflammatory cytokines in addition to alterations in brain areas associated with mood regulation. A systematic review found that individuals with at least four abusive childhood experiences (ACEs) are at increased risk of multiple health outcomes compared with individuals with no ACEs (Hughes et al., 2017). Associations were found to be weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (Odds Ratios, ORs, of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). 

Exposure to violence is thought to activate a set of threat-responses in a child’s developing brain. Excessive activation and arousal of the neural systems involved in threat responses alter the developing brain which, in turn, produces functional changes in emotional, behavioural and cognitive functioning. The existence of a  graded relationship of ACE scores to outcomes in multiple domains parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions (Anda et al., 2006).

One implication of trauma-dependent neurobiological changes is that paranormal ideation is able to becomes an adaptive coping strategy for victims of child abuse.  I describe next a series of linkages, beginning with fantasy proneness, mental imagery and dissociation.


Everybody daydreams. Fantasy, daydreams, and imagination are integral processes within healthy functioning, playing an adaptational role in daily life (Klinger, 1990; Singer, 1983; Marks, 2019).  Fantasy and daydreams reflect our current concerns, regulate mood, organize experience, provide self-relevant information, facilitate learning, and stimulate decision making (Rauschenberger and Lynn, 1995).  But, like everything else, there are widespread variations in fantasy proneness across the population.  Fantasy proneness (FP) refers to an enduring personality trait of individuals who are thought to spend a large part of their life daydreaming in fantasy.  Daydreaming is ubiquitous (Singer and McCraven, 1961), taking up 30–50% of our daily thinking time (Kane et al., 2007). 

I am reminded of an incident at school when I was about 13.  I had missed the first year of a course in Latin, and, because I wasn’t ‘taking’ Latin, I had to sit through Latin classes reading a book. One day, as I dreamily stared out of the classroom window, the master clipped me over the ear with his ruler, telling me to concentrate.[3] “But, sir”, I said, “I am not taking Latin.”  Raptus regaliter!

From the very beginning of research on FP, Wilson and Barber (1983, pp. 359-364) suggested that people with FP have psychic experiences, realistic out-of-the-body experiences and experiences of apparitional entities. Wilson and Barber also proposed that extreme fantasy is a coping strategy for dealing with loneliness and isolation by providing a means to escape from aversive environments. FP requires the generation of  mental imagery, those quasi-perceptual experiences that occur in the absence of an objective stimulus.  Large individual differences exist along a continuum of reported vividness and controllability of images (Marks, 2019). Individuals at the fantasy-prone end of the normal distribution (1-5%) experience vivid, uncontrollable images of hallucinatory quality which seem as real as actual events (Marks and McKellar, 1982; Wilson and Barber, 1983). Another small percentage (2-3%) of people at the opposite end of the distribution are unaware of any mental imagery at all (Zeman, Dewar and Della Sala, 2015).

The brain has a special  ‘default network’ that participates in internal modes of cognition such as autobiographical memory retrieval, envisioning the future, conceiving the perspectives of others and daydreaming. The default network appears to be a specific, anatomically defined brain system (Buckner, Andrews‐Hanna & Schacter, 2008) that would be activated on a frequent basis among people with FP. The default network also has a key role in the brain’s representation of the self (see Chapter 10).From the 1980s and 90s it had been hypothesised that FP is a process that is exacerbated by child abuse and that it may be a trait, like absorption, a variable that is related to FP (Kunzendorf, Hulihan, Simpson, Pritykina & Williams, 1997/98) and which is genetically mediated  (Tellegen, Lykken, Bouchard, Wilcox, Negal & Rich (1988). Lynn and Rhue (1988) elaborated the FP construct to include “a unique constellation of personality traits and experiences coalesced around a deep, profound and long-standing involvement in fantasy and imagination” (p.35). Fantasy prone individuals are believed to share a unique set of characteristics, including the experience of vivid memories, the ability to voluntarily hallucinate and superior hypnotic abilities (Wilson & Barber, 1983). Many phenomena associated with FP also includeabsorption (Lynn, & Rhue, 1988; Green & Lynn, 2011; Levin & Young, 2001/2002; Merckelbach, Horselenberg & Muris, 2001), aversive childhood experiences (Geraerts et al., 2006; Pekala, Kumar, Ainslie, Elliot, Mullen, Salinger, & Masten, 1999/2000; Rauschenberger & Lynn, 1995; Rhue & Lynn, 1987; Sanchez-Bernardos & Avia, 2004; Somer & Herscu, 2017), hypnotic abilities (Green & Lynn, 2008; Terhune, Cardena, & Lindgren, 2010), hallucinatory abilities (Giambra, 1999/2000; Laroi, DeFruyt, Van Os, Aleman, & Van der Linden, 2005), mentalimagery (Levin & Young, 2001/2002), and paranormal beliefs and experiences (Bartholomew, Basterfield, & Howard 1991; Berkowski & Macdonald, 2014; French, Santomauro, Hamilton, Fox, & Thalbourne, 2008; Gow, Lang, & Chant, 2004; Hough & Rogers, 2007/2008; Irwin, 1990; Lawrence, Edwards, Barraclough, Church & Hetherington, 1995; Merckelbach et al., 2001; Parra, 2006; Perkins, 2001; Rogers, Qualter, & Phelps, 2007; Spanos, Cross, Dickson, & DuBreuil, 1993).

There are two connections with FP that are particularly salient: (i) among individuals reporting a history of childhood abuse, the incidence of FP is especially high (Rhue, Lynn, Henry, Buhk & Boyd, 1990; Lynn and Rhue,  1988); (ii) dissociation is linked to both child abuse and FP (Rauschenberger & Lynn, 1995;  Pekala et al., 1999). These two findings have led to a renaissance of Janet’s trauma theory (TT).

As noted, dissociation is considered a psychological defence mechanism for victims of traumatizing events such as sexual molestation, natural disaster, or combat (Putnam, 1991). The TT  holds that victims are able to compartmentalize their perceptions and memories and detach themselves from the full impact of the trauma and that these dissociative processes possibly continue throughout their entire lives.  Vonderlin et al. (2018) investigated the relationship between childhood interpersonal maltreatment and dissociation in 65 studies with 7352 abused or neglected individuals using the Dissociative Experience Scale (DES). The results revealed higher dissociation in victims of childhood abuse and neglect compared with non-abused or neglected subsamples sharing relevant population features with highest scores for sexual and physical abuse. Earlier age of onset, longer duration of abuse, and parental abuse significantly predicted higher dissociation scores.

Skeptics – as expected – doubt the correctness of the TT and propose a fantasy theory (FT) instead.[4] Dissociation is alleged to produce fantasies of trauma among naturally fantasy-prone, suggestible patients who are vulnerable to the ‘planting’ of false memories by overly zealous psychotherapists. The FT is associated with the “False Memory Syndrome” movement, an organization of people accused of childhood sexual abuse,[5] with multiple court cases brought by alleged perpetrators, usually parents claiming total innocence of abuse (Belli and Loftus, 1994; French, 2009; Porter, Yuille & Lehman, 1999); Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008; Lynn et al., 2014 ). The possibility that therapeutic techniques could create illusory memories of abuse became a major debating point that has divided psychotherapists and researchers into opposite camps. The vehemence of the opposing camps is reminiscent of the ‘Battle over Psi’.

In a systematic review of memory implantation, Brewin and Andrews (2017) found that recollection of suggested events can be induced in 47% of participants, but only in 15% of cases are these experiences likely to be rated as full memories. Brewin and Andrews concluded that susceptibility to false memories of childhood events seem to be quite restricted. The jury is still out, but there is little doubt that a significant proportion of recovered memories of child abuse is veridical, i.e. they are based on actual events.

Dalenberg et al. (2012, 2014) also reviewed numerous studies in a meta-analysis to determine whether the TT or FT received the majority of empirical support. They concluded that the TT was most consistent with the evidence, which included several supportive longitudinal studies.  Dalenberg and colleagues found the trauma–dissociation relationship to be modest for childhood sexual abuse (CSA; r = 0.31) and physical abuse (r = 0.27) but stronger among individuals with DID (0.54 for CSA and 0.52 for physical abuse). However, dissociation scores predicted only 1–3% of the variance in suggestibility. Other studies have found that individuals with DID are no more suggestible or prone to creating false memories than individuals with PTSD, actors simulating DID, or healthy controls (Vissia et al., 2016). A continuum of trauma-related symptom severity was found across the groups, which supports the hypothesis of association between the severity, intensity and age at onset of traumatization, and the severity of trauma-related psychopathology. The evidence from Vissia et al. (2016) supported the TT of DID and challenged the core hypothesis of the FT. However, the issue is not yet fully resolved (Merckelbach & Patihis, 2018; Brand et al., 2018). A further issue to complicate this already complex picture is that unusual sleep experiences can precipitate episodes of trait dissociation (van Heugten–van der Kloet, Merckelbach, Giesbrecht & Broers, 2014).

The closeness of victims to perpetrators has also been the focus of studies. The impact of abuse is more intense and longer lasting when linked to a sense of betrayal. The betrayal version of the TT proposes that one response to betrayal may be to keep knowledge of the trauma out of conscious awareness (Freyd, 1996, 1997). Although this ‘betrayal blindness’ may benefit survival for ongoing abuse by helping to maintain significant relationships, this compartmentalization of reality can lead later to psychological and behavioural problems. Gómez, Kaehler and Freyd (2014) ran three exploratory studies to examine the associations between exposure to betrayal trauma, dissociation and hallucinations which found betrayal trauma increases the likelihood of dissociation and hallucinations.

How might high proneness to fantasy, then, lead to SPEs? The Vividness Hypothesis claims that fantasy-prone people are more likely to experience visions, voices and apparitions of extreme vividness leading them to conclude that such events have a psychic origin (Blackmore, 1984; Marks, 1988). Hallucinogens and psychedelic substances tend to increase a state of FP in people who might otherwise be less fantasy prone. The discoverer of LSD, Albert Hofmann (1980), wrote: “in the LSD state the boundaries between the experiencing self and the outer world more or less disappear….Feedback between receiver and sender takes place. A portion of the self overflows into the outer world, into objects, which begin to live, to have another, a deeper meaning. In an auspicious case, the new extended ego feels blissfully united with the objects of the outer world and consequently also with its fellow beings. This experience of deep oneness with the exterior world can even intensify to a feeling of the self being one with the universe.” A sense of awe and oneness with nature does not require LSD but is likely to be magnified by LSD and may also trigger ‘paranormal’ experiences (Luke and Kittenis, 2005).

As noted, multiple studies have examined the relationship between FP, imagery vividness and SPE. Merckelbach, Horselenberg and Muris (2001) found that the Creative Experiences Questionnaire (CEQ), a brief self-report measure of FP, correlated with dissociativity in the range of .47 – .63 and also with paranormal experiences. Wiseman and Watt (2006) felt that the evidence should be treated with caution given that the measures employed are intercorrelated and may reflect the operation of a single underlying concept. They refer to Kirsch and Council (1992) and cite Thalbourne’s (2000) concept of ‘transliminality’, which is claimed to underpin a range of imagery factors including frequency of dream interpretation, FP, absorption, magical  ideation and mystical experiences. Other studies, however, suggest that the Vividness Hypothesis may indeed be correct, especially when combined with high absorption (Glicksohn and Barrett, 2003).  In Brazil, Alejandro Parra and Juan Carlos Argibay (2012) compared people who claimed psychic abilities with a non-psychic control group to find that the ‘psychic’ group (N = 40) had significantly higher scores on dissociation, absorption and FP than did the ‘non-psychic’ group (N = 40). In Australia, Gow, Hutchinson and Chant (2009)  tested 114 females and 59 males who were classified as ‘anomalous experiencers’ (n = 125), ‘anomalous believers’ (n = 39) and ‘non-believers’ (n = 9), according to their responses on a ‘Measure of Anomalous Experiences and Beliefs’. In the experiencer group, significant correlations occurred between FP and five subscales of paranormal belief and significant moderate to low correlations with both the “intuition” and “feeling” dimensions of the Myers–Briggs Type Indicator. Dissociation was also found to be related to global paranormal belief and to the subscales of psi, superstition, and extraordinary life forms.

Parra (2015) assessed 348 educated believers for their paranormal or anomalous experiences, and capacity for visual imagery under eyes-open- and eyes-closed conditions using the Vividness of Visual Imagery Questionnaire Revised (VVIQ-R; Marks, 1995) and a 10-item self-report inventory designed to collect information on spontaneous paranormal/anomalous experiences. The results showed that VVIQ scores and paranormal/anomalous experiences correlated significantly, especially for Aura, Remote Healing, and Apparitions, but only in the Open-Eyes condition. Parra (2015) noted: “These results also highlight the fact that mental imagery ability may be psi-conducive, and it is interesting to note that the VVIQ may be helpful in identifying and selecting better psi-scorers in psi experiments, and may even be of use in psychomanteum (sic) and aura-seeing research. The other advantage of the VVIQ is its ease of administration and speed of data analysis.”  In another study, Parra (2018) found that psychic/high-psi-scorers scored significantly higher than nonpsychic/low-psi-scorers on both sub-scales of the VVIQ.

Lawrence and colleagues (1995) proposed a model of paranormal experience (SPE) and belief (PB) which included fantasy (but not dissociation) as a predictor. In Lawrence’s model, trauma was found to have two causal routes in influencing SPE, one direct, the other indirect (Figure 2.1). However, the omission of dissociation appears to have been a significant limitation of the Lawrence et al. model. My current proposal is to assume that dissociation is the most significant sequela[6] of extreme forms of ACE and that fantasy, paranormal experience and paranormal belief are among the consequences of the process of dissociation. Figure 2.1 show the supervenient role of dissociation in the fantasy that is generated following childhood trauma.

Figure 2.1: A theory of childhood trauma, dissociation, paranormal experience and belief as an extension of the model originally suggested by Lawrence et al. (1995) shown with continuous lines. The model is extended to include dissociation as the main sequela of childhood trauma with causal connections to childhood fantasy, paranormal experience and paranormal beliefs (broken lines).

This extended Dissociation + Trauma Theory suggests that the psychological system strives to restore safety, security and equilibrium by dissociating into compartments to inhibit action and generate compensatory fantasy. Homeostasis performs a restorative function with its ability to deploy the entire resources of the psychological system, including affect, fantasy, and the approach-avoidance-inhibition system to reset the imbalances created by dissociation. The reset restores feelings of safety and control (Marks, 2018, 2020). The hypothesised stabilising role of homeostasis is consistent with the theory of Silvan Tomkins who proposed that the primary motivational system is the affective system and biological drives have impact only when amplified by the affective system (Tomkins, 1962). Clinical studies have established that involuntary images and difficult-to-control memories are associated with dissociation, trauma, stress, anxiety and depression. Sufferers often report repeated visual intrusions concerning real or imaginary events that are ‘usually extremely vivid, detailed, and with highly distressing content’ (Brewin, et al., 2010).  These elements are precisely the sequelae of a dissociative response to ACE.


The association between childhood adversities (CAs) and the onset of psychotic episodes (PE)  is receiving the attention of clinical researchers who widely agree that childhood trauma is a risk factor for the development of psychosis.  Since Janet, the relationship between childhood trauma and symptoms of psychosis has been explained as one consequence of dissociation. For example, Varese, Barkus and Bentall (2012) explored the hypothesis that the effect of childhood trauma on hallucination-proneness is mediated by dissociative tendencies. Patients with schizophrenia spectrum disorders (n=45) and healthy controls (with no history of hallucinations; n=20) completed measures of hallucination-proneness, dissociative tendencies and childhood trauma. Compared to healthy and non-hallucinating clinical control participants, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation was found to positively mediated the effect of childhood trauma on hallucination-proneness, a mediational role that was “particularly robust for sexual abuse over other types of trauma” (Varese et al., 2012, p. 1025). They concluded that the results are consistent with dissociative accounts of the trauma-hallucinations link.

Meta-analyses of the association between childhood trauma and severity of hallucinations, delusions, and negative psychotic symptoms in clinical populations have confirmed the association. In a meta-analysis of 29 studies (4680 participants) Bailey et al. (2018) found that, in individuals with psychosis, childhood trauma was significantly correlated with severity of hallucinations (r = .199, P < .001) and delusions (r = .172, P < .001) but not with severity of negative symptoms. These results lend support to theories that childhood traumas may lead to hallucinations and delusions. McGrath et al. (2017) assessed CAs, PE and DSM-IV mental disorders in 23,998 adults in the WHO World Mental Health Surveys. People who had experienced any CAs were found to have an increased odds of later PE [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.9–2.6]. CAs reflecting maladaptive family functioning, including abuse, neglect, and parent maladjustment, were found to exhibit the strongest associations with PE onset at all life-course stages. Sexual abuse was observed to produce a strong association with PE onset during childhood (OR 8.5, 95% CI 3.6–20.2), while other CA types were associated with PE onset in adolescence. McGrath et al. (2017) concluded that exposure to CAs is associated with PE onset throughout the life-course, with sexual abuse being most strongly associated with childhood-onset PEs.

 Muenzenmaier et al. (2015) tested the dose–response relationship between CA and delusions and hallucinations including the effects of dissociation on the relationship. The prevalence of CA in individuals with psychotic disorders was high, with each additional CA being associated with a 1.20 increase in the incidence rate ratio (95% confidence interval [CI; 1.09, 1.32]) for hallucinations and a 1.19 increase (CI [1.09, 1.29]) for delusions, supporting a dose–response association. After controlling for the mediating effects of dissociative symptoms at follow-up, CA remained independently associated with delusions. Muenzenmaier et al. (2015) proposed that cumulative CA can result in complex reactions including dissociative, posttraumatic stress disorder, and psychotic symptoms.

A review of 19 quantitative studies investigated the relationship between voice-hearing and dissociation between 1986 and 2014 (Pilton, Varese, Berry and Bucci, 2015). The authors concluded that dissociation may be implicated in voice-hearing as a mediating factor. In a clinical study with 71 patients diagnosed with psychosis, Perona‐Garcelán et al. (2012)  found that childhood trauma was positively associated with the dissociation scale scores (r = .40) and the hallucination (r = .36) and delusions scale scores (r = .32).  Depersonalization was found to be a potential mediator between childhood trauma and hallucinations, but not between childhood trauma and delusions. In another study of  depersonalisation mediation in the relationship between childhood maltreatment and both hallucination-proneness and delusional ideation, Cole, Newman-Taylor and Kennedy (2016) used a cross-sectional design in a non-clinical group. They found that dissociation mediated the relationship between early maltreatment and hallucination-proneness and delusional ideation.

It has been suggested that the content of hallucinations may be formed out of dissociative memories of traumatic events (Mauritz, Goossens, Draijer & van Achterberg, 2013) and that it could reflect the experiencer’s perceived lower social self-appraisal as a consequence of childhood abuse (Birchwood, Meaden, Trower, Gilbert & Plaistow, 2000).

In the next section, I examine another piece in the jigsaw, the Polyvagal Theory, which concerns the organism’s defences when safety is challenged by an imminent threat.


The Polyvagal Theory is a neurobiological theory of safety. The Polyvagal Theory describes an inbuilt system within the nervous system for evaluating threat, which enables a shift in the body’s physiological defences. Think of the drawbridge going up at the main gates of a castle when enemy soldiers are detected at the edges of the estate. The goal of the psychological system is to continuously monitor the environment for threats by searching for unique cues. When a threat or lack of safety is perceived, the system actively inhibits outward responses to promote safety and well-being with feelings of love, security and trust. Safety is associated with specific environmental features and unconscious bodily responses as well as making conscious cognitive evaluations. Adaptive survival resides in the evolutionary wisdom of the body and nervous system that function outside the realm of awareness. These neural processes that evaluate risk in the environment without awareness are called neuroception.[7]  Evaluations of risk and lack of safety in potentially dangerous relationships play a secondary role to our visceral reactions to people and places (Porges, 2017, p. 43; Figure 2.2).


The Polyvagal Theory concerns the vagus, the tenth cranial nerve and the primary nerve in the parasympathetic nervous system (PNS). The vagus connects brainstem areas with structures in the body including the neck, thorax, and abdomen. Polyvagal Theory involves the changes in the autonomic nervous system (ANS) and a unique change in the vagal motor pathways that first occurred with the emergence of mammals in evolution. When the ventral vagus and the associated social engagement system are optimally functioning, the ANS supports health, growth, and restoration. According to the Polyvagal Theory, defence reactions are manifested as either an increase in SNS activity that inhibits the function of the dorsal vagus to promote fight and flight behaviours or as a shutdown manifested as depressed SNS activity and a surge of dorsal vagal influences that results in fainting, defecation, and an inhibition of motor behaviour, as seen in mammals feigning death (Porges, 2017).

Neuroception is the neural process that evaluates environmental risk from cues which trigger shifts in autonomic state prior to conscious awareness. We constantly monitor the environment for safety both with and without awareness. One example is the sense of danger we may experience immediately prior to a mugging. If somebody suddenly runs up from behind and rips one’s bag off one’s shoulder, it would be a perfectly natural reaction to freeze. Other victims may switch into ‘fight’ mode, others into ‘flight’. These response occur prior to any conscious decision. Neuroception shifts the ANS response to cues of safety, danger or threat by activating the social engagement system and shutting down the fight/flight and the body’s defence systems. This includes the face, heart, and myelinated vagus (Porges, 2017).  Finally, I show how the pieces of the jigsaw fit together.

FIGURE 2.3: A graphic representation of the Trauma + Dissociation Theory of SPE (Marks, 2020).


Here we take a look at the complete picture produced by the theory.

If we are to make sense of the connections between childhood trauma, dissociation, and SPE we need to consider the options for an infant or child who is confronted by a significant threat of harm from a person who may be a close family member, another known person or even a complete stranger. Being able to cope with such a threat has profound evolutionary significance, and how the organism responds is likely a life and death issue.  Every living organism is endowed with a powerful mechanism that has been especially designed to deal with threats to life called the ‘Approach-Avoidance-Inhibition (AAI)’ system. This system controls the individual’s fight, flight or freeze response. A well-established principle is the universal striving towards pleasure and away from pain that underlies all approach and avoidance behaviour. Organisms approach sources of potential pleasure and satisfaction and studiously avoid potentially aversive stimuli and confrontations with danger. Essential similarities in the neural systems underlying painful and pleasant sensations are based on the opioid and dopamine systems respectively  (Leknes and Tracey, 2008).  This ‘do or die’ neural circuitry evolved to ensure survival. This survival circuitry is activated either by stimuli that are life-sustaining or by stimuli that threaten survival. Activation of the pain and pleasure circuits alert the sensory systems to pay attention and prompt motor action (Lang and Bradley, 2010). The approach–avoidance concept is pivotal to the organisms’ systems of self-defense (Elliot, 1999). However, the AAI system also includes a mechanism for behavioural inhibition, which is activated in approach–avoidance conflict. It has been proposed that an ‘Action Schemata’ (AS) system coordinates and controls action with the AAI system (Marks, 2018).  Further details of these systems are given in Chapter 10.

The innate species-specific defense reactions of the AAI system – fleeing, freezing or fighting – are rapidly acquired when organisms are still young and relatively immature (Bolles, 1970; Wichers et al., 2015). In infants and young children, the first reaction to continuing threat is to cry and then to freeze. The ability to fight or fright is not usually available. Freezing allows better sound localization and visual observation of the environment for potential threat. Cessation of movement is also a form of camouflage which reduces the risk of attracting attention by predators. Traumatised children often develop a “sensitized” hyperarousal or “sensitized” dissociative pattern in association with freezing when they feel anxious. Freezing can escalate to complete dissociation (Perry et al., 1990).

An adaptive homeostatic mental and physical response to childhood trauma consists of a dissociative response of freezing and/or surrender involving fantasy and imagery. The diagram in Figure 2.4 shows a representation of a general behavioural control system with two co-active sub-systems for the control and timing of action, the ‘Action System’, and for the control and timing of imagery, the ‘Image System’ (Marks, 2018 a, b).

FIGURE 2.4: A diagram of the Trauma + Dissociation Theory of SPE. The control system consists of two co-active, parallel systems, an ‘Action System’ and an ‘Image System’. In any response to danger, one system can switch down its activity allowing the other system a greater share of control. In the left panel, the Image System is dominant with a setting for freeze or surrender while, in reciprocal fashion, the Action System is inhibited. The Image System is fully activated to produce fantasy, calmness, stillness and self-control. In the right panel, the Action System is dominant and set for mobilization of fight or flight with actions of aggression or revenge, while the Image System is switched off. The arrangement shown in the right hand panel is not available to infants and young children, who would normally respond with the system shown in the left-hand panel, but the right-hand panel system would be available to older adolescents and adults.

The Dissociative Setting is activated as the child’s response to trauma. The Image System is fully switched on and the Action System is switched off, giving a Freeze or Surrender response. The child-under-threat withdraws into an inner world of detachment and derealization in which stabilizing fantasy of calm and self-control are utilized to restore homeostasis. Post-traumatic fantasy is a normal homeostatic balancing process to produce equilibrium in a system experiencing unjustified life threat, loss or harm. There is every reason to expect trauma-based fantasy to be restorative of missing love objects in the form of voices, hallucinatory images or the felt presence of missing persons, or in fantasies of personal survival beyond death.  The genesis of fantasy- and affect-laden paranormal experience in dissociative self-defense causes paranormal ideation of coping and survival. Fantasy and daydreaming increase the likelihood that a person will experience altered states of consciousness, striking coincidences, and beliefs in the paranormal which help to restore a sense of balance and control.

The theory views dissociation as the system’s innate response to threat with defensive immobilization and involuntary freezing or the feigning response of playing dead. As in all behaviours, there are gradations in reactions to life threats ranging from total shutdown and collapse to immobilization when muscles lose tension and the mind dissociates from the traumatic event similar to the REM state during sleep. I turn to consider 13 hypotheses that follow from the theory with a brief statement of the support from the research literature.


I list here 13 hypotheses that follow from the theory and cite illustrative studies relevant to these hypotheses:

H1:  SPEs should be more common  in people reporting childhood abuse (supported:Lawrence et al.,1995;Rabeyron and Watt, 2010; Sar, Alioğlu and Akyüz, 2014; Scimeca et al., 2014; Parra, 2019).

H2: SPEs should be more common among people with dissociative symptoms (supported: Wahbeh, McDermott & Sagher, 2018).

H3: SPEs should be more common in females than by males (supported: Castro, Burrows and Wooffitt, 2014).

H4: One common response of children to extreme negative affect (trauma, fear and anxiety) is dissociation, detachment, derealisation and restorative fantasies of control and calm (supported: Cook et al., 2017).

H5: Dissociation in adulthood is more common in people reporting childhood abuse (supported:Chu and Dill, 1990; Vonderlin et al., 2018).

H6: Dissociative experiences are more common among females than males (inconsistent findings: Ross, Joshi & Currie, 1990; Putnam et al., 1996; Spitzer et al., 2003; Brosky & Lally, 2004; Maaranen et al.,2005; Steuwe, Lanius & Frewen, 2012; Wolf et al., 2012a, 2012b; McLaughlin  et al., 2013; Stein et al., 2013).

H7: FP is more common in people reporting childhood abuse (supported:Rhue and Lynn, 1987; Somer and Herscu, 2018).

H8: FP is more common in women than in men (supported: Minakowska-Gruda, 2006).[8]  

H9: Paranormal beliefs are more prevalent in people reporting high levels of FP than in others (supported:Ellason and Ross, 1997; Irwin, 1990).

H10: Individuals who claim paranormal abilities score higher on dissociation and fantasy than individuals who do not claim paranormal experiences (supported:Parra and Argibay, 2012).

H11: FP and coping style fully mediate the relationship between trauma and paranormal beliefs (supported: Berkowski and MacDonald, 2014).

H12: Belief in ESP and PK is a vehicle for exercising a need for power and control at a fantasy level (supported: Roe and Morgan, 2002).

H13:  Among victims of childhood abuse, a dissociative response such as PTSD is more likely to be released when trauma occurs in adulthood (supported: Brewin, Andrews and Valentine, 2000).


The overall fit between the theory and empirical findings provides one solution for the jigsaw of pieces that I have identified. However, there may be missing pieces to be filled into a bigger picture that is not yet clearly visible.  It is unlikely the theory can explain the origins of all SPEs.  That really would be too good to be true.  All theories are eventually replaced by better theories.  It has been well documented that dissociative states are much more common among individuals who have been traumatized in childhood and that the defensive use of fantasy provides a beneficial coping strategy.  However, there must be other causal pathways to SPE, one of which is the possibility that some of the experiences are veridical, let us not forget.

The inconsistent findings in relation to H6:Dissociation is more common among females than males”, does not perfectly align with the confirmations obtained with the other 12 hypotheses. At least the uncertainty about H6 eliminates any accusation that the theory is too good to be true.  One can think of post hoc reasons why H6 might not be correct. Perhaps the greater levels of abuse experienced by girls than boys as younger children are counterbalanced at older ages when boys generally receive greater levels of trauma from physical bullying than girls. In 35 countries surveyed in the WHO International report from the HBSC, 11-15 year-old boys report significantly more physical bullying and fighting than same-age girls (Craig & Harel, 2001).  In an older sample of 18-24 year-old US college students, however, the prevalence of PTSD and risk for trauma were greater for the female gender. The uncertainty about H6 awaits further analysis. A further limitation is the cross-sectional nature of the majority of studies. Future research needs to include longitudinal designs to explore directional, causal effects while controlling for potential confounding factors. It seems unlikely that everybody who experiences SPE has been a victim of abuse as a child, although this remains an open question. It’s horses for courses: SPEs in people who were never abused would require a different kind of theory.


The Trauma + Dissociation Theory holds that childhood trauma and dissociation act together to produce SPE in a significant number of people. Childhood trauma is a prevalent social scourge requiring a robust system of self-defence against potential  perpetrators. One instinctive defensive strategy is dissociation that is known to produce fantasies and feelings of calm and control. The theory provides a comprehensive account for a large number of findings in the published literature. New prospectively controlled research is required to test theoretical hypotheses on a large sample of children to enable rigorous testing together with alternative hypotheses about the origins of SPE.


[1] Readers interested in anomalous phenomena themselves rather than their origin may wish to head straight to Chapter 4 and return here later.

[2] In this review, child abuse applies to individuals aged 0-17 years inclusive.  

[3] Corporal punishment with canes and rulers was routinely administered by school teachers in those days.  An ear clipping by a teacher today would be a sackable offence.

[4] Also called the ‘socio-cognitive’ or ‘iatrogenic’ model.  Any effect resulting from healthcare professionals, products or services that unintentionally lead to illness or adverse effects is termed ‘iatrogenic’.

[5] The False Memory Syndrome Foundation (FMSF) is a non-profit organization founded in 1992by Pamela and Peter Freyd after their adult daughter Professor Jennifer Freyd  accused Peter Freyd of sexually abusing her as a child (Dallam, 2001). 

[6] Sequela = consequence.

[7] We will return to consider neuroception in Chapter 6 when discussing the theory of human magnetosensitivity.

[8] Many publications on FP report correlational studies of FP with other variables but not gender differences. Wilson and Barber’s (1981) original study was with girls only.


The Tyranny of Positive Thinking

Earlier posts here and here discussed recent claims in national newspapers and mainstream media that positive thinking may be a cure for Long-Covid. Similar claims have been made previously for cancer and for MECFS but these claims are unsupported by scientific evidence.

Anecdotes by vocal advocates receive disproportionate publicity compared to the more reasoned research by seasoned investigators. The anecdotes supporting cure claims are at the bottom of the Evidence Pyramid. In-depth investigations of positive thinking among patients with serious illnesses suggest that the psychological effects of thinking positive can be far from positive. In some cases, it can actually be counter-productive.

When a person with a serious medical condition uses ‘positive thinking’ as a coping device, the technique can backfire and make things feel even worse. The patient may easily be convinced that they are not performing well and that they are to blame for their symptoms. People in the media who are advocating ‘positive thinking’ as a cure are acting irresponsibly and may be contributing to a worsening of symptoms.

Some researchers have even referred to the ‘tyranny of positive thinking’.

In their review of research on positive thinking, Lisa Aspinwall and Richard Tedeschi (2010) suggested:

the principal danger of popular versions of positive psychology, namely,
those with a seemingly relentless emphasis on mandating
optimism, individual happiness, and personal growth no
matter the circumstances, is that the general public may
come to believe that one can conquer cancer by thinking
positively and that if one is not getting a good response,
one is not thinking positively enough, not laughing enough,
or not being spiritual enough. Indeed, the explicit blame of
people with serious illness for their failure to cure
themselves in best-selling popular treatments of positive
thinking … is shocking and reprehensible.

Lisa Aspinwall and Richard Tedeschi (2010)

Sue Wilkinson and Celia Kitzinger at Loughborough University studied discussions of positive thinking in breast cancer patients.

There is an extensive social science and psycho-oncology literature on coping with cancer which claims that “thinking positive" is correlated with - and, by extension, causally implicated in - individuals' morbidity and mortality rates, and their overall level of mental health... We show that previous literature overwhelmingly relies on self-report data, which are taken as offering more or less accurate depictions of speakers’ psychological states (i.e. their mental adjustment or coping style). A discursive approach, by contrast, explores talk as a form of action designed for its local interactional context, and pays detailed attention to what statements about “thinking positive" actually mean for speakers in the contexts in which they occur. We show that “thinking positive” functions not as an accurate report of a internal cognitive state, but rather as a conversational idiom, characterised by vagueness and generality, and summarising a socially normative moral requirement; we also show that even those breast cancer patients who report “thinking positive” can also actively resist its moral prescriptions.

Sue Wilkinson & Celia Kitzinger, 2000

Media claims that positive thinking can cure cancer, MECFS, long-covid and any other serious health condition are irresponsible and pseudo-scientific.


Trash Science of Positive Thinking

So here we have it in The Times: the re-arrival of that great cliché of pseudo-psychology, Positive Thinking.

The ‘wearied souls in the pandemic’s wake’ will become a lot more weary after the Trash Science of Positive Thinking has taken its toll. Victim-blaming, gaslighting and the ‘all-in-the-mind’ philosophy of lazy doctors will become the mainstay of Long-Covid patients’ everyday experience. Just like the MECFS patients before them.

An earlier post reviewed the speculations of ‘nutty professor’, Paul Garner. Here he is again, stamping his name on the Long Covid band wagon, this time, in the Times. Science Editor, Tom Whipple claims: “A lack of data and definition is isolating the potential millions left with long Covid.”

Actually there is plenty of data e.g. see here, or here. If you’re a journalist and that data proves too complex or you’re too lazy to read it – why spoil your weekend – a quack can fill up your report with anecdotes about how he healed himself with positive thinking.

Here’s what Tom Whipple in the Times says about Garner:

More than that, his [Garner’s] is an argument that comes with baggage. Everything is political now. From some of those in the ME community, who say the idea that post-viral conditions might be in part psychosomatic has been used to dismiss their worries for years, his story, and his willingness to tell it, has caused deep anger. They find the idea they could merely think themselves better offensive. However, he still insists on telling it. “We’ve kind of got into this mess,” he said. “This illness has taken me to a new level of understanding of medicine. Where we’re missing out is by dividing things into mental and physical. Then we ignore that you can have some agency in getting better.”

Whipple, The Times, 17 January, 2022

A new level of understanding of medicine? Really? Are you serious? Then, please Professor Garner, keep it to yourself.

It isn’t new, it isn’t understanding, and it isn’t science, it’s unmitigated trash.


‘Brilliant’ – But Censored

Here I post a chapter described as ‘brilliant’ by the book’s editor but censored by the book publisher. British Psychology In Crisis: A Case Study in Organisational Dysfunction (Ed., David Pilgrim, University of Southampton; Publisher, Kate Pearce, Phoenix Publishing House) will be available later in 2022. The publisher insisted on censoring words such as ‘sordid’ and ‘white supremacist’, which accurately describe the history of this beleaguered organisation.

The chapter describes the betrayal of academic values, ethics and freedom of expression within the BPS. The refusal to publish the piece without enforced sanitisation indicates the level of rank hypocrisy that exists among a few of today’s so-called ‘liberal’ thinkers. I quote here my response to the editor and publisher:

With regret, I must withdraw. I do not agree to have my chapter butchered into a dialogue with a sanitized title and content palatable to particular sensitivities. That was not what we agreed beforehand.  In no other edited volume to which I have contributed has the publisher intruded on the content already agreed between editor and author except for matters based on consultations with lawyers. As previously noted, your deletions are not required for legal reasons but appear to be matters of tone and taste, for example, the words ‘sordid’ and ‘white supremacist’. When I write ‘sordid’ I mean exactly that, and no publisher or editor has any right under any set of ‘rules’ regarding tone or taste to request this kind of deletion.

Email to David Pilgrim and Kate Pearce, 18 December, 2021

If liberty means anything at all, it means the right to tell people what they do not want to hear. (George Orwell, 1953).



The current crisis within the British Psychological Society is interpreted by the majority of contributors to this book as an indication that the Society is being misgoverned.  I go one step further. To this author, the Society is morally bankrupt and acting fraudulently.[1] The scale of the fraud is evidenced by a well-documented catalogue of ethical and academic betrayals. As a ‘learned society’, the Society’s core business is to serve the members, accredit degree programmes, publish books, produce scholarly publications and provide protection to the public from false therapeutic claims and malpractice. The Society’s legitimacy to perform these functions is severely compromised by its negligence of ethical probity and academic values such as equality of rights and freedom of expression.  I discuss here the Society’s failure to: i) fulfil the first object of its Charter to disseminate the science of psychology in an impartial and even-handed manner; ii) expunge and correct its sordid track record of institutional racism, eugenics, and classism; 3) investigate probity in the conduct and research of society members for the protection of patients and the general public from incorrect theories and harmful therapies. These examples indicate an abandonment of core values and duty of care to produce a Society that is a morally bankrupt and fraudulent enterprise.


The BPS website states:

the British Psychological Society …is responsible for the promotion of excellence and ethical practice in the science, education, and application of the discipline…

We strive to:

  • be the learned society and professional body for the discipline 
  • embrace equity, diversity and inclusion in everything we do 
  • promote and advance the discipline 
  • be the authoritative and public voice of psychology 
  • determine and ensure the highest standards in all we do.  

1. Introduction

Consider the following :[2]

The first BPS President, also an Editor of the British Journal of Psychology, is a white supremacist advocate of eugenics who writes about the ‘mental differences between the higher and lower races’. The Society names a special annual lecture after him.[3]

An ex-officer in the British Army and BPS President – another white supremacist- writes about the inferiority of working class people [4] and questions their right to have children but, until very recently, has a prestigious medal awarded to up-and-coming psychology researchers.[5]

A leading psychology professor writes in the British Journal of Psychology [6]that large families are breeding grounds of the feeble-minded. After his death, this person is found guilty of faking the existence co-workers, authors, data and correlations to bolster his claim that intelligence is genetically determined.

A 1990 paper in The Psychologist claims that racial group differences in intelligence occur worldwide and these IQ differences are “paralleled by more than 50 other variables including brain size, maturation rate, personality and temperament, sexuality, and social organisation”.[7] This disgusting, unscholarly piece of work is supported by Britain’s most famous psychologist and by the BPS President.

A 2006 paper in the British Journal of Health Psychology proposes that black, sub-Saharan African people have problems living in the modern world because they are less intelligent than people living in richer, more egalitarian countries.[8]   In a well-known Psychology magazine, the same writer later claims that black women are objectively less attractive than women of other races.[9]

At a BPS webinar on ‘How to implement anti-racist practice’ on 12 October 2021, the President of the Society, Katherine Carpenter, also Chair of the Division of Neuropsychology, stated that she was “absolutely aghast to discover that other psychologists think that neuropsychologists think that – uhm – black people may be less intelligent…” [10]  

At a BPS clinical psychology conference in 2019, a live portrayal of the slave trade is presented as ‘entertainment’. The organisers fail to warn participants, obtain their informed consent or to stop the performance to prevent audience members becoming upset.[11] 

In 2020, a BPS Division of Clinical Psychology annual conference delegate displays a poster describing her research on forensic services. Another participant writes a sordid racial slur onto the poster, which is left on display for all participants to see.[12]

On multiple occasions, a clinical psychology professor sexually abuses a vulnerable 20-year old patient. Claiming drink problems, the professor is permitted by the Society to continue as a member.[13]

Britain’s most famous Psychology professor secretly obtains tobacco industry funding and uses fraudulent data to claim that tobacco is less harmful than the smokers’ own personalities and that behaviour therapy can be used to lower smokers’ risk of fatal diseases. An investigation at the professor’s university concludes that the professor’s publications are ‘unsafe’ and many papers are retracted by journals. However the professor’s fraud is never investigated by the Society, which continues to have a special lecture after him.[14]

According to the Chair of the Society’s Ethics Committee, alleged ethical breaches and misconduct by the Society’s employees are not dealt with by the Society’s Ethics Committee but by a Complaints Procedure.[15]

You are not dreaming – this is not dystopian fiction. All of these actually happened inside the BPS.[16]

How can a Society profess “excellence, ethical practices and highest standards” and yet also be responsible for the above list of unmitigated disasters? [17]  This ‘Catalogue’ is a sample of the breaches of moral codes and core values that are discussed elsewhere in this book, e.g. the alleged fraud currently under police investigation, the violation of human rights of the 2020-21 President-Elect, Nigel MacLennan, the publication of a libellous YouTube video about the same person, the lack of accountability of  the ‘Change Programme’, secret procurements of services, the unexplained use of membership fees for legal costs, and – no doubt – a thousand-and-one invisible infringements of civil decency that will never see the light of day.


Who am I and why do I care?  I am membership number 3829, David Francis Marks, Chartered Member, Fellow of BPS since 1984, founder member of the Division of Health Psychology and the Consciousness and Experiential Psychology Section. Born and raised in Portsmouth. I discovered Psychology in the reading rooms of the public library. On arrival at the University of Reading in 1963, my tutor, Professor Magdalene D Vernon, suggested I join the BPS. Here I am 58 years later. Never in my wildest dreams could I have imagined anything remotely similar to the above and that I would be writing about it now as a whistle-blower. I am especially concerned with a core academic and ethical value that few ‘white’ BPS members tend to discuss: equality of treatment of all people regardless of age, ability, class, ethnicity, race, gender and sexual preference, without fear or favour. I discuss these issues because they have generally been woefully neglected. For me, these are significant gaps in the Psychology discipline and professions which must be filled. In A General Theory of Behaviour[18], a textbook on methodology[19], six editions of Health Psychology Theory, Research and Practice [20] and in two peer-reviewed journals I founded, Journal of Health Psychology and Health Psychology Open, equality and diversity are corner stones.

I always liked to believe that improved knowledge and understanding of behaviour can be a positive force for good and that the wellbeing of all can be improved by the application of Psychology to social and economic problems. To achieve such a noble objective, associations of psychologists intent on improving the lot of fellow humans like the BPS should be helpful. This is why I joined the Society as an 18-year-old and have remained a member to the present day.

In the early 90s, I was elected to chair the BPS Health Psychology Section. My colleagues and I took the Health Psychology Section to Special Group status and then to BPS Division status. We designed the BPS accreditation of the first MSc and Stage 2/doctoral training programmes in health psychology in the UK. I attended APA conferences, represented the BPS on international bodies such as the European Federation of Psychologists’ Associations and the International Association of Applied Psychology.[21] BPS Presidents and senior officers became trusted colleagues and personal friends. My motivation was to further Psychology as an applied scientific discipline and the BPS was also a helpful avenue for career advancement.

The current cabal of career managers conducts the Society’s business in an autocratic, tick-box manner that wastes resources and is spinning out of control. Large sums are invested in ill-founded projects such as the ‘Change Programme’ operating beyond the attentions of members.[22] Under the sleepy eye of the Charity Commission, the BPS continues its descent into a Kafkaesque calamity as a dilapidating lip-stick and powder puff phizog seeking purpose and meaning within a ruinous existential crisis. The dead hand of tick-box managerialism is anaesthetising and irreversible. Breathe a little longer, if you can, but in this author’s opinion, the Society is finished. In the remainder of this chapter, I explain why.

2. Failure to fulfil the first object of the Society

The first object of the Society[23] is: to promote the advancement and diffusion of a knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of Members of the Society by setting up a high standard of professional education and knowledge. One key way to implement the first object is to accredit academic programmes for awards of Psychology degrees within British universities. Such degrees require BPS approval to fulfil the conditions of the Graduate Basis of Chartered Status (GBC).[24] Graduate Basis for Chartered Membership (GBC) ensures that, before any student can start a professional training course, they have already studied psychology in sufficient breadth and depth to provide a sound basis for their postgraduate training. BPS accreditation of awards presumes a foundation of academic values that have evolved over centuries. Sadly, these values have been manifestly betrayed by the BPS, with nobody in the university system seeming to have noticed.

The primary academic value is freedom of speech.[25] Exercising freedom of speech requires institutions to enable and encourage open expression of thought, ideas and beliefs through discussion, criticism and debate. It also requires the institutions themselves to be open and transparent. If an institution hides or redacts or fails to openly display its decision making, the members are themselves powerless to even form opinions, never mind actually expressing them. The fitness of the BPS to operate as a learned society rests on its ability to demonstrate its adherence to academic ethics and values including freedom of expression.

In March 2021 the Society published a paper[26] outlining its current thinking. In processing this document, as any other, it is necessary to distinguish words and actions and judge the organisation’s authenticity by the latter. Unfortunately the actions of the Society’s officers and paid employees betrays a concerning lack of openness and transparency. Letters remain unanswered or receive cursory or cryptic responses. Postings on the Society’s website are deleted if judged to be too critical of the Society. Freedom of expression is routinely blocked by the Editor of The Psychologist. To give one example, when this author questioned the zenophobic conduct of the Editor of The Psychologist, my comments were deleted from the public record.[27] The Society’s CEO has failed to respond to an open letter published more than two years ago.[28] Such experiences of non-response, cancellation and deletion have been repeated multiple times with a variety of dissident members.

The Psychologist’s official guidance states: “In terms of ethical practice, The Psychologist will not publish material that is discriminatory, libellous, prejudiced or otherwise offensive, either by the nature of the content or by the manner of presentation.” Yet the monthly mouthpiece of the Society, The Psychologist, has broken this principle on numerous occasions. There is a notable betrayal of the code of ethics and academic values including freedom of expression within the offices and outlets of the British Psychological Society on frequent occasions. Its recent public actions show that the Society:

  • Lacks commitment to the pursuit of truth (e.g. the Memory and Law Task Force);
  • Fails in its responsibility to share knowledge (e.g. its partisanship over scientifically contentious issues of memory and gender dysphoria);
  • Cancels freedom of thought and expression (e.g. the deletion of criticism on the Society’s websites; partisanship on scientific issues including improperly evaluated therapies such as IAPT).
  • Fails to analyse evidence rigorously by reasoned argument to reach a conclusion (e.g. again the lack of discussion on memory, gender dysphoria the IAPT programme)
  • Is unwilling to listen to alternative views and judge them on their merits;
  • Neglects to consider how its conduct will be perceived by others (e.g. xenophobic public statements by the Editor of The Psychologist and blocking of the author’s criticism of same on Twitter).
  • Betrayal of the Society’s ethical code of conduct. The lack of ethics applies to senior BPS officers (e.g. alleged criminality of one or more officers in the BPS Leicester office, the illegitimate dismissal of the President-Elect, Professor Nigel MacLennan, and the publication of a libellous YouTube video about Nigel MacLennan). The betrayal of ethics also includes the failure to investigate alleged fraud by prominent members  (e.g. the late Professor Hans  J Eysenck). All of this evidence demonstrates that the Society’s fitness to be an accreditor of academic programmes can no longer be supported. 

3.    The British Psychological Society as institutionally racist   

“The visibility of race alongside the invisibility of racism is a dilemma all of us continue to deal with” (Sambaraju & McVittie, 2021).[29]  Invisible or not, British institutions are permeated by racism often evidenced as micro-aggressions rather than out-and-out plain nastiness. Multiple significant health differentials between ethnic groups within Britain are one of the consequences. [30]  Professional organisations like the BPS that are responsible for accrediting academic programmes and training must themselves be free of all forms of racism. Sadly, as a microcosm of British society, the BPS manifests in ways I have documented above all of the features of a racist organisation.  The only way the BPS could avoid this situation would be to adopt a policy of anti-racism to prevent racist incidents in its activities and publications, but no such action has even been taken. The scientific context is that biological ‘races’ do not exist and the term ‘race’ is an anachronistic  social construct. The term is placed here in single quote marks. In agreement with Richards (2012), there is no core of objective scientific knowledge about ‘race’ and  there have been, and can be, no enduring gains in scientific understanding about ‘race’. In spite of this, racism and racialism are potent determinants of social and scientific conduct and both have been prominent in BPS publications. All such publications based betray academic values and the Society’s Code of Ethics. 

The term ‘racism’ refers to any attitude or practice that is hostile and denigratory towards people defined as belonging to another ‘race’ with emotional or psychological involvement on the racist’s part. Racism and racialism within science extended into the 20th century including a significant number of prominent British psychologists who belonged to the eugenics movement. This aimed to improve the ‘quality’ of the human population using a variety of control measures such as attempting to influence the genetic ‘mixing’ of people that are alleged to be of higher/brighter and lower/duller quality e.g. sanctioning ‘mixed’ marriages, confining the ‘feeble-minded’ in institutions, using apartheid policies to separate ‘races’, and sterilization of people of low intelligence or of perceived poor ‘quality’. Sir Francis Galton  of University College London coined the term ‘eugenics’ and was the first president of the Eugenics Educational Society. From the perspective of the colonial British Empire, the eugenics mission was an emblem of ‘white supremacy’, the traces of which seep into the British Psychological Society to the present day. 

Before his death Galton wrote a book about a eugenic Utopia, called ‘Kantsaywhere’  where “a system of competitive examination for girls, as well as for youths, had been so developed as to embrace every important quality of mind and body”.  The results of this examination defined the status of the individual and the number of children they would be permitted to raise. Reproductive functions were to be regulated by an oligarchy selected by tests; social status was decided by four tests which together took only four hours” (Galton, n.d.). Galton’s fantasy was brought to fruition by several distinguished British psychologists who saw Galton as their mentor.  This train in thought has not yet been extinguished and a few recent studies help explain why.

Historically, indigenous, First Nation people have been classified as ‘primitive’ or ‘savage’ and they have been likened to animals or children. Saminaden, Loughnan and Haslam[31] examined these associations in contemporary consciousness in a subtle, implicit form. Consistent with colonial portrayals of indigenous people, research participants continued to associate traditional people with animal- and child-related stimuli more readily than people from contemporary, industrialized societies. Indigenous people also were ascribed fewer uniquely human attributes. The authors suggest vestiges of colonial ‘images of savages’ persist in contemporary western society as a cultural residue. Racial stereotypes from the colonial past are having a residual impact on psychologists’ practices and research publications.

In May 2020, a Minneapolis police officer, Derek Chauvin, murdered 46-year-old George Perry Floyd by kneeling on the victim’s neck for 9 minutes and 29 seconds in broad daylight in front of members of the public. A teenager Darnella Frazier made a video of this incident that went viral and triggered an unprecedented level of protest and huge support for the ‘Black Lives Matter’ movement.[32] The response by British psychologists was muted. The Society President, David Murphy (2020) published a statement[33] and The Psychologist collated members’ letters.[34] In my own letter, I wondered if the BPS is structurally racist. The evidence comes from two main sources: accounts by psychologists from ethnic minority backgrounds of racism they have encountered and the Society’s publications.

Several members wrote moving accounts of their struggles as psychologists from an ethnic minority. Bruno De Oliveira (2020) argued that “We must act to decolonise Psychology” stating that: “During my educational and academic life, I have struggled with the lack of diversity in psychology. To this date as a lecturer, I ask myself whether psychology is for me. Can I make it in my field? As I look around me, there are still a few Black, Asian, and minority ethnic (BAME) academics in senior positions. From the research topic to the participants, psychology is not a welcoming environment for minorities” [35] 

Dr Rosabel Ng, an Educational and Child Psychologist, offered her thoughts as a psychologist working with diverse communities. She suggests that such work involves “reading, listening and actively engaging in discussions with others, while adopting an explicitly self-aware, open minded and curious position throughout.” [36]

Shameema Yousuf (2020)[37], an HCPC Registered Practitioner Sport Psychologist, had written about the ‘perpetuation of unequal access’ in sport and sport psychology. The article sparked discussions with two White colleagues who argued that Yousuf’s experience did not suggest racism, which Yousuf perceived as a ‘microaggression’.[38]

Apparently, the majority of the BPS membership was dumb-struck by #BlackLivesMatter. British psychologists appeared unprepared and untrained to deal with ingrained racist concepts and practices instilled like ‘residues’ conditioned by our early experiences, training and textbooks. We tacitly know the meaning and the harm of our silence, which is to make matters worse, most likely providing deeper offence and confirmation that, as an organisation, the BPS is indeed systemically racist.

Our complicity as white people in holding the residues of colonial  society, offering political-correctness but lacking any authentic actions of solidarity with our BAME colleagues is nothing less than shameful. Unless and until the non-BAME membership of the Society fully and uncompromisingly implements a transformative anti-racist policy at all levels of practice, nothing will ever change. Tinkering with reports, committees and warm words from the President achieve nothing. The Society must retract all of its racist publications. The racist underbelly of the Society is revealed by the appearance of essentialist, racist works in its peer-reviewed journals. As the statues of slavers fall, BPS publications by racist psychologists like Charles Spearman and William McDougall should be retracted, as should any recent examples such as the publication by LSE academic Satoshi Kanazawa.[39] Given the complexity of contemporary society and the relative sophistication of the social sciences today compared to the 19th century, it is breath-takingly offensive that this scientific racist article can be peer-reviewed and published by a journal of the BPS, the British Journal of Health Psychology, in the 21st century.  What kind of signal does such a publication send out about the ethics and academic values of the BPS?

Next, I discuss one of the most sordid and disgusting articles ever to appear in print: J. Philippe Rushton’s 1990 paper on ‘race’ differences published in The Psychologist.[40] In spite of the furore created by this publication over 30 years ago, this article remains published on the website of the BPS.[41] Personally, I find it difficult to understand how a professional body can maintain its position as a non-racist organisation while having these overtly racist publications on its website. Can I really be the only BPS member seeking retraction of racist science from BPS journals? There is nothing covert about Rushton’s repugnant paper, which was given full approval by the editors of The Psychologist.  It  is one of the most blatant statements of undiluted racist science one could ever find in the 20th Century. To restore as much of the dwindling faith in the BPS among its minority BAME and anti-racist members as possible, Rushton’s article should be retracted with a full public apology by the the Society.

Glynis Breakwell and Graham Davey, Honorary Editors of The Psychologist, apologised and promised that in future: “all academic articles (and replies) appearing in The Psychologist will have been reviewed by at least two independent referees”.[42] However that promise has not been kept; to the best of this author’s knowledge, academic articles in The Psychologist are not peer reviewed.  In a derogation of duty, the BPS President at the time, Professor Peter Morris, forgave the unforgivable.[43] As if matters could not get any worse, Professor Hans J Eysenck[44] (who reappears later in this chapter) could not resist the opportunity to defend Rushton, and while doing so, the Pioneer Fund [45], and one of the most welcoming journals to racist science, his own journal Personality and Individual Differences (October, 1990).

So here we have it: an undivided front of the leading British psychologists joining arms in defence of a sordid, blatantly racist article in The Psychologist. Apparently the entire BPS, its Presidents, Trustees, senior officers, committees and student members see nothing wrong here that requires correction. Inaction is to be complicit: “He who accepts evil without protesting against it is really cooperating with it.” (Martin Luther King). A golden opportunity exists for the BPS to ‘get its house in order’ by retracting all racist science articles from its journals. It’s never too late to do the right thing: to say sorry, retract, and move on.

4. The Society’s failure to investigate probity in research

In my capacity as Editor of the Journal of Health Psychology, an independent, non-BPS journal, and a BPS Fellow, I wrote an Open letter to the Chief Executive of the BPS about the malpractice of a major figure within British Psychology, the late Professor H J Eysenck:

Dear Mr Bajwa,

I am writing about a serious matter concerning the research integrity of a person who one can presume was a member of the British Psychological Society. In the interests of openness and transparency, this is an Open Letter. If left unresolved this is a matter that can be expected to produce potential harm to patients, to biomedicine and science, to your institution, to its members and students. Although Professor Hans Eysenck died in 1997, the issue of alleged falsified science committed by the late Professor remains current to the present day.

To give a few examples, the 2017 edition of Eysenck’s autobiography published by Springer, in relation to the causal link between smoking and cancer, states, ‘On a purely statistical basis the causal efficacy of smoking – if this can be deduced at all from a simple correlation – is very much less than that of psychosocial factors; about one-sixth in fact’ (Eysenck, 2017Rebel with a Cause. Kindle Locations 3759–3761). Is the claim that psychosocial factors are six times more important than smoking something that the British Psychological Society is content to endorse or is it a claim that the BPS would like to see corrected? Or consider where Eysenck describes the effectiveness of psychotherapy in preventing cancer: ‘The total number of deaths in the control group was 83 per cent, in the placebo group 81 per cent, and in the therapy group 32 per cent, again demonstrating the efficacy of the method in preventing death from cancer and coronary heart disease’ (Eysenck, 2017, Kindle Location 3804–3806). Or the section where Eysenck claims that ‘there is some evidence that behaviour therapy may be useful in prolonging life, as well as in preventing disease’ (Eysenck, 2017, Kindle Locations 3821–3822).

I hope that the Society will add its voice to those who are requesting that the relevant publishers and journals should correct or retract Eysenck’s publications wherever they can be shown to contain questionable data-sets or claims that are known to be false.

The case is fully documented in Dr. Anthony Pelosi’s peer-reviewed article: ‘Personality and fatal diseases: revisiting a scientific scandal’. As the Editor responsible for the peer review and publication of Dr. Pelosi’s article, I have every confidence that Dr. Pelosi’s evidence and conclusions are reliable and true. In light of the policies and statutes of the British Psychological Society concerning research integrity I bring this case to your attention for investigation. A full and thorough investigation would be good for Psychology, for the research integrity of the BPS as a professional society and for the welfare of patients and the general public.

I look forward to your response.

Kind regards, David F Marks BSc PhD CPsychol FBPsS
Editor, Journal of Health Psychology

In three years I had received no response.  This indicates how seriously the Society regarded the issue of fraud carried out by British Psychology’s most famous Professor. In November 2021 I re-sent the letter to Sarb Bajwa seeking an explanation and an apology.  Dr Rachel Scudamore, Head of Quality Assurance and Standards, informed me that: “We accept that a failure to respond is discourteous and that it would leave you in a position of not knowing what action has been taken. I can only apologise on behalf of the Society for this error on our part.”

On 9th November, 2021, Roger Paxton, Chair of the BPS Ethics Committee, responded as follows:

The BPS Ethics Committee shares the concerns that you, Anthony Pelosi and others have expressed about some of Hans Eysenck’s publications. At its meeting in June this year, the Committee established a working group to consider these and other apparent instances of historical unethical conduct, including the work of Francis Galton and others on eugenics. The work of the group is underway and is drawing on a range of information sources, including the recent investigations by KCL and UCL into Eysenck and Galton respectively. The group is also considering the integrity of research by Eysenck reported in journals published by the BPS  The group regrets that the BPS did not respond more strongly when Anthony Pelosi first raised concerns about some of Eysenck’s research. 

The aim is that this project should comment publicly on these historical matters, refer to the Society’s current ethical standards and procedures, and offer recommendations about the teaching of these topics. We hope that the outputs from the project will be broad and emphatic, with the BPS taking a clear ethical stance, and, if appropriate, expressing regret that the Society, and the discipline of psychology, have at times been on the wrong side of history.

Before signing off, Roger Paxton stated that he would keep me updated on the outputs of this working group. Yet, in the December 2021 issue of The Psychologist, a half-page notice called for statements of interest for a new Chair of the Ethics Committee with immediate effect.

I wrote to Roger Paxton asking for more details, but he did not respond. Apparently, the offer to keep me updated was not something he was able to implement.


Over many decades the British Psychological Society has betrayed its core values of equity, diversity and inclusion. In abandoning its core values, the Society has become a morally bankrupt and fraudulent enterprise.  Its current parlous state means that the Society is failing to serve members, patients and the public well. Its failures have ignored evidence of false  knowledge claims and, at times, exposed the public to harm by turning a ‘blind eye’ to alleged fraud and malpractice. The BPS displays all of the characteristics of a morally bankrupt and fraudulent enterprise.



[1] ‘Fraudulent’ means deceiving others, not telling the truth, acting illegally: https://dictionary.cambridge.org/dictionary/english/fraudulent

[2] I do not include here alleged incidents of criminal fraud, arson and malfeasance, which are discussed in other chapters.

[3] In the British Journal of Psychology, Charles Myers wrote: “Advantage has also been taken of Nature’s own variation such conditions, as in  the clinical and  laboratory study of individual mental differences, normal and abnormal, of excess or defect, including those produced by disorder, disease or injury, racial mental differences, e.g. the mental differences between the higher and lower races…”  Myers, C. S. (1920). Psychology and industry. British Journal of Psychology10(2), 177. Myers’ contributions are memorialised by ‘The C.S. Myers Lecture of the British Psychological Society’.

[4] In the British Journal of Psychology, Charles Spearman advocated the use of intelligence testing to select people who would be given the right to have offspring:…an accurate measurement of everyone’s intelligence would seem to herald the feasibility of selecting the better endowed persons for admission into citizenship—and even for the right of having offspring (Spearman, 1927).

[5] Almost a century after Spearman’s eugenicist publications, the BPS retired the Spearman Medal which, from 1965 to 2020, had been willingly accepted by 47 of British Psychology’s brightest and whitest: https://thepsychologist.bps.org.uk/volumethe-34/april-2021/spearman-medal-retired

[6] Sir Cyril Burt (1950) discussed the alleged reduction in average intelligence that had been appearing in the literature as an empirical finding: “One  of the  earliest  results was the discovery  that the birth rate among families from which the duller children were drawn was about twice as high as  among those supplying the brighter junior county scholars.  What seemed most significant of all was the fact that, even within the same social and economic class, fully significant correlations were found. From the correlations observed (about 0.20) it was calculated that, if no counteracting factors were operative, the intelligence quotient would drop at the rate of about 11/2 points per generation; and (what would be far easier to verify) “in little over fifty years the number of pupils of scholarship ability would be approximately halved, and the number of feebleminded almost doubled.”  Curiously, this is exactly the opposite to the facts which show sustained increases in IQ scores over the last century (Flynn, J., 1984).

[7] The article by J. Philippe Rushton, president of the Pioneer Fund, was published by The Psychologist: Bulletin of the British Psychological Society in 1990. One of the most blatant statements of undiluted racist science one can find in the 20th Century, this article remains on the BPS website to the present day. Rushton justified his racist science in the following terms: “…racial group differences in intelligence are to be observed worldwide, in Africa and Asia, as well as in Europe and North America and that they are paralleled by more than 50 other variables including brain size, maturation rate, personality and temperament, sexuality, and social organisation”. Rushton, J. P. (1990): Race Differences, r/K theory, and a a Reply to Flynn,” The Psychologist: Bulletin of the British Psychological Society, 3, 5 (May): 195-98. In July 1990, the magazine’s Editors, Professors Glynis Breakwell and Graham Davey apologised but remained in post. The BPS President, Professor Peter Morris, wrote in support of the publication, as did Professor Hans J Eysenck. The Society membership witnessed an extraordinary closing of the ranks in the name of supporting the most egregious form of scientific racism.

[8] Kanazawa, S. (2006). Mind the gap … in intelligence: Re-examining the relationship between inequality and health. British Journal of Health Psychology, 11, 623–642. There was considerable embarrassment at LSE and flaws in Kanazawa’s analysis were published by this author who provided a very different conclusion about the data: Marks, D F (2007) Literacy not intelligence moderates the relationships between economic development, income inequality, and health. British Journal of Health Psychology, 12(2), 179-184.

[9] Prof Kanazawa stated in Psychology Today that black women are objectively less attractive than women of other races. LSE subsequently prohibited him from publishing in non-peer-reviewed outlets for 12 months.

[10] The recording of the webinar is available at: https://youtu.be/mIxstDoqbq0 (see 1:29:37).

[11] Delegates at the Group of Trainers in Clinical Psychology (GTiCP) forum viewed a 12-minute dramatisation of the transatlantic slave trade in which one scene could be interpreted as a slave auction. A clinical psychologist Chris Jones later wrote: “Let’s not equivocate: The re-enactment of the slave auction at #GTiCP2019 was a shameful day in the history of British Clinical Psychology”. 


Subsequently asurvey of 352 clinical psychology trainees and a twitter site @AntiRacismDClin were organised: https://www.bps.org.uk/sites/www.bps.org.uk/files/Member%20Networks/Divisions/DCP/Racism%2C%20power%20and%20privilege%20in%20psychology.pdf

[12] Dr Kimberly Sham Ku (2020) describes her experience in an article in The Psychologist, A culture of silence and denial: “Disappointment. That was the emotion when I came face-to-face with the words ‘keep BME out of services’, boldly and shamelessly graffitied on my poster. The poster considered a project to support African and Caribbean men in forensic services who are transitioning back into the community, a population often facing the double challenge of cultural stigma and a lack of community support. Hostility towards minorities in all forms, be it religious, gender and the like, is a centuries old problem that we are tackling daily. The disappointment came from the ‘who’ and the ‘where’ – these words were written by a fellow Psychologist at the British Psychological Society’s Division of Clinical Psychology (DCP) annual conference held in Solihull. This was a conference with the overarching theme of social inequality and racism.” https://thepsychologist.bps.org.uk/volume-33/april-2020/culture-silence-and-denia

[13]  https://www.theguardian.com/uk/1999/jun/04/sarahboseley1

[14] Anthony J Pelosi (2018) Personality and fatal diseases: Revisiting a scientific scandal. Journal of Health Psychology, 24, 4: 421-439. David F Marks (2018).The Hans Eysenck affair: Time to correct the scientific record. Journal of Health Psychology, 24, 4: 409-420. David F MarksRoderick D Buchanan (2019). King’s College London’s enquiry into Hans J Eysenck’s ‘Unsafe’ publications must be properly completed. Journal of Health Psychology, 25, 1: 3-6. Russell CraigAnthony PelosiDennis Tourish (2021). Research misconduct complaints and institutional logics: The case of Hans Eysenck and the British Psychological Society. Journal of Health Psychology, 26, 2: 296-311. 


[15] The Complaints Procedure is dysfunctional and under investigation by the Charity Commission. https://atomic-temporary-150481510.wpcomstaging.com/2021/08/13/the-silly-season-psychologists-at-the-british-psychological-society-not-subject-to-the-societys-ethics-code/

[16] The default position for a BPS member historically was whiteness.

[17]  “He who accepts evil without protesting against it is really cooperating with it.(Martin Luther King).

[18] Marks (2018). A General Theory of Behaviour

[19] Marks & Yardley

[20] Marks, Murray and Estacio (2020).

[21] Mixing with the ‘great and the good’ of international psychology, I have the photos to prove it.  

[22] According to the spokesperson for the Society:

[23] Specified by its Royal Charter.

[24] Or ‘GBR’ as it was previously known.

[25] Flynn (2019) describes freedom of speech thus: “the great goods of humanity include human autonomy and the liberation of the human mind. It argues that this is possible, or at least likely, only under certain conditions, one of which is that free speech prevails. It also assumes that the university has a peculiar mission: the good society has designated it as an institution that, above all, not only seeks truth but also graduates people whose minds are prepared to seek the truth. I am not sure that there are many good universities today. Rather than feeling free to debate, professors and students walk about, and indeed, even off of campus are apprehensive of making slips of the tongue or behavior and being sent to mind – cleansing sensitivity training, harassed by mobs of their angry fellows, pilloried on social media, or brought before nebulous administrative tribunals with the power to punish them with consequences up to expulsion or termination of employment.” (Flynn, 2019, A Book Too Dangerous To Publish, pp. 14-15).

[26] “The Psychologist Policies and Protocols” (PPP) published by ‘The Psychologist and Digest Editorial Advisory Committee’ (PDEAC)

[27] The author was blcked from the twitter account of The Psychologist and my comments on the online version of The Psychologist were deleted.

[28] This letter is discussed later in the chapter.

[29] Sambaraju, R., & McVittie, C. (2021). Mobilizing race and racism: Visible race and invisible racism. British Journal of Social Psychology.

[30] David R. WilliamsYan YuJames S. JacksonNorman B. Anderson (1997). Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination. Journal of Health Psychology, 2 (3): 335-351.

[31] Saminaden, A., Loughnan, S., & Haslam, N. (2010). Afterimages of savages: Implicit associations between primitives, animals and children. British Journal of Social Psychology49(1), 91-105.

[32] BlackLivesMatter (2020). Black Lives Matter – About. Retrieved from: https://blacklivesmatter.com/what-defunding-the-police-really-means/

[33] https://www.bps.org.uk/news-and-policy/bps-statement-racial-injustice.

[34] https://thepsychologist.bps.org.uk/volume-33/september-2020/standing-against-racism.

[35] De Oliveira notedthe negative impact that psychological theories and practices have had on minority groups, which has been “further exacerbated by the failure of the bodies that oversee the discipline to recognise the key, distinctive cultural and social determinants that contribute to forming the subject. As the BPS oversees the university’s course for validation, the BPS could also ask for evidence as for what are psychology departments across the country doing to decolonise their curriculum. By decolonising the curriculum, I mean the fundamental reconsideration of who is teaching, what the subject matter is and how it is being taught. To illustrate, a report from the University and College Union stated that in the 2016-17 academic year 25 black women were recorded as working as professors compared to 14,000 white men.” 

[36] Dr Ng used a family resilience perspective to explore the views, stories and experiences of Black and Minority Ethnic parents raising a child with autism. She commented that: “The research revealed that in order to go beyond a tokenistic glance at race and culture, reflection needs be applied at different levels. This is needed so that we can recognise and manage underlying power imbalances that might persist. We would need to recognise the impact race and culture has on our own decision making and responses. At a less conspicuous level, we need to be introspective, being aware of cultural assumptions and the nuances that exist, recognising our own biases and blind spots and therefore explicitly locating our position in relation to others.” (Ng, 2020). 

[37] Yousuf, S. (2020). ‘It is a system that perpetuates unequal access’. https://thepsychologist.bps.org.uk/it-system-perpetuates-unequal-access

[38] It is valuable to quote Yousuf more fully as follows: “It is also problematic that the people working with diverse athlete clientele are predominantly homogenous White. A recent conversation with a trainee sport psychologist in BPS Stage 2, highlighted that in group supervision, the impact of recent Black Lives Matter (BLM) events had not been discussed nor had any aspect of ‘Race’ and ethnicity ever been explored…I am curious why it is our British colleagues – except for a few people – have not taken a stance just as they do for male mental health, cancer, LGBTQ + and women in sport, all of which are necessary. How many colleagues have explored the connection between mental health and racism?. My identity is intersectional, my heritage raised in Rhodesia during the Apartheid (segregation) era. As a British citizen my entire life of nearly 50 years, I am still judged and socialised by the colour of my skin (along with my name and gender), by the very British ideology that forcibly separated during Apartheid. In the UK, the words ‘you Paki, go back to where you are from’, have been hurled at me despite not being Pakistani. This ideology still exists institutionally in less oppressive, but more insidious forms of racism. 

As psychologists we would rightly stand united against sexism and sexual abuse, discrimination of LGBTQ+, ageism, and disability. So let’s stand together against all forms of racism and racial abuse. As a Boston University alumna, I will end with the words of Ibram Kendi, who leads an anti-racism research centre at the university: ‘it is not enough to say you are not racist, you need to be anti-racist!’.

[39] Kanazawa, S. (2006). Mind the gap … in intelligence: Re-examining the relationship between inequality and health. British Journal of Health Psychology, 11, 623–642.

[40] J. Philippe Rushton (1990): “‘Race’ Differences, r/K theory, and a Reply to Flynn,” The Psychologist: Bulletin of the British Psychological Society, Vol. 3, 5 (May): 195-98.

[41] https://thepsychologist.bps.org.uk/archive?page=30

[42] “The article by Rushton, for which the Honorary Editors took pre-publication responsibility, was not reviewed by independent referees, but was published as a reply to the earlier critical article by Flynn…Although the majority of the material in the Rushton article had been published previously in journals elsewhere, the Honorary Editors admit that it was a serious error that the article was not submitted for independent review. Among other things, the process would have subjected the table in the paper to greater critical scrutiny. The Honorary Editors agree that the scientific content of the table is below the standard which is required by The Psychologist and regret its publication. Publication of an article in The Psychologist does not constitute an endorsement by the Society of the views expressed by the author, and this disclaimer appears in every issue of The Psychologist. However, both the Honorary Editors and the Psychologist Editorial Committee have acted on the concerns expressed by members of the Society over this issue (including some members of Council), and have introduced an explicit policy for dealing with academic articles published in The Psychologist. In the future, all academic articles (and replies) appearing in The Psychologist will have been reviewed by at least two independent referees, and any articles that are signalled by reviewers as likely to cause offence will be published only with the consent of the Managing Editor and the Psychologist Editorial Committee. The Honorary Editors deeply regret any offence that this series of articles may have caused to some members. We hope that having made editorial procedures explicit, The Psychologist can continue to provide members with a forum for the discussion of controversial issues in contemporary psychology.”

[43] “As President, on behalf of Council, I welcome the frank and positive response by the Honorary Editors published above. I wish to express my confidence in them, the Editorial Committee and the new procedures that they have introduced.”

[44] In 1990 Hans J Eysenck was Professor Emeritus of Psychology, University of London, Editor-in-Chief of Personality and Individual Differences.

[45] The Pioneer Fund is a major funder of racist science from which Hans J Eysenck and J Philippe Rushton both obtained research grants.


The Paradoxical Nature of Coincidence

I am no mystic. By nature, I believe that I am inclined towards scepticism. Occasionally, however, events have occurred that appear to defy reason or scientific explanation. Coincidence is a good example. The traditional scientific explanation holds that coincidences are inevitable within the laws of chance. An alternative explanation entertains the possibility of an as-yet undefined, ‘paranormal’ mechanism existing beyond known science.  

I describe here a coincidence with statistical odds of one quintillion to one (10-18). This example poses a dilemma because there is no logical way of confirming or disconfirming either of the two theories. The usual procedures for testing statistical significance cannot be applied. Whether this particular coincidence is a chance event or evidence of the paranormal must remain a subjective judgement.

Two Opposing Theories

My intention is to explore two contrasting theories of coincidences, which I refer to as the ‘normal’ or ‘N Theory’ account and the ‘paranormal’ or ‘P Theory’ account.  N Theory is represented by R.A. Fisher who stated:

. . . for the ‘one chance in a million’ will undoubtedly occur, with no less and no more than its appropriate frequency, however surprised we may be that it should occur to us.

Fisher, 1937, p. 16.

The P Theory is represented by Carl Gustav Jung who stated:

Synchronicity – ‘a certain curious principle… [which] takes the coincidence of events in space and time as meaning something more than mere chance…’

Jung, 1951.

These two main lines of thought about coincidences are: 1) the statistical theory that coincidences are inevitable by the normal operation of the laws of chance (N Theory),  and 2) the paranormal theory that coincidences are a special category of experience based on an ‘acausal’ process of synchronicity (P Theory). It can be said from the outset that P Theory and N Theory are mutually exclusive. 

In The Roots of Coincidence, Koestler (1972) discusses the paranormal speculations of scientists, especially those of the physicist Wolfgang Pauli, biologist Paul Kammerer, and psychoanalyst Carl Jung. Koestler developed the suspicion that Darwin’s theory of evolution must be wrong and conjectured, following Hamlet, that there are more things under the stars than are dreamt in our philosophies. The question is, what are those things?

Koestler made no secret of his acceptance of paranormal interpretations coincidences. Koestler’s thinking about the roots of coincidence can be summarised by the assumption that coincidences do not arise by chance from any normal progression of natural events. Koestler liked to collect coincidences that he or his contacts encountered, automatically assuming that something paranormal had occurred. This fallacy is made by almost everybody who attributes a paranormal interpretation to a coincidence.

It is one consequence of probability theory that an event that is very unlikely in the short run becomes inevitable somewhere in the long run. To explore how this happens, imagine that we flip five coins at once. The probability of obtaining five heads is 1/ 32, or .03125.  If we repeatedly flip the five coins ten different times, then the probability of obtaining five heads somewhere in the ten tests is about .27.  In 100 coin flips, the probability of five heads rises to .96, almost a certainty.  However, if we stop flipping the coins anywhere in these 100 tests and ask, what is the  probability of obtaining five heads on the very next trial, we are back at the starting probability of 0.03125 because we have switched from a long-run question to a short-run question.

The illusion of the short run occurs because human memory and attention are limited commodities. In “The magical number seven, plus or minus two”, George A Miller (1956) begins:

My problem is that I have been persecuted by an integer. For seven years this number has followed me around, has intruded in my most private data, and has assaulted me from the pages of our most public journals. This number assumes a variety of disguises, being sometimes a little larger and sometimes a little smaller than usual, but never changing so much as to be unrecognizable. The persistence with which this number plagues me is far more than a random accident. There is, to quote a famous senator, a design behind it, some pattern governing its appearances. Either there really is something unusual about the number or else I am suffering from delusions of persecution.

Miller, 1956, p. 81.

The essential psychological point about Miller’s persistent integer 7 (+/- 2) is that it represents the number of items, thoughts or events one can readily recall in one’s short term memory of the stream of one’s consciousness. It is as if we are living in a resetting ‘bubble’ consisting, at any one moment, of a short run of only 7(+/- 2) things.  When we are bobbing along in our bubbles attending to everyday wants and needs, everything goes swimmingly by, and, at each successive moment, we are content with what we are focusing on.  When, on rare occasion, we come across a peculiar, anomalistic occurrence, and because we still can only perceive the limited contents of the bubble, we conclude that something of true moment has occurred. What we cannot see within our bubble of 7 +/- 2 is the long run of events accumulating over our entire lifetime. If we could see all of the astronomically long sequence of events in one go, we would more easily perceive that anomalistic synchronies or coincidences inevitably must happen.

This statistical perspective leads to the ‘Principle of the Long Run’ (PLR) which maintains that, in a long run of events, coincidences are inevitable.[1]  The PLR holds that coincidences are normal occurrences within any long series of events, hence the name, ‘Normal’ or ‘N Theory’. The principle is  easiest to understand in simple coin, dice or card situation where all the choices are fixed in advance and well defined. It is much less obvious in the more chaotic and complex world of everyday experience where so many different kinds of things are happening all of the time to every single living being. It is possible to show the application of the PLR  to coincidences with a simple thought experiment (Marks and Kammann, 1980; Marks, 2000).  At the end of an ordinary day,  let us assume that it would be possible for a person to recall 100 distinct events.[2] A coincidence requires a match  between one event A and another event B and to calculate the probabilities involved we need to know the total number of PAIRS of events available within a series of 100 (n) single events. This is calculated by the formula:

N x N-1 / 2

From this formula we arrive at a total of 4,950 pairs of events for  a single person in a single day. We tend to remember coincidences for years to come, so that a person can remember all of the important coincidences over the past 10 years, which is approximately 3650 days). [3] Let us assume further that, throughout his/her lifetime, a person has access to 1000 people consisting of family, friends, acquaintances, neighbours, colleagues, etc. This means that there would be a total of 4,950 x 3,650 x 1000 or 18,067,500,000 pairs of events.  That a coincidence collector such as Koestler could find 40 striking coincidences out of 18 billion pairs of events is not so surprising and no reason to invoke P Theory. On the contrary, a good sample of coincidences is inevitable in any population of 18 billion pairs of events.[4]

Of course, when each coincidence individually occurs in each person’s short-run bubble, it seems exceedingly odd. Our memory is not up to the task of paying attention to the entire collection of multiple billions of non-synchronous, non-coincidences. These ‘non-events’ are not perceived as paired in any way compared to the matches that might occur between the names of race horses and Aunt Sally’s pet dog or thoughts about people who then mysteriously telephone a few minutes later  –  these all  make equally striking  anomalous encounters.  We can call this the Principle of Equivalent Coincidences; any coincidence is as good as any other. It is not the probability of any particular coincidence that matters, but the probability of any coincidence over the long run, which approaches 1.0. This, then, is the first root of coincidence, missed by Koestler: the inevitability that, sooner or later over the long run, a thought will match an event purely by chance. Nothing paranormal is happening, just the playing out of chance. There are literally billions of possible combinations of thoughts and events over one’s lifetime and some are bound to produce synchronicities.

Another root of coincidence is the ‘unseen’ or ‘hidden’ cause. A variety of unseen causes can interfere with our interpretations of anomalistic phenomena both as individual perceivers and as scientific investigators. Examples of unseen causes are: sensory cues, non-randomness, deception, tricks and pranks, expectancy, confirmation bias, subjective validation, population stereotypes, hidden knowledge and, finally, feelings (Marks, 2020). This set of factors are always a possibility but, for the present purposes, it will be set to one side. It must be assumed that the possibility of hidden causes is an unwanted nuisance factor that has to be eliminated before the main scientific task of choosing between N Theory and P Theory.

Carl Gustav Jung’s (1969) synchronicity theory focuses on the meaningfulness in the relationship between the two coinciding events, A and B.  It is the striking significance of meaning that promotes the cause of paranormality, especially precognition.  Jung viewed synchronicity as an “Acausal Connecting Principle”, which is “informative, emotionally charged, and transforming the observer’s beliefs or point of view.”  Following a significant anomalous experience, a person tends to ruminate about the event, talk about it, and they cannot let the matter rest until they have worked out a sensible explanation.  Synchronicity between inner thoughts, dreams or images and external events is innately engaging. But here comes the paradox.

The Paradox of Coincidence

According to the PLR, a coincidence is always deemed to be a chance event, no matter how long the odds. Consider another thought experiment: what if paranormal, or P coincidences exist, then they would be mixed in with the normal N coincidences and we would have no way of distinguishing the P type from the N type. By assuming that all coincidences are of type N,  Science is ruling out of existence the very phenomenon that it should be attempting to explain: the possibility that one group of coincidences is caused by an, as yet, undefined non-chance process, process P.

This N Theory assumption that all coincidences are created by chance means that the conventional criterion for evaluating the statistical significance of an observation does not work for coincidences. Null hypothesis significance testing (NHST) could not be applied because we would have no way of knowing the distribution of the population of type P events, e.g. the mean and standard deviation.  The standard criterion for rejecting a null hypothesis H0 is p<.05.  For coincidences, however, this probability can be as low as p<.000000000001 (10-12) or even smaller and the occurrence is accepted as falling within chance levels. 

This double standard in evaluating the statistical significance of coincidences is rather odd and interesting: the more improbable a coincidence, the more it is allowed to be said that it is consistent with the null hypothesis, that the event was caused purely by chance. To avoid miscounting paranormal events as chance events, and thereby defining them out of existence, it is necessary to hypothesise two populations of coincidental events, those due purely to chance, and those that have a putative paranormal source.   

How can we escape this paradox? Imagine a coincidence with an odds of 10 to the minus 12. This is one chance in a million million.  Consider the  possibility that there is an alternative to the normal, null hypothesis, which we can call the ‘paranormal hypothesis’ which assumes coincidences can also have paranormal origin. According to this hypothetical framework, a cross-over point with a Bayes Factor of 1.0 occurs will occur somewhere along the horizontal axis (Figure 1). Let us assume purely for the sake of discussion that the cross-over point occurs with an odds value of 10-12. The hypothesised existence of a separate population of paranormal events places ‘N Theory’ and P Theory on an equal footing and avoids a double standard in hypothesis testing. Of course, it is absolutely impossible to say if this theory correct as, at present, it remains pure speculation.[5]

H0: The null hypothesis – what occurred was purely chance.

H1: The paranormal hypothesis – what occurred was too improbable to be caused by chance and must have a paranormal explanation. 

With this background theoretical analysis in mind, I turn to a consider a specific coincidence experienced by the author. For convenience,  I will refer to as the “Chiswick Coincidence’.  I analyse its structure, meaning, the odds of its occurrence, and possible explanations. A coincidence like the one to be described is both puzzling and remarkable, a contiguity of events that appears to have no causal connecting principle between one another. A coincidence that seems to go way beyond the laws of chance can elicit a strong sense of the paranormal. Although one must never rush to make conclusions, case studies like this provide the opportunity to discover personal meanings and the underlying psychodynamics of the experience. I analyse here the Chiswick Coincidence for the light it may shed on the peculiarities of anomalistic experience.[6] 

The Chiswick Coincidence

23rd August, 2018: At 35,000 feet, on the midday flight from Marseille to Heathrow, I am thinking how to spend the afternoon. Unable to go straight home because an estate agent had arranged to show my flat to a potential tenant, how would I fill this time?  I decide to go for lunch at one of my local haunts on the Thames bank, the City Barge. Set aside for a moment the fact that the estate agent who had arranged the viewing was Chesterton’s, a family firm with connections to the writer GK Chesterton (1874 – 1936),  known as ‘the prince of paradox’.  A few seconds after I made the  decision to go for a pub lunch ‘on the Chiswick bank of the river’, I open my kindle and make a fairly random decision to continue reading ‘The Man Who Was Thursday, a Nightmare by Gilbert K Chesterton (GKC). I flip over the page to see in black and white a description of that very place which, moments previously, I had decided to visit, viz:

“”I think,” said Gregory, with placid irrelevancy, “that we will call a cab.” He gave two long whistles, and a hansom came rattling down the road. The two got into it in silence. Gregory gave through the trap the address of an obscure public-house on the Chiswick bank of the river. The cab whisked itself away again, and in it these two fantastics quitted their fantastic town.”

‘The Man Who Was Thursday, a Nightmare by Gilbert K Chesterton

The correspondence between the free and voluntary thought of going to the pub on the Chiswick side of the river and Gregory’s choice to do the identical thing is particularly striking. This coincidence, like others that I, or close family members, have experienced is multi-layered. I discuss here each of these 7 layers.

Seven Layers of Synchronicity

First layer

The ‘Chiswick Coincidence’ consisted of two elements:

Element 1: Because an agent, Chesterton’s, would be showing my flat to a potential tenant, I decided to go to the City Barge for lunch.

A few seconds later:

Element 2:  Reading the line ‘an obscure public-house on the Chiswick bank of the river’ from a novel by G K Chesterton on my kindle.

Thus, the first layer of coincidence is the fact that the estate agent and the author GKC are members of the same family.

Second layer

The second layer is the fact that the decision to go to the Chiswick riverside pub was followed only seconds later by reading a piece of text referring to a ‘public-house on the Chiswick bank of the river’. My immediate reaction being “Wow!”, “Whoa!” “WTX!” in no particular order. I knew how much text is on my kindle and, seeing these particular lines immediately I began reading, was a complete surprise.

Historical records indicate that The City Barge has existed since 1484 when it was known as ‘The Navigator’s Arms’. Its first appearance in the licensing lists was in 1787 when it was the ‘City Navigation Barge’. As the ‘City Barge’ it was refurbished in 2014.  Historical sources point to at least 5 or 6 pubs on the Chiswick side of the river at the time of GKC’s story. The pub mentioned by GKC could have been any or none of these, perhaps only a figment of GKC’s fluid imagination. Two clues make the City Barge a good candidate however. Photographs of the City Barge from 1910, two years after the publication of TMWWTAN, show Thames barges actually tied up directly outside the City Barge. Also, when the two characters in GKC’s story, Gregory and Syme, leave the pub, they go out by the door and “close to the opening lay a dark dwarfish steam-launch”. This description fits the immediate riverside proximity of The City Barge perfectly.[7]

A kindle is a portable library. Mine is 1.33 GB with multiple books, both fiction and non-fiction, the complete works of Shakespeare, Chaucer, Dickens, Joyce, Austen, Pepys, Swift and Zola.  On the date in question, there were 498 works containing 146,817 pages [8]. With 350 words per page, there were around 50 million words on my kindle.  The odds of seeing the words “public-house on the Chiswick bank” on the first page I opened is around one-in-10 million (10-7).

Third layer

I checked my diary for the days immediately following the date of this event. My diary says that I would be meeting my publisher Robert Patterson to discuss a new book on the paranormal (Marks, 2020).  Was I perhaps on the lookout for anomalistic experience at this time?  If so, I had been presented with a brilliant example.

Fourth layer

The idea of writing the book meant that I would soon be seeking new material.  Although I was at the early preparatory stages when this incident happened, I can imagine no more suitable an illustration for a book on anomalous experience than this very incident. Reflecting back on this period, I see how helpful the coincidence was in resetting my paranormal ‘Belief Barometer’. 

Fifth layer

Enter – or, I should say, re-enter – Martin Gardner.  Martin had contributed Forewords to two editions of my previous book on ‘psi’ (Marks and Kammann, 1980; Marks, 2000).[9]  Martin died in 2010 leaving a huge legacy of 100s of literary and scholarly works with a readership of millions. I have copies of many of Martin’s books including Fads and Fallacies in the Name of Science (Dover, 1957), Mathematics, Magic and Mystery (Dover, 1956), The Annotated Alice. The Definitive Edition. Lewis Carroll (W W Norton, 2000).

In researching TMWWTAN, however,  I made the new (to me) discovery that Martin had written a Special Annotated Edition of TMWWTAN (Gardner and Chesterton, Ignatius Press, 1999). Goose bump territory! How very strange. Discovering this Special Annotated Edition seemed enigmatic and enthralling in equal measure. The three-way connection between Gilbert K Chesterton, Martin Gardner and this author, however, does not end here.

Sixth layer

As Chesterton noted, “hardly anybody who looked at the title ever seems to have looked at the sub-title; which was “A Nightmare,” and the answer to a good many critical questions” (Autobiography, Kindle Locations 1301-1303). Two key themes of TMWWTAN are free will and evil.  The Chiswick Coincidence triggered a change in my stance from disbelieving sceptic to neutral inquirer.  My eyes were opened to the genius of Gilbert K Chesterton, certainly a special writer and TMWWTAN is no ordinary book.It has been rated as one of the greatest works of 20th century literature. To quote from the American Chesterton Society website (https://www.chesterton.org/who-is-this-guy/):

“Gilbert Keith Chesterton (1874-1936) cannot be summed up in one sentence. Nor in one paragraph…But rather than waiting to separate the goats from the sheep, let’s just come right out and say it: G.K. Chesterton was the best writer of the 20th century…The reason he was the greatest writer of the 20th century was because he was also the greatest thinker of the 20th century… What was it he defended? He defended “the common man” and common sense. He defended the poor. He defended the family. He defended beauty. And he defended Christianity and the Catholic Faith.”

Reading that GFK had defended the “common man”, common sense and the poor, was pleasing because these are, what I like to believe, my own values exactly.  Clearly, Gilbert Chesterton made no secret of the fact that he believed in God, prayer and the afterlife, beliefs that I do not share. 

Seventh layer

Like GKC, and he also made no secret of it, Martin Gardner believed in God, prayer and the afterlife. In his autobiography, Martin stated he loved reading “anything by G. K. because of his never-ceasing emotions of wonder and gratitude to God, not only for such complicated things as himself, his wife, and the universe, but for such “tremendous trifles” (as he once called them) as rain, sunlight, flowers, trees, colours, stars, even stones that “shine along the road / That are and cannot be,” (Undiluted Hocus-Pocus.The Autobiography of Martin Gardner, 2013, p. 205).  In digging a little deeper into the two men’s biographies,I discovered thatGKC, together with the Basque philosopher and poet Miguel de Unamuno, were Martin’s two mentors. Martin’s autobiography mentions God no less than 128 times.[10] According to Martin Gardner (2013):

“Just as knowing how a magic trick is done spoils all its wonder, so let us be grateful that wherever science and reason turn they plunge finally into stygian darkness. I am not in the least annoyed because I do not understand time and space, or consciousness, or free will, or evil, or why the universe is made the way it is. I am relieved beyond measure that I do not need to comprehend more than dimly the nature of God or an afterlife. I do not want to be blinded by truths beyond the capacity of my eyes and brain and heart. I am as contented as a Carnap with the absence of rational methods for penetrating ultimate mysteries” (p. 341).

For many reasons, and in completely unexpected ways, the Chiswick Coincidence ‘opened my eyes’. At a seventh layer, I find that the coincidence revealed another synchronicity: the shared values and beliefs of Martin Gardner and a man I could never have met, GKC, author of the metaphysical novel, TMWWTAN.  


I estimate here the probabilities for the synchronicities at each layer, followed by a combined probability estimate. 

Layer 1: The probability that the estate agent and GKC are from a single family is estimated to be 10-3. This estimate takes into account the number of West London estate agencies (500+) and the chance that the agent that I had selected would have a strong familial connection with GKC, the central character in this episode.

Layer 2: The probability that my intention to visit the riverside pub at Chiswick would be followed a few seconds later by seeing the words ‘public-house on the Chiswick bank ’on the first page of my kindleis estimated to be 10-7. This estimate takes into account the huge quantity of kindle text (in excess of 50 million words).

Layer 3:The probability thaton the same visit to London I would meet my publisher to discuss a new book on anomalistic psychology is estimated to be 10-1. This accords with the frequency of such meetings, which is approximately once a year.

Layer 4:Taking into account the fact that no contract for this book existed at this time, the probability thatthe Chiswick Coincidence would be helpful to the book is estimated to be 10-1   

Layer 5:Taking into account of the fact that, before this incident, I knew almost nothing about GKC, the probability thatsomebody I knew and had written forewords to two of my books, Martin Gardner, would also be the very person who had written a Special Annotated Edition of TMWWTAN is estimated to be 10-4.

Layer 6: The probability that lifelong personal values to defend the “common man”, common sense and the poor, I later discovered to be GFK’s values, is estimated to be 10-1 [11].

Layer 7: The synchronicity between the values and beliefs of Martin Gardner and G K Cis estimated to be a certainty. Martin loved GKC’s writing, shared his values and beliefs, and would not have produced an annotated edition of TMWWTAN otherwise.

In addition, it is necessary to consider one of the boundary conditions. Sitting on an aeroplane on a short-haul flight, offers a variety of activities, viz: doing nothing, doing a puzzle, watching a film, listening to music, snoozing,  chatting,  looking out of the window, drinking a tea or coffee, reading a non-kindle item (newspaper, magazine or book), or reading a kindle. I estimate the probability that I would have chosen to read my kindle on this occasion as one-in-ten ( 10-1 ).

The combined probability P of the seven synchronicities and the boundary condition is:

 P  = 10-3 X  10-7 X  10-1 X  10-1   X  10-4   X 10-1  X 1 X  10-1   = 10-18

= one in 1,000,000,000,000,000,000 

i.e. one in one quintillion (a million, million, million) [12] 


One quintillion is so huge, it is difficult to comprehend without a concrete illustration. As another thought experiment, imagine that we convert this abstract number into rice grains, one quintillion rice grains. The rice grains are all husked and light brown in colour. Completely at random, imagine that I replace one of the rice grains with a grain-sized gold nugget.  There are 15,432 grains in each kilogram. The total weight of the one quintillion rice grains is 64,798,909,802,406 kilograms. With a density of 753 kg/m3, the rice occupies a volume of 86,054,329,087 cubic metres. Comparing this to the world’s largest mountain, this amount is one-and-a-half Mount Everests. For the last 20 years, global rice consumption has averaged close to 54 kilograms per person (Statista, 2019). The enormous rice mountain created by one quintillian grains would feed the entire world population of 7.7 billion for 156 years. The odds of finding a single grain of gold inside this enormous mountain would be identical to the odds of my Chiswick Coincidence. These odds are so astronomical, one must consider the possibility of a paranormal explanation. Not to do so would be irrational and contrary to science.

Explaining the Chiswick Coincidence

How might this remarkable 7-layered coincidence, together with its impact and meaning, all be explained?  Let’s consider the explanations that are available from each side of the theoretical divide.

Hypothesis 1 – N Theory Explanation: Coincidences are bound to occur every once in a while, purely by chance.

From the perspective of N Theory, I give the first type of explanation. The nugget of the Chiswick Coincidence lies within Layer 2:

Event A: choosing by free will to go to the City Barge for lunch.

Event B: choosing by free will to read, only moments later, a story, I would soon discover, that contains an incident about a  ‘public-house on the Chiswick bank of the river’.

When considered independently, neither event is in any way extraordinary. Only their near simultaneity appears extraordinary. If I had read the passage a few months, weeks or even days previously or sometime later, I would have noted that I knew just such a place but would not have blinked an eyelid.  Any Londoner is familiar with the experience of coming across familiar places in novels or movies.

It is necessary to consider the possibility of a hidden cause, something that might create the illusion of synchronicity when it isn’t really there. One possibility is that GKC may have been frequently mentioning things in and around Chiswick. In this case the coincidence might not be so odd after all.  It is possible to test this hypothesis relatively easily. It is said that Chesterton was one of the most prolific writers of all time. He wrote around 80 books, several hundred poems, 200 short stories, 4000 essays, and several plays. I downloaded the Delphi Collected Works of GK Chesterton onto my kindle. Using the kindle search function, I found that there only 7 occurrences of the word “Chiswick” in GKC’s Collected Works. This fact makes the Chiswick Coincidence seem even odder than before.

Another possibility that must be considered is that I had already seen the crucial passage on a previous occasion. This possibility can be safely eliminated for two different reasons. Firstly, if I had already seen this passage, I would already have noticed the connection between one of my favourite riverside haunts and GFC’s mention of it. In this case, seeing it for a second time would not have seemed terribly remarkable. Secondly, a kindle automatically remembers the point reached at a previous reading and obligingly opens the selected book at that page.

The ultimate sceptical explanation is possibly the most accurate. It says that coincidences are just – coincidences!  A coincidence is a coincidence is a coincidence; a random, chance kind of thing. Something similar to the Chiswick Coincidence is occurring with someone somewhere almost every second of the day. When this extremely striking kind of coincidence occurs, it is bound to attract the experiencer’s attention. It is purely the wheels of chance turning and nothing else.

Hypothesis 2 – P Theory Explanation: Reverse causality by unconscious reading of the text triggers the decision to visit the pub on the Chiswick side of the river.

What of a paranormal interpretation? It is essential to air all possible explanations and the P Theory warrants a fair hearing.  The two key elements of the Chiswick Coincidence remain :

Event A: deciding by free will to go to the City Barge for lunch.

Event B: deciding by free will to read, only moments later, a story, which contains an incident about a ‘public-house on the Chiswick bank of the river’.

What about the possibility of retro-causality such that Event B occurs immediately before Event A?  However fantastic it may seem, it is only fair that it be stated. The P Theory explanation goes like this: I read the part of the story about the Chiswick pub by an unconscious process of clairvoyance, clairvoyantly seeing the text about a ‘public-house on the Chiswick bank of the river’ inside my kindle.  Reading this text at an unconscious level triggers my decision to go to the City Barge for lunch. Afterwards, at a conscious level, when I switch on the kindle and actually read the text, I feel a sense of wonderment and surprise. This is no coincidence at all – reading about the Chiswick pub naturally and logically led to my plan to visit it.

If one is open to psi as a scientific possibility, there should be no problem in accepting the P Theory explanation.[13]  The P Theory nails it. If the sceptic demurs that there is no evidence for clairvoyance, unconscious perception or reverse causality and it just cannot be so, the P Theorist might retort: “Normally, yes, but on this occasion all three happened.” There is no rational way of resolving the matter; which interpretation one accepts rests entirely upon subjective judgement.


On a homeward journey, involving multiple free choices, a striking coincidence happened (Figure 2). The laws of chance suggest that the odds against the Chiswick Coincidence are around one-quintillion-to-one. Both ‘N Theory’ and ‘P Theory’ interpretations remain logical possibilities. There can be no definitive method of proving which explanation is the correct one. This incertitude requires a neutral stance and a degree of humility about one’s reaction to striking anomalous experience.[14]

My search for a scientific explanation was matched by an equally compelling realisation that there might not be one. Which interpretation is true cannot be decided by reason. Only personal preference – based on one’s a pre-existing bias – allows one to reach a definite conclusion. This insight led me to question my lifelong mental habit of scepticism.  In one ultimate act of scepticism – I became sceptical of scepticism.



In addition to the Chiswick Coincidence, I describe elsewhere four other striking coincidences over my lifetime.[15] It is enlightening to compute the odds that all 5 of these events could happen to the same individual. To determine the probability of five independent events, A – E,  we multiply the individual probabilities together: 

P(A and B and C and D and E) = P(A)×P(B) x P(C)×P(D) x P(E)  

The five coincidences are as follows:

A) An obscure public house on the Chiswick bank of the river: P=10-18 = one chance in 1,000,000,000,000,000,000  = one in one quintillion (a million, million, million)

B) Coincidence or Luck?: P = 10-10  = one chance in ten billion.

C) Citizen 63 – Marion Knight: P= 4.5 x 10-10  = 4.5 chances in ten billion

D) The Case of the Flying Horseshoe:  P = 1.3 x 10-12 = 1.3 chances in a million, million

E) Under the Wallpaper:   P = 5.08 x 10-9  = 5 chances in a billion

By simple multiplication, the combined probability of these five independent events is :

P =   10-18   x   10-10   x   4.5 x 10-10  x 1.3 x 10-12    x 5.08 x 10-9

P = 3 x 10-58 

A probability of 3 x 10-58 is one of the smallest probabilities imaginable.  Yet according to the widely accepted Principle of the Long Run, of N Theory,  there is nothing extraordinary here. To try to make sense of such astronomical odds, we may speculate about the possibility of a second source of coincidence anomalies with a paranormal origin.

Synchronicity and meaning are existential processes with an ancient biological role. Synchronicity binds thoughts, feelings and behaviour with meaning. The standard scientific explanation based on normal probability theory adduces the statistical Principle of the Long Run which dictates that improbable coincidences are inevitable. However, an alternative hypothesis that there is the possibility of psi cannot be ruled out. There is no rational method for determining which interpretation is more likely to be correct. We each must draw our own conclusions.


Browne, L. (2017). The many faces of coincidence. Imprint Academic. Kindle Edition.

Carroll, L. (2000). The annotated Alice. The definitive edition. Introduction and notes by Martin Gardner. New York and London: WW Norton.

Chesterton, G. K. and Gardner, M. (1999). The man who was Thursday. A nightmare. With annotations by Martin Gardner. San Francisco: Ignatius Press.

Chesterton, G. K. (2006). The autobiography of GK Chesterton. San Francisco: Ignatius Press.

Diaconis, P. and Mosteller, F. (1989). Methods for studying coincidences. Journal of the American Statistical Association84(408), 853-861.

Feinberg, G. (1975). Precognition—a memory of things future. In L. Oteri (ed.), Quantum physics and parapsychology. Parapsychology Foundation. Pp. 54—64.

Fisher, R.A. (1937). The design of experiments (2nd ed.). London: Oliver & Boyd.

Gardner, M. (1956). Math, magic and mystery. New York: Dover.

Gardner, M. (1957). Fads and fallacies in the name of science. New York: Dover.

Gardner, M.(2013). Undiluted hocus-pocus. Princeton University Press. Kindle Edition.

Martin, B. (1998). Coincidences: Remarkable or random? Skeptical Inquirer, 22(5).

Hand, D. J. (2014). The improbability principle: Why coincidences, miracles, and rare events happen every day. Scientific American/Farrar, Straus and Giroux.

Jung, C. G. (1951). Foreword to Richard Wilhelm’s translation of the I Ching. UK: Routledge & Kegan Paul.

Koestler, A. (1972). The roots of coincidence. New York: Vintage Books.

Marks, D.F. and Kammann, R. (1980). The psychology of the psychic. Foreword by Martin Gardner. New York: Prometheus Books.

Marks, D.F. (2000). The psychology of the psychic (2nd ed.). Foreword by Martin Gardner New York: Prometheus Books.

Marks, D.F. (2020). Psychology and the paranormal. Exploring anomalistic experience. London: SAGE Publications.

Miller, G. A. (1956). The magical number seven, plus or minus two: Some limits on our capacity for processing information. Psychological review63(2), 81.

Statista (2019). Global use of rice per capita from 2000/2001 to 2018/2019 (in kilograms per year). Available at:


Thalbourne, M. A. (2006). A brief treatise on coincidence. Unpublished manuscript. Online at http://parrochia. wifeo. com/documents/coincidence. pdf. Accessed 06 December 2010.

[1] The Principle of the Long Run reappeared in a new guise as the ‘Law of Truly Large Numbers’ in a Science paper by Diaconis and Mosteller (1989)  See also: ‘The Improbability Principle’ (Hand, 2014).

[2] The estimate of 100 is not empirically based, but simply a convenient, round number. The true figure could be lower or higher.

[3] We can compute the number of pairs over a single person’s adult lifetime of 60 years 4950 x 60 x 365 = 1,084,050,000 pairs + 15 x 4950 = 74,250 extra pairs for leap days giving a total of  1,084,124,250, i.e. slightly more than one billion pairs. If a coincidence is a one-in-ten-million event, then we can expect around 100 striking coincidences in one lifetime. At one-in-100-million, however, there would be only 10 per lifetime, and at one-per-billion, only one. These figures are based on the assumption that there are 100 discrete events per day. If this estimate is changed, then the above figures would need to be revised proportionately.

[4] In Irrationality: the enemy within (p. 227) Stuart Sutherland misapplied the 18 billion figure as follows: “Arthur Koestler sought to establish the truth of the paranormal by pointing to fifty coincidences that had occurred in his life, which he claimed could not be given any normal explanation, but Marks and Kammann point out that in a lifetime he would have been exposed to over 18 billion pairs of events: it would be most unlikely if some of the members of a pair did not match.” As computed in footnote 17 above, there should be only about one billion event pairs in a single lifetime.

[5] Laurence Browne (2017) proposes four categories —a) random chance; b) natural causality; c) supernatural causality; d) synchronicity—to represent the four main ways in which coincidences are customarily explained. In the model of Figure 1, we include only types a and c. There is no evidence that type d is necessary as a separate category from type c.

[6] I freely acknowledge some readers may well view my ‘Chiswick Coincidence’ with scepticism. See: ‘One person’s coincidence can be another person’s yawn’; https://wordpress.com/post/coincidences.blog/251

[7] The City Barge is only a 10-minute drive from Bedford Park, the “queer artificial village” of  ‘Saffron Park’ in GKC’s novel.

[8] With the settings on the kindle as they were at that time, there are 4-5 kindle pages to every printed page.

[9] Martin Gardner (Foreword to the Second Edition, Marks, 2000) wrote: “Twenty years have passed since The Psychology of the Psychic, by David Marks and Richard Kammann, was published…Much has happened on the psi frontier since then. Kammann died in 1984…Marks has so thoroughly revised and expanded the text that it is almost as if he has written an entirely new volume. It will rank as one of the strongest and best exposés ever directed at the more outlandish claims of parapsychology”(p. 13).

[10] By comparison, Chesterton’s autobiography mentions ‘God’ 62 times.

[11] I share GKC’s values as listed but not his Roman Catholic religious beliefs.

[12] A quintillion is cardinal number represented by 1 followed by 18 zeros (US) and by 1 followed by 30 zeros (UK). Here I use the US definition.

[13] Physicist Gerald Feinberg (2005) sees no incompatibility between modern physics and precognition:  “Instead of forbidding precognition from happening, [accepted physical] theories typically have sufficient symmetry (between past and future) to suggest that phenomena akin to precognition should occur. . . . Indeed, phenomena involving a reversed time order of cause and effect are generally excluded from consideration on the ground that they have not been observed, rather than because the theory forbids them. This exclusion itself introduces an element of asymmetry into the physical theories, which some physicists have felt was improper or required further explanation. . . . Thus, if such phenomena indeed occur, no change in the fundamental equations of physics would be needed to describe them.

[14] Michael Thalbourne (2006) dismisses sceptical explanations based on chance “as a bottomless pit, able to swallow up each and every coincidence that does not already have anormal explanation.”The fact is, in regard to this coincidence, there is no fool-proof method to say whether the P Theory of the N Theory interpretation is correct. It comes down to making one’s own subjective evaluation.

[15] See: https://wordpress.com/post/coincidences.blog/321


Mental Imagery, Creativity and Planetary Survival

This post discusses one of the foundations of human creativity – mental imagery – and its role in human and planetary survival. The post is based on a Keynote Presentation I gave to the Japanese Imagery Association, University of Sapporo, Japan, in August, 2010.

Mental imagery – seeing in the “mind’s eye” – can be studied in its pure form or as it is applied in different kinds of performance. In its purest form, mental imagery exists as mental representations of experience, experiences that actually occurred or ‘pretend’ experiences that never happened but can be conceived as possibilities.  

Research on imagery has  relevance to diverse fields ranging from psychology to science and technology and across literature, fine art and music. Scientific study of mental imagery has advanced through development of measuring instruments such as the Vividness of Visual Imagery Questionnaire (VVIQ). The VVIQ has been used in more than 2000 studies as a measure of individual differences in vividness of visual imagery. The VVIQ is a predictor of the person’s performance in a variety of cognitive, motor, and creative tasks. Recent studies have found that individual differences in VVIQ scores can be used to predict changes in a person’s brain while visualizing different activities.

Cui et al. (2007) used functional magnetic resonance imaging (fMRI) to study the association between early visual cortex activity and visual imagery. The investigators found that reported image vividness correlates with the relative fMRI signal in visual cortex. Thus the subjective experience of a mental image and objective measurement of visual cortical activity show a strong and significant relationship. Studies reviewed also show strong associations between imagery vividness and cognitive processes, motor activity and creativity. 

Human evolution and planetary survival may ultimately depend upon the effective use of the human imagination – and mental imagery in particular.

Definitions, theories and paradigms

Mental imagery is quasi-perceptual experience, that is, experience that subjectively resembles perceptual experience, but which occurs in the absence of the relevant perceptual stimuli. This definition is consistent with research that has been carried out within different research traditions and theoretical frameworks. Research paradigms for the scientific study of mental imagery have included:

A. N=1 case studies

B. Introspection

C. Self-report & questionnaire measures

D. Experimental methods

E. C + D: Experimental methods combined with self-report or questionnaire measures

In this article, I review studies that fall within category E. 

Theories of mental imagery include the Picture Theory (e.g. Plato), Description/Tacit knowledge Theory (e.g. Pylyshyn, 1973) and Enactive Theory (e.g. Ellis, 1995; Thomas, 1999), PT, DT and ET respectively. Picture theory (PT) assumes that visual mental images are like pictures.  PT is a “naïve” theory, which does not hold up to serious scrutiny. For example, pictures are static, whereas images are dynamic; pictures are fixed, while images may fade or change. The un-picture-like characteristics of mental images are easily demonstrated using Professor Hatakeyama’s Open Circle Test (Hatakeyama, 1974). Description theory (DT) assumes that the brain represents information including images in a propositional format like a digital computer. But is the digital computer a good model for the brain? Perhaps an analogue computer is a better model for the brain?

A third theoretical approach, Enactive Theory, allows that mental imagery is similar to perception, but without the questionable assumption that mental imaging is similar to looking at pictures at an exhibition. Perception itself is not even analogous to looking at pictures in a gallery. Perception is integrated with action, the affordances of stimuli, activities carried out by the organism. Perception is multi-modal, not only visual, as is imaging. The perceiving organism is exploring and asking questions of the environment (Ellis, 1995), actively and intentionally seeking out answers from the sensory stimuli that surround it. The studies to be reviewed here can be seen as providing general support to Enactive Theory.  The particular version of Enactive Theory discussed here, Activity Cycle Theory, was proposed by Marks (1995, 1999). The Imagery System is conceptualized as a cyclical set of processes which includes the mental image itself (I), schemata (S), actions (A), and affect (A) (Figure 1). The imagery cycle or ‘ISAA’ may be triggered by activation of any one of the four processes and, in principle, the cycle can proceed in either direction.

Meta-analysis of VVIQ data up to mid-1990s was carried out by McKelvie (1995). Consistent with Activity Cycle Theory, the meta-analysis showed that the vividness of visual imagery is strongly associated with performances which benefit from mental practice using perceptual-motor imagery. According to the Activity Cycle Theory, vivid images influence schemas more than weak images, and weak images influence schemas less than vivid images.

The Vividness of Visual Imagery Questionnaire (VVIQ) consists of 16 items which the participants are asked to mentally image and rate on a 5-point vividness rating scale, where 1 = vivid and 5 = no image at all (Marks, 1973).  Citations over the period 1974-2009 show an upward trend with over 400 studies in 35 years. The VVIQ has been used in 29 countries, with the greatest output in the USA (40%), England (14%), Canada (14%), Australia (7%), Italy (6%), Spain (6%), France (5%), Germany (3%), and Japan (2.6%). A few representative studies will be reviewed in the following sections.

Imagery and cognition

As noted above, McKelvie (1995) reviewed all VVIQ studies up to that time and these empirical findings have been reinforced by hundreds of studies showing that the VVIQ is a predictor of cognitive perfomance. What is less well-established is the function of imagery in development and aging. Of relevance here is Hilgard’s (1958) review of learning research and what he referred to “transfer of training”, the effects of old learning in new situations. Does mental imagery help us to transfer learning from older experiences to new ones, the concept of “cognitive plasticity”. It is often alleged that older people are less flexible and adaptive to new situations because they suffer from memory loss. In the vernacular, it is said that: “if you don’t use it, you lose it”.  This leads to the interesting question of whether imagery ability shows a decrement during aging. Do we become less able to use mental imagery in cognitive tasks when we are older? If so, are imagery experts less affected by this decrement in imagery competence?  We turn here to a study of precisely these questions.

Lindenberger (1991) studied aging, professional expertise, and cognitive plasticity in groups of older expert designers and non-expert older and younger controls. The professional expertise in expert designers was expected to transfer to new laboratory tasks. The tasks involved a skill base that the experts could easily utilise: imagery formation. Lindenberger used the Method of Loci to enable the participants to maximize their memory of word lists by using associative imagery.  Examples of how places (loci) can be linked to word items is shown below:

Locus (place)     Item        Associative image

Church               bread       priest gives bread

Fountain            cat            cat drinks water

Shop                   plant         shop has plants by door

Park gate           rice           rice bag hanging on gate

Café                   book          man reading book in cafe

Car park           fish            fish drives a car

Lindenberger used 20 Berlin landmarks as loci in study. In the more difficult trials, the new items were presented at a speed of one every 1.5 sec, which is quite rapid for associative learning. Mnemonic skill of the older subjects (expert and controls combined, n =12) was significantly correlated with the VVIQ scores, r = -.54, p < .05.

In the group of combined older subjects (n=12), the correlation between age and VVIQ score was .76 (p < .05).  This finding suggests that older people experience images of lower vividness than younger people.  This finding has interesting implications. If imagery vividness fades with age, the Verbal system could be expected to become more dominant with age. This could be one reason why older people generally show a preference for fixed routines, and become less flexible and adaptable to change. There is also an important link between imagery and creativity and evidence that people become less creative in older age (see below).

Imagery and cortex

Another significant issue in recent studies has been the relationship between imagery and cortical activation. The objective methods of brain research have been employed to investigate the more subjective experience of mental imagery. An excellent example of this approach is the study by Cui, Jeter, Yang, Montague and Eagleman (2007) who employed three tasks consisting of the VVIQ, a colour word discrimination task and an fMRI scan of visualization. Participants visualised themselves or another person bench pressing or stair climbing. Participants began to visualize upon hearing the ‘go’ signal, and stopped visualization upon hearing the ‘stop’ signal. This produced a 10-second imagery phase and a 10-second rest phase. The results showed that there was a strong correlation between vividness of imagery as measured by the VVIQ and the relative fMRI signal in visual cortex (r = -.73; p=.04). Thus individual differences in the vividness of visual imagery can be measured objectively. The subjective experience of forming a mental image and objective measurement of visual cortical activity show a strong and significant relationship. The correlation between relative fMRI signal and congruent- incongruent performance was also quite strong (r = -.77, p=.03). These findings suggest that visual images are coded in cortical activity in quite a specific fashion. The level of activation reflects the intensity of the image.

Vingerhoets, de Lange, Vandemaele, Deblaere and Achten (2002) asked 12 right- handed men to perform two mental rotation tasks and two control tasks while whole-head fMRI was applied. Mental rotation tasks required the comparison of different sorts of stimulus pairs, viz. pictures of hands and pictures of tools that were either identical or mirror images and which were rotated in the plane of the picture. Control tasks were similar except that stimuli pairs were not rotated. Imaging data showed an important difference in premotor area activation: pairs of hands engender bilateral premotor activation while pairs of tools elicit only left premotor brain activation. The results suggested that participants imagined moving both their hands in the hand condition, but imagined manipulating objects with their hand of preference (right hand) in the tool condition.  The motor imagery mimicked the “natural way” in which a person would manipulate the object in reality, and the activation of cortical regions during mental rotation were apparently influenced by the afforded actions elicited by the stimuli presented.

Image content is also specifically encoded by the cortex and may be measured in an objective fashion. This has important applications in clinical patients who are unable to communicate by any normal means. Some patients have damage to the peripheral motor system which prevent overt responses to command although the cognitive ability to perceive and understand such commands may remain intact. Such patients include those who are in a Persistent Vegetative State (PSV). Activation using fMRI can be used to identify residual cognitive function and conscious awareness in patients who are assumed to be in a vegetative state yet retain cognitive abilities. Owen et al (2007) studied three healthy volunteers imagining playing tennis during real-time fMRI. In this figure functional MRI data are superimposed on 3-dimensional reconstructions of structural MRI data for online examination of brain activity during mental imaging. Similar significant activation is observed in the supplementary motor area in all 3 healthy volunteers. Data from a patient suffering from PVS showed supplementary motor area activity during tennis imagery which was highly similar to the pattern of activation shown in a healthy volunteer.

Parahippocampal gyrus, posterior parietal lobe, and lateral premotor cortex activity while imagining moving around a house in the patient and in a healthy volunteer are on the right. Similar imagery gave similar cortical responses in both people. Imagery of moving around the house gave a more complex activation pattern than imaging tennis. The pattern is quite distinctive in each case.

This previous study led the investigators to wonder whether the content-specific fMRI activation could be used to communicate ‘Yes’ and ‘No’ answers to questions which a patient would be unable to answer by any normal means. Monti et al. (2010) published a study indicating that a PVS patient is able to willfully modulate their brain activity to communicate with the outside world. They performed a study involving 54 patients with disorders of consciousness. They used fMRI) to assess each patient’s ability to generate willful, content-specific responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions. Five of the patients were able to correctly answer questions by using the imagery coding of Yes and No:

Yes = mental image of playing tennis

No = mental image of moving through house

The results for the 54 patients enrolled in the study showed that five patients could willfully modulate their brain activity. In three of these patients, additional bedside testing was carried out which revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment.

The implications of this study are quite profound. The evidence suggests that patients should be able to communicate with the outside world by using their internal mental images to trigger different fMRI responses associated with Yes and No answers.  The study confirms that image content is specifically encoded in the cortex.  It also shows the power of motor activity in defining the distinctiveness of mental imagery: imagery of playing tennis and moving through a house have distinctive motor components which are encoded differentially in the cortex. This leads to our next topic: studies of mental imagery and action.

Mental imagery and action

We have seen in the preceding section evidence that the cortical encoding of visual images included motor components. It has been established for several decades that mental imagery as a form of rehearsal has a highly beneficial effect in motor skill learning (Feltz & Landers, 1983; Suinn, 1980). Subjects with higher imagery ability replicate movement patterns more accurately than subjects of lesser imagery ability (Ryan & Simons, 1982; Goss, 1986). This leads to the interesting question: Can some kind of action enhance mental imagery? If so, motor programs may underlie imagery processes. Hishitani (2003) examined this hypothesis. The task involved guided mental synthesis – combining two images together to form a new synthesis, an image of a different thing. One example of the instructions is as follows:

Imagine Capital “L”,

Imagine Capital “P” on the right side of the “L,”

Put two letters close to each other, and contact the right endpoint of horizontal line of the “L” with the bottom of vertical line of the “P”. What do you see as an image? Write down its name, and draw its picture.

What did you make with these 2 letters?

The correct answer is a mug. All participants closed their eyes during the task. In the closed-fists group, they put their closed fists on a table. In the drawing-action group, they draw the image on a table with an index finger of their dominant hand. The lowest third and highest third on VVIQ scores were selected from 180 undergraduates. The groups receiving the two different conditions were closely matched for their VVIQ scores. There were two significant findings:

1) With closed fists, good imagers showed significantly more correct answers. This result indicates that vivid imagery facilitated the synthesis of the correct solutions. 2) With a drawing action, the two groups did not differ. Poor imagers scored more highly, while good imagers scored slightly worse. This produced a significant interaction between imagery group and task condition. These findings indicate that the motor action of pointing out the image of the two letters was a surrogate for vivid mental images (or vice versa). We can conclude from Hishitani’s (2003) study that: Imagery ability may be functionally equivalent to the drawing action in the synthesis task. The formation and operation of mental imagery is intimately linked to motor programs. Motor programs can be activated by drawing action. Such activation induces performance enhancement in the poor imagers.

A parallel case exists for the sense of smell. When we try to image a smell we may make spontaneous sniffing responses with our noses.  Sniffing activity enhances the vividness of the resulting imagery. So what happens to the vividness of our olfactory imagery when we are unable to make these sniffing motions? Arshamian et al. (2008) studied the effect on olfactory image vividness of blocking sniffing using a simple nose clip. Examples of odour stimuli used in their study were: Alcohol; Pen; Grilled chicken; Red wine; Almond; Honey; Resin; Apricot; Ketchup; a Rose.

Confirming their hypotheses, Arshamian et al.’s  (2008) results showed that preventing sniffing resulted in a selectively poorer olfactory but not visual vividness, whereas blocked vision showed no effect on either the visual or olfactory vividness ratings. These observations confirm that sensorimotor activity is an important aspect for the quality of evoked olfactory images. The studies reviewed in this section confirm Action Cycle Theory, which holds that sensori-motor actvity is an intrinsic part of the cycle of processes (‘ISAA’) that are linked to image generation: schemas, actions, affects and images.

Creativity and mental imagery

The study of imagery and creativity is of special importance. Many of the problems faced by mankind involve the use of creative thinking. In this section I review one representative study indicating the strong links that exist between imagery vividness and creativity. Kobnithikulwong (2007) at the University of Florida, presented her masters thesis on “Creativity and Imagery in Interior Design…” Kobnithikulwong’s conceptual framework consisted of a Person, a Process and a Product. The Person needs to have a creative personality and vivid visual imagery. The Process needs to have an Internal Visualization and an External Representation of that visualization which is the Product. Kobnithikulwong designed a drawing and writing task and also measured students’ VVIQ and creativity scales.

The students were allowed 30 minutes to do a drawing of a “transitional space within a building” and 10 minutes to write a description of being in the space. Significant differences were found between the high and low creative performance students. Low creative performance produced narratives averaging 73 words. High creative performance produced narratives averaging at 133 words, nearly double the length. The low creatives contained linear and rectangular forms that gave the designs a static look. High creatives produced stronger dynamic movement in their designs by using curves and free-form elements. Solutions in the high group employed movement from curves to create perspective “Pulling a viewer into their spaces”, while low creatives did not make this kind of connection with the viewer. High creatives showed better quality perspective building techniques and designed spaces which were open on one side or end. Low creatives were mostly enclosed with a more limited perspective. High creatives showed high contrast and line weight while lows produced drawings that were less legible with low line weight and low contrast.

Kobnithikulwong (2007) concluded that: “The qualitative analysis indicated that judged creative performance, as an external representation of visualization, positively related to vividness of visual imagery or internal visualization.” The correlation between VVIQ score with eyes closed and creativity scores was .31, p<.02. Dividing the two groups at the median creativity score gave a significant difference of around 10 points in the VVIQ with eyes closed between the two creativity groups, p = .006. However, the scatterplot shows that the relationship is curvilinear and so the use of curvilinear regression (instead of linear) would have yielded a much stronger association.

New applications of mental imagery

Applications of  mental imagery cross many different fields, including the arts, architecture, design, science, education, sports, IT,  policy and planning. Global problems caused by human behaviour such as warming, poverty and over-population may be helped by applying mental imagery in creative ways. Human and planetary survival may ultimately depend upon the effective use of  human imagination, including mental imagery.

William Blake showed God creating the Universe (1794) (Figure 3). I doubt Blake, a visionary though he was,  would have dreamed of the World we have today. Global warming with unprecedented temperatures, population growth, water shortages, hunger and poverty.

In choosing strategies for the solution to global warming one can consider Geo-engineering solutions; Behavioural solutions; Prayer; or Do-nothing-and-wait. Sometimes, we cannot see what is right in front of our noses: how to change things using simple tools we already possess. We become attracted to dramatic solutions that require massive injections of funding and commercial exploitation. For example,  the U.N. Climate Panel has reviewed the idea of installing a metallic screen or shield covering a 106 sq km (40.93 sq mile) patch of space 1.5 million kms (930,000 miles) away from earth in the direction of the sun. The 3,000- tonne structure could be put in place over 100 years by 100 space shuttle flights with an indeterminate cost expected to run into trillions of dollars (Reuters, 2008).

Human behaviour change using mental imagery can help to solve world problems. Tobacco use is one the world’s greatest health scourges. Paul Sulzberger and I applied mental imagery techniques to help tens of thousands of people to quit smoking (Sulzberger & Marks, 1977; Marks, 1993; 2005).  If applied on national and international scale, the numbers of quitters could be tens or hundreds of millions. My work in health psychology tells me that the situation isn’t hopeless (e.g. Marks, Murray, Evans & Estacio, 2011).  There is a huge potential for change.

In conclusion, using the VVIQ, and other methods, we have established the important role of mental imagery in human cognition, consciousness, action and creativity.  In designing solutions to global problems such as warming and population growth, there is no machinery to rival the human imagination. The same techniques that were successfully applied to smoking can be applied to the human behaviours to prevent further global warming and population growth.


Arshamian A., Olofsson, J.K., Jönsson, F.U. &  & Larsson, M.  (2008).     Sniff your way to clarity: The case of olfactory imagery. Chemosensory perception, 1, 242-246.

Cui, X., Jeter, C.B., Yang, D., Montague, P.R., & Eagleman, D.M. (2007). Vividness of mental imagery: Individual variability can be measured objectively. Vision Research, 47, 474-478.

Ellis, R.D. (1995). Questioning Consciousness: The Interplay of Imagery, Cognition, and Emotion in the Human Brain. Philadelphia: John Benjamins.

Feltz, D.L., and Landers, D.M. (1983). The effects of age and number of demonstrations in modeling of form and performance. Research Quarterly, 53, 4, 291-296.

Hatakeyama, T.  (1974). The process of having identified an adult eidetic person and her eidetic experiences in daily life. Tohuku Psychologica Folia, 33, 102-118.

Hishitani. S. (2003). A fundamental study on the cognitive mechanisms of imagery training. Desant Sports Science, 24, 104-113. (イメージ・トレーニングの認知的メカニズムに関する基礎的研究 デサントスポーツ科学, 24, 104-113.)

Kobnithikulwong (2007). Creativity and imagery in interior design students: exploring relationships among creative personality, performance, and vividness

of visual imagery.  MID thesis, University of Florida, Department of Interior Design.

Lindenberger, U. (1991). Aging, professional expertise, and cognitive plasticity. The sample case of imagery-based memory functioning in expert graphic designers. Stuttgart: Klett.

Marks, D.F. (1973). Visual imagery differences in the recall of pictures. British Journal of Psychology, 64, 17-24.

Marks, D.F. (1993). The QUIT FOR LIFE Programme: An Easier Way To Quit Smoking and Not Start Again. Leicester: British Psychological Society.

Marks, D.F. (1995). New directions for mental imagery research. Journal of Mental Imagery, 19, 153-167.

Marks, D. F. (1999). Consciousness, mental imagery and action. British Journal of Psychology, 90, 567 – 585.

Marks, D.F. (2005). Overcoming Your Smoking Habit. London: Robinson.

Marks, D.F., Murray, M. Evans, B. & Estacio, E.V.G. (2011). Health psychology. Theory, research and practice. London: Sage Publications.

McKelvie, S. J. (1995) The VVIQ as a psychometric test of individual differences in visual imagery vividness: a critical quantitative review and plea for direction. Journal of Mental Imagery, 19, 1-106.

Monti, M.M., Vanhaudenhuyse, A.,  Coleman, M.R., Boly, M.,Pickard, J.D., Tshibanda, L., Owen, A.M. & Laureys, S. (2010). Willful modulation of brain activity in disorders of consciousness. New England Journal of Medicine, 362, 579-589.

Pylyshyn Z. W. (1973). What the mind’s eye tells the mind’s brain: A critique of mental imagery. Psychological Bulletin, 80, 1-24.

Thomas, N.J.T. (1999). Are theories of imagery theories of imagination? An active perception approach to conscious mental content. Cognitive Science (23) 207–245.

Reuters (2008). http://www.dawn.com/2008/10/28/int15.htm

Ryan, E.D., and Simons, J. (1982). Efficacy of mental imagery in enhancing mental rehearsal of motor skills. Journal of Sport Psychology, 4, 1, 41-51.

Suinn, R.M. (1980). Seven Steps to Peak Performance: The Mental Training Manual For Athletes. Toronto: Lewiston, N.Y., H. Huber Publishing Co.

Sulzberger, P. & Marks, D.F. (1977). The Isis Smoking Cessation Programme. Dunedin, New Zealand: Isis Research Centre.

Vingerhoets, G., de Lange, F.P., Vandemaele, P., Deblaere, K., & Achten, E. (2002). Motor imagery in mental rotation. NeuroImage, 17, 1623-1633.


The SAGE Secretive Seven

In keeping with best practice, members of government advisory groups are invited to declare their interests in any companies or organisations that could be interested in influencing decisions made by the group. Seven members of SAGE are revealed here as having interests in companies that they chose not to declare. Of course, human memory is fallible and it is possible that these members simply forgot to declare these interests or, for whatever reason, did not consider them relevant or important. It could be a pure coincidence that all seven people with undeclared interests were linked to the Wellcome Trust or Pfizer. Also, five of the seven members with undeclared interests are employed at University College London with an active research team working towards a new COVID-19 vaccine.

The motive for not declaring interests remains uncertain. As noted, lapse of memory is always a possibility. Yet that seems unlikely. In every case the undeclared interests can be found with a few clicks on Google, so why bother to raise concerns or suspicions?

The list below shows details of the ‘secretive seven’ SAGE members. It indicates their declared and undeclared interests.

Professor Charles Bangham  IMPERIAL COLLEGE LONDON


  • None


Research funded by the Wellcome Trust



  • None


Henry Wellcome postdoctoral research fellowship

Professor Andrew Hayward   UNIVERSITY COLLEGE LONDON


  • Trustee, Pathway Homeless Health Care Charity
  • Recipient of research funding from UK Research and Innovation (UKRI)
  • Director, UCL Institute of Epidemiology and Health Care
  • Range of grants held by staff within the Institute of Epidemiology and Health Care (NIHR, ESRC, UKRI)
  • Recipient of COVID-19 research funding for Virus Watch (UKRI and NIHR). No personal financial gain
  • Recipient of COVID-19 research funding for COVID Health Equity Study Virus Watch (UKRI and NIHR). Co-applicant but no personal financial gain
  • Provision of Antibody testing in Virus Watch Study (DHSC) – no personal financial gain
  • Co-investigator of the Vivaldi Nursing Home Study, funded by DHSC – no personal financial gain
  • Occupational risk analyses in Virus Watch, (occupational analyses funded by Health and Safety Executive (HSE) – no personal financial gain
  • UNDECLARED: Led the MRC Wellcome Flu Watch Study from 2006-11
  • Co-led of the Wellcome/DH ICONIC 2013-18 programme (https://iris.ucl.ac.uk/iris/browse/profile?upi=ACHAY31)



  • Co-investigator on an NIHR funded study evaluating diagnostic pathways, pharmacological and non-pharmacological treatments for Long COVID (STIMULATE-ICP) at UCLH and UCL.
  • Held a Wellcome Trust Clinical Training Fellowship from 2007 to 2011

Professor Dame Anne Johnson    UNIVERSITY COLLEGE LONDON


  • Employee, UCL
  • Co-investigator, NIHR and UKRI virus watch study (COVID)
  • Member, COVID National Core Studies (NCS) Oversight Group
  • Chair, MRC and UKRI Accelerating Detection of Disease cohort scientific advisory group
  • Recipient of research income from Engineering and Physical Sciences Research Council (EPSRC) – iSense project
  • Member, Medical Research Council PRP Advisory Group
  • Member, COVID Research and innovation task force, UK Research and Innovation (UKRI)
  • President, formerly Vice-President international, Academy of Medical Sciences (December 2020 to present)
  • LUSTRUM grant coinvestigator and National Institute for Health Research (NIHR) Emeritus senior investigator
  • Member, Royal Society DELVE committee on COVID-19
  • Chair, OSCHR Sub-committee for Strategic Co-ordination of Health of the Public Research (SCHOPR)


From  2011 to December 2019, a member of the  Board of Governors of the Wellcome Trust (https://iris.ucl.ac.uk/research/personal?upi=AMJOH29)

Professor Vittal Katikireddi    UNIVERSITY OF GLASGOW


  • Recipient of research funding from Medical Research Council (MRC), UK Research and Innovation (UKRI), CSO, Health Foundation, European Research Council, Swedish Research Council, Baillie Gifford.
  • Co-chair, Expert Reference Group on ethnicity and COVID-19, Scottish Government
  • Honorary Consultant in Public Health, Public Health Scotland


Grants From the Wellcome Trust



  • Professor of Health Psychology and Director of the Centre for Behaviour Change, University College London
  • Co-Investigator of research projects including behavioural aspects of COVID-19transmission, UCL
  • Unlocking Behaviour Change, Director


Funding from the Wellcome Trust and, previously, from Pfizer.


DFM’s declaration of interests: I have received three inoculations of the Pfizer SARS-CoV-2 vaccine courtesy of the French public health system.


Who Owns SAGE?

The UK’s government’s Scientific Advisory Group for Emergencies (SAGE) was established in 2020 to “provide scientific and technical advice to support government decision makers during emergencies”. The latest of these has been the COVID-19 pandemic. SAGE members are drawn from a spectrum of disciplines including epidemiology, immunology, pharmaceutics, public health, psychology, modelling and statistics.

Beginning with George Stiglitz, it has been widely acknowledged that regulators of industries tend to be captured by specific commercial interests. Stiglitz defined regulatory capture as “the problem of discovering when and why an industry is able to use the state for its purposes.”  Capture also occurs in public health policy through corporate members of advisory groups. Like any other advisory group, SAGE is vulnerable to capture by commercial interests in the control of the pandemic, e.g. primarily behaviour control and vaccines.

The question here is: who influences SAGE, or more plainly, who owns SAGE? Now one might think the answer to this question must be one answer and one only, the UK Government. But what if other interests from outside of the government take it over and manage to control it? This would be possible as a form of capture. One way to understand how this could be possible is to examine the interests of SAGE participants.  If a sufficient number of members had the same particular affiliation to a cause or company, then that would be a form of capture.

An analysis was carried out in 2020 by Dr Zoë Harcombe, summarised in the next section, reached precisely this conclusion.

SAGE Conflicts of Interest 

Organisations invested in vaccines make money from vaccines. People who acquire natural immunity have less or no need for a vaccine. Harcombe’s analysis focuses on the crucial first two months of the COVID-19 pandemic when the government formulated its initial response. On March 11th, 2020, the UK government issued advice to combat the spread of SARS-CoV-2. On March 16th, Professor Neil Ferguson at Imperial College London and colleagues published a modelling paper with the the prediction that, if suppression measures were not introduced, there would be 510,000 deaths in the UK and 2.2 million in the US. Panic stations followed everywhere. Twelve days later, the first UK lockdown was announced. It must be noted that people ‘locked’ inside their homes have less chance of acquiring natural immunity than free-moving agents.

In Harcombe’s analysis, 12 out of the 20 key influencers worked for or have received funding from organisations involved in the COVID-19 vaccine.

Harcombe made this discovery by logging the attendance of SAGE members over the first two crucial months of meetings in February and March 2020. Those who attended most regularly were deemed to be key influencers. Examining the 20 key influencers on SAGE, Harcombe revealed that 11 out of 20 work for the government (some hold government roles in addition to other roles) and that 12 out of 20 work for or have received funding from organisations involved in COVID-19 vaccines.

Fear as Coercion

Harcombe logged the fact that the two behaviour experts among the key influencers collaborated on a controversial paper which stokes fear to increase adherence to COVID-19 rules: “A substantial number of people still do not feel sufficiently personally threatened… The perceived level of personal threat needs to be increased among those who are complacent, using hard‐hitting emotional messaging based on accurate information about risk.” This paper by Michie et al. has sections on coercion, compulsion and how to harness “social disapproval” to coerce people into doing what government wants them to do.

Essentially, what we are witnessing with SAGE is the old-fashioned method of ‘carrot and stick’.

It is apparent that fear is deliberately stoked by SAGE to induce people to adopt specific control measures of ‘hands, face and space’ together with working at home and lockdowns all helping to  prevent the spread of the disease. These measures also leave the majority of the population without natural immunity and in fear of their lives. Only vaccines can save them.

Financial Interests of SAGE members

People with a financial interest in a vaccine are conflicted if they give advice that is likely to increase the use of that vaccine. Remember that in 2020 when the first lockdowns were called, there were no vaccines. No vaccines means no profits for vaccine companies. Recommending a lockdown removes people from circulation and minimises the spread of the disease. It also increases the eventual need for vaccines.

The Centre for Evidence Based Medicine highlighted inaccuracies in the forecasts that resulted in Lockdown 2. Slides shown on national TV on 31st October had to be revised downwards by the time the slides were published on line. Vallance and Whitty were summoned to appear before the Science and Technology Committee on 3rd November and it was necessary for Vallance to express regret for frightening people, ‘regret’ being the closest thing to an apology in any mandarin.

However, a core part of SAGE’s modus operandi is to frighten people into compliance as Michie et al.’s paper documents. Holcombe suggests that “fear might turn to anger if people realise that the committee may not be the independent body that it has been assumed to be.”

The Director of Wellcome Leaves SAGE

In its policies to control the COVID-19 pandemic, the UK Government has consistently stated that it ‘follows the science’.   However, the recent resignation of Sir Jeremy Farrar, the Director of the Wellcome Trust, suggests otherwise. Sir Jeremy expressed disappointment with the slow and inadequate responses of the government. Voting with his feet, he decided his time would be better spent developing a global vaccination strategy led by the Wellcome Trust.

Was Sir Jeremy frustrated with the Government’s limp response of reintroducing mask wearing in shops and on transport but deciding against working from home and another full lockdown?

Writing in The Guardian on 4th December, Sir Jeremy stated:
It’s almost two years since we first heard of Covid-19, and a year since the first Covid vaccines were rolled out. Yet this staggering progress is being squandered. We have drifted for months now, with richer countries, taking a very blinkered domestic focus, lulled into thinking that the worst of the pandemic was behind us. This variant reminds us all that we remain closer to the start of the pandemic than the end.

This political drift and lack of leadership is prolonging the pandemic for everyone, with governments unwilling to really address inequitable access to the vaccines, tests and treatment. We are not yet in control of this pandemic – Omicron or an even worse variant could arise at any time. There have been wonderful speeches, warm words but not the actions needed to ensure fair access to what we know works and would bring the pandemic to a close.

We will only bring this pandemic to an end by working together globally and sharing access to all the vital public health tools needed to reduce transmission everywhere and save lives. It is staggering and utterly frustrating that, two years on, governments still haven’t woken up and realised this is in their enlightened, shared self-interest.

Acting in national self-interest will only ever perpetuate this crisis, trapping us in a cycle of waves, new variants, lost lives and continued economic and societal disruption.

No country should believe they are safe, purely because they’ve vaccinated their own populations. We can and must do better than this.

With Sir Jeremy’s departure, who will carry the torch for Wellcome at SAGE?

I have counted 39 of 146 (27%) SAGE members with links to companies producing vaccine. In addition there are at least 40 members (27%) linked to universities with vaccine-related research projects.

So there’s little for Sir Jeremy to worry about on that score.

There can be little question that Big Pharma vaccine producers own SAGE.


DFM’s statement of interests: I have received two inoculations and a booster of Biontech/Pfizer vaccine.



Fear is a basic emotion that is activated in response to perceived threat

COVID-19 Milestone Series

This post republishes: “The four horsemen of fear: An integrated model of understanding fear
experiences during the COVID-19 pandemic” by Adriano Schimmenti, Joël Billieux and Vladan Starcevic

Citation: Schimmenti, A., Billieux,J., Starcevic, V. (2020). The four horsemen of fear: An integrated model of understanding fear experiences during the COVID-19 pandemic. Clinical Neuropsychiatry, 17 (2), 41-45. https://doi.org/10.36131/ CN20200202 Copyright: © Clinical Neuropsychiatry

Authors: Adriano Schimmenti, Joël Billieux and Vladan Starcevic

In this article, we argue that fear experiences during the COVID-19 pandemic are organized on the psychological level around four interrelated dialectical domains, namely (1) fear of the body/fear for the body, (2) fear of significant others/fear for significant others, (3) fear of not knowing/fear of knowing, and (4) fear of taking action/fear of inaction. These domains represent the bodily, interpersonal, cognitive, and behavioural features of fear, respectively. We propose ways of addressing these fears and minimising their impact by improving appraisal of the body, fostering attachment security, improving emotion regulation, adopting acceptance and promoting responsibility.

The coronavirus pandemic poses a huge challenge to the society because it tests its ability to cope with a multifarious threat under the constraints of the situation.
Political actions are taken in the realm of health
management, public security, financial economics,
protection of assets and production of goods. Although
important, psychological health is probably the most
neglected aspect of the COVID-19 pandemic. It is
not an immediately visible part of the global picture
of this disaster, but the negative psychological impact
of the pandemic and measures taken in response to
the pandemic is well known (Brooks et al., 2020;
Morganstein, Fullerton, Ursano, & Holloway, 2017).
Crucially, the resilience of a society facing such a
catastrophic event also depends on how its individual
members cope with their anxiety and fears. Widespread
fears of aloneness, contagion and death affect our
sense of agency, relatedness and the way we behave,
in addition to restrictions imposed by governments.
Coping with these fears is thus critical on the individual
level, and effective coping can also help the society to
better manage the pandemic.

Fear is a basic emotion that is activated in response to perceived threat.
In the current article, we propose that fear during the COVID-19 pandemic
is organized on the psychological level around four
interrelated dialectical domains. These domains of fear
are (1) fear of the body/fear for the body, (2) fear of
significant others/fear for significant others, (3) fear
of not knowing/fear of knowing and (4) fear of taking
action/fear of inaction, and they represent the bodily,
interpersonal, cognitive, and behavioural features of
fear, respectively. We contend that the four domains of
fear observed during the COVID-19 pandemic reflect
the main psychological means of grasping the reality.
Moreover, we propose a dialectical structure of the
identified fears, whereby each aspect of a fear domain
may coexist with its counterpart (the apparent opposite)
and may relate to the aspects of other fear domains.
Thus, fear domains and their aspects are not organised
in a hierarchical manner and represent “ingredients” of
the complex experience of fear during the pandemic.
Figure 1 provides a graphical representation of
the domains of fears and their reciprocal interactions.
These “four horsemen of fear” are discussed in more
detail in the next section.

The four horsemen of fear during the COVID

The first domain of fear (fear of the body/fear for the
body) concerns the body and its signals. The body is the
first organizer of our human experience (Stern, 1985)
and it “keeps the score” (van der Kolk, 2015) of events
that threaten our physical and psychological integrity. In
the current experience of the COVID-19 pandemic, fear
of the body relates to a sense of physical vulnerability
due to which the body is a potential source of danger and
cannot be trusted (Starcevic, 2005). Such perception of

The second domain of fear (fear of significant
others/fear for significant others) relates to important
interpersonal relationships. As Aristotle said in his
Politics (Lord, 2003), human beings are by nature
“social animals”. Interpersonal relationships are at
the core of human identity, especially those involving
attachment figures such as parents, offspring and people
with whom we have romantic relationships. These
individuals provide us with a safe haven and a secure
base (Bowlby, 1988) from which we feel comfortable
to explore our internal experience and the external
world. The COVID-19 pandemic has affected our
perception of close interpersonal relationships with the
recommendations surrounding “social distancing”. We
are told by the authorities that maintaining a physical
distance even from people to whom we are attached
will slow down the spread of the coronavirus and keep
everyone safe. The consequence of this is a perception
that even the loved ones might harm us or kill us,
although unwittingly. Therefore, instead of providing
protection or a sense of safety, a parent, a child or an
intimate partner becomes a potential threat, with our
survival possibly depending on protecting ourselves
against people with whom we have the strongest
affective bonds. Conversely, we experience ourselves
as being potentially dangerous to our loved ones and
responsible if they become infected. We are thereby
deprived of our normal role to care for them or protect
them. These changes have profound consequences not
only in terms of how we relate to the significant others,
but also in terms of further undermining our sense of
safety and our need to “be there” for our loved ones.

The third domain of fear (fear of not knowing/fear
of knowing) concerns the cognitive aspect of mastering
the situations. In the context of the current COVID-19
pandemic, knowledge about the pandemic is bounded
and partial, which is deeply unsettling. One way of
coping with this situation is using the availability
heuristic (Tversky & Kahneman, 1973), that is, relying
on information that can be recalled, usually information
to which the person was exposed very recently. This

Figure 1. The “four horsemen” of fear (the four domains of fear) during the COVID-19 pandemic. Each fear

The fourth domain of fear (fear of taking action/fear
of inaction) concerns behavioural consequences of fear
during the COVID-19 pandemic. Our lives also consist
of actions, that is, intentional and purposeful activities
that are not reflexive, but are subjectively meaningful
(Davidson, 1980). As already noted, fears in the bodily,
interpersonal and cognitive domains often have a direct
impact on the behaviour. This is especially the case
when the “mutually opposing” fears alternate quickly,
producing indecisiveness and paralysing action. For
example, it may be very difficult to decide whether to
visit one’s elderly parents because of the possibility
of infecting them; such a person is torn between a
duty to care for parents and responsibility for keeping
them safe by avoiding such visits. In some vulnerable
individuals, a fear of taking action may manifest itself
in obsessive doubts about doing simple things, such
as buying groceries or opening a package sent from a
parent living in a heavily contaminated area. The other
“side of the coin” in this fear domain relates to people
who have a strong need to take some action and who
may be afraid of being passive or of being perceived
as such. This may explain the behaviour of individuals
who became hyperactive on social networking sites
only during the COVID-19 pandemic. Such individuals
spend most of the time online, going live on webcams,
publishing their own pictures or videos or posting news
related to the pandemic. In addition to alleviating these
individuals’ fear of inaction and of being invisible in
the world of the social media, such behaviour may
satisfy their narcissistic needs (Gnambs & Appel,
2018) and/or a need for belonging to a group that might
provide a sense of security. However, this behavioural
pattern may also reflect the problematic use of social
networking sites or apps which may have addictive
aspects that are difficult to attenuate and could require
clinical intervention.

Managing fear domains

Conquering pathological fear in the context of
the COVID-19 pandemic requires measures that
are relatively simple, as well as those that are more
complex and are best implemented in collaboration
with a mental health professional. Considering a
need to maintain social distance, psychoeducation
and psychological treatment delivered remotely via
communication technologies can provide individuals
with appropriate support (Sucala, Schnur, Constantino,
Miller, Brackman, & Montgomery, 2012) and improve
their quality of life (Lange, van de Ven, & Schrieken,

In fact, improving psychological health of
individuals is vital for strengthening the resilience
of the society as a whole. We argue here that this
objective could be achieved by applying the following
measures: (a) improving appraisal of the body, (b)
fostering attachment security, (c) improving emotion
regulation, (d) adopting acceptance and (e) promoting

Improving appraisal of the body

It is crucial for people in the midst of a pandemic
to be able to accurately appraise the physiological
signals of their bodies and to neither underestimate
nor overestimate their susceptibility to infections and
the associated physical threat. Most people find useful
physical and mental exercises that increase the feelings
of safety and control over the body, such as improving
posture (Weineck, Messner, Hauke, & Pollatos, 2019),
tracking the body autonomic response (Porges & Dana,
2018) and practicing mindfulness (Gibson, 2019).
People who are severely anxious about their health or
develop a full-blown hypochondriasis may need further
psychological treatment that specifically addresses
their bodily concerns (Bouman, 2014); sometimes,
this approach can be accompanied by antidepressants
(Harding & Fallon, 2014).

Fostering attachment security

Developing secure attachments is likely to improve
coping with the fear of the significant others and fear for
the significant others. Secure attachment has been linked
with the positive quality of interpersonal interactions
(including interactions with strangers; Roisman, 2006)
and with a capacity for effective self-regulation and topdown control (Pallini, Chirumbolo, Morelli, Baiocco, Laghi, & Eisenberg, 2018). Attachment security can
be fostered in the family and in other relationships via
mutually constructive communication (Domingue &
Mollen, 2009) that involves synchronous interactions
(e.g., by phone, if the communication partner is not
present; Gentzler, Oberhauser, Westerman, & Nadorff,

2011). When problematic relationships in the context of
the fears of COVID-19 call for a clinical intervention
improving the capacity to represent and mentalize the
internal states and the interpersonal motivations of
the significant others may be critical for both adults
(Allen & Fonagy, 2006) and children (Midgley, Ensink,
Linqvist, Malberg, & Muller, 2017). Also, it is important
to assess the quality of the attachment relationships,
identify the problems in these relationships and address
any internal conflicts that may surround the problems
(Lemma, Target, Fonagy, 2011). This should make a
tailored intervention to interpersonal fears possible.

Improving emotion regulation

Adopting acceptance

Clinical interventions based on acceptance
and compassion target the maladaptive emotional
avoidance and the unwillingness to experience
negatively evaluated feelings, sensations and thoughts
that generate inappropriate or detrimental behaviours.
These interventions increase flexibility and allow
adaptive behavioural change.

Promoting responsibility

Finally, situations like the COVID-19 pandemic
may bring out both the best and the worst in people.
It is a test of human ability to empathise, exhibit
solidarity and put the good of the society above one’s
own interests. Thus, individual responsibility is crucial
in the time of the COVID-19 pandemic. Individuals
are moral agents and their actions may positively or
negatively affect the lives of other people. Therefore,
promoting awareness of the pandemic and responsible
behaviour towards oneself and others may help people
feel morally sustained when confronting their fears.
Ultimately, it is responsible action that may prove
critical for our survival.


Allen, J. G., & Fonagy, P. (Eds.). (2006). The handbook of
mentalization-based treatment. New York, NY: John Wiley
& Sons Inc.
Bouman, T. K. (2014). Cognitive and behavioral models and
cognitive-behavioral and related therapies for health
anxiety and hypochondriasis. In Starcevic, V., & Noyes,
R. (Eds.). Hypochondriasis and Health Anxiety: A Guide
for Clinicians (pp. 149-198). New York, NY: Oxford
University Press.
Bowlby, J. (1988). A secure base. Clinical applications of
attachment theory. London, UK: Routledge.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L.,
Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The
psychological impact of quarantine and how to reduce it:
Rapid review of the evidence. The Lancet, 395(10227),
912–920. https://doi.org/10.1016/S0140-6736(20)30460-8
Davidson, D. (1980). Essay on Actions and Events. Oxford,
UK: Oxford University Press.
Domingue, R., & Mollen, D. (2009). Attachment and conflict
communication in adult romantic relationships. Journal of
Social and Personal Relationships, 26(5), 678–696. https://
Garcia, D., Al Nima, A., & Kjell, O. N. E. (2014). The
affective profiles, psychological well-being, and harmony:
Environmental mastery and self-acceptance predict the
sense of a harmonious life. PeerJ, 2, e259. https://doi.
Gazzillo, F., Schimmenti, A., Formica, I., Simonelli, A., &
Salvatore, S. (2017). Effectiveness is the gold standard
of clinical research. Research in Psychotherapy:
Psychopathology, Process and Outcome. https://doi.
Gentzler, A. L., Oberhauser, A. M., Westerman, D., &
Nadorff, D. K. (2011). College students’ use of electronic
communication with parents: Links to loneliness,
attachment, and relationship quality. Cyberpsychology,
Behavior and Social Networking, 14(1–2), 71–74. https://
Gibson, J. (2019). Mindfulness, Interoception, and the Body:
A Contemporary Perspective. Frontiers in Psychology, 10.
Gnambs, T., & Appel, M. (2018). Narcissism and Social
Networking Behavior: A Meta-Analysis. Journal of
Personality, 86(2), 200–212. https://doi.org/10.1111/
Harding, K. J. K., & Fallon, B. A. (2014). Pharmacological
treatment and neurobiology of hypochondriasis, illness
anxiety, and somatic symptoms. In Starcevic, V., & Noyes,
R. (Eds). Hypochondriasis and Health Anxiety: A Guide for
Clinicians (pp. 241-258). New York, NY: Oxford University
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L.,
& Pistorello, J. (2013). Acceptance and commitment therapy
and contextual behavioral science: Examining the progress
The four horsemen of fear
Clinical Neuropsychiatry (2020) 17, 2 45
of a distinctive model of behavioral and cognitive therapy.
Behavior Therapy, 44(2), 180–198. https://doi.org/10.1016/j.
Koole, S. L. (2009). The psychology of emotion regulation: An
integrative review. Cognition and Emotion, 23(1), 4–41.
Lange, A., van de Ven, J.-P., & Schrieken, B. (2003). Interapy:
Treatment of post-traumatic stress via the internet.
Cognitive Behaviour Therapy, 32(3), 110–124. https://doi.
la Repubblica (2020). Coronavirus, l’allarme dei cardiologi: ‘Per
il timore contagi meno ricoveri per infarto’ [Coronavirus,
the cardiologists’ alarm: “Due to fear of contagion, less
ospitalization for infartion”]. (2020, March 25). Retrieved
from https://www.repubblica.it/salute/medicina-ericerca/2020/03/23/news/coronavirus_meno_ricoveri_per_
Lemma, A., Target, M., & Fonagy, P. (2011). Brief Dynamic
Interpersonal Therapy: A Clinician’s Guide. Oxford, UK:
Oxford University Press.
Lord (2003). Aristotle’s Politics. Chicago, IL: University of
Chicago Press.
Midgley, N., Ensink, K., Lindqvist, K., Malberg, N., & Muller, N.
(2017). Mentalization-based treatment for children: A timelimited approach. Washington, DC: American Psychological
Association. https://doi.org/10.1037/0000028-000
Morganstein, J. C., Fullerton, C. S., Ursano, R. J., & Holloway, H.
C. (2017). Pandemics: Health Care Emergencies. In Ursano,
R. J., Fullerton, C. S., Weisaeth, L., & Raphael, B. (eds.).
Textbook of Disaster Psychiatry (2nd ed., pp. 270–284).
Cambridge, NY: Cambridge University Press.
Pallini, S., Chirumbolo, A., Morelli, M., Baiocco, R., Laghi,
F., & Eisenberg, N. (2018). The relation of attachment
security status to effortful self-regulation: A meta-analysis.
Psychological Bulletin, 144(5), 501–531. https://doi.
Philippot, P. (2013). Emotion Regulation: A Heuristic Paradigm for
Psychopathology. Journal of Experimental Psychopathology,
4(5), 600–607. https://doi.org/10.5127/jep.034513
Porges, S.W., & Dana, D. (2018). Clinical Applications of the
Polyvagal Theory: The Emergence of Polyvagal-Informed
Therapies. New York, NY: WW Norton.
Roisman, G. I. (2006). The role of adult attachment security in nonromantic, non-attachment-related first interactions between
same-sex strangers. Attachment & Human Development,
8(4), 341–352. https://doi.org/10.1080/14616730601048217
Schimmenti, A., Santoro, G., La Marca, L., Costanzo, A., &
Gervasi, A. M. (2019). Emotion dysregulation: a correlation
network analysis. Psychotherapy and Psychosomatics,
88(S1), 115. https://doi.org/ 10.1159/000502467.359
Starcevic, V. (2005). Fear of Death in Hypochondriasis:
Bodily Threat and Its Treatment Implications. Journal of
Contemporary Psychotherapy, 35(3), 227–237. https://doi.
Starcevic, V. (2017). Cyberchondria: Challenges of Problematic
Online Searches for Health-Related Information.
Psychotherapy and Psychosomatics, 86(3), 129–133. https://
Stewart, J. M. (2014). Mindfulness, acceptance, and the
psychodynamic evolution. Oakland, CA: Context Press.
Stern, D. N. (1985). The Interpersonal World of the Infant: A View
from Psychoanalysis and Developmental Psychology. New
York, NY: Basic Books.
Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J.,
Brackman, E. H., & Montgomery, G. H. (2012). The
therapeutic relationship in e-therapy for mental health: A
systematic review. Journal of Medical Internet Research,
14(4), e110. https://doi.org/10.2196/jmir.2084
Tversky, A., & Kahneman, D. (1973). Availability: A heuristic for
judging frequency and probability. Cognitive Psychology, 5(2),
207–232. https://doi.org/10.1016/0010-0285(73)90033-9
van der Kolk, B. (2015). The Body Keeps the Score: Mind, Brain
and Body in the Transformation of Trauma. New York, NY:
Penguin Random House.
Watkins, E. R. (2016). Rumination-focused cognitive-behavioral
therapy for depression. New York, NY: Guilford Press.
Weineck, F., Messner, M., Hauke, G., & Pollatos, O. (2019).
Improving interoceptive ability through the practice of
power posing: A pilot study. PLoS ONE, 14(2). https://doi.

Commentary by DFM:

  1. There are multiple connections between this paper and the The General Theory of Behaviour.
  2. Emotion regulation by the ‘four horsemen’ follows principles of homeostasis laid out in the theory.
  3. The regulation of fear makes the difference between chaos and control.


Fear of COVID-19

COVID-19 Milestone Series

In previous posts, here and here, I have drawn attention to the role of functional fear in human responses to COVID-19 pandemic. For various imaginable reasons, the government’s policy advisors do not openly discuss the use of fear in public health interventions, yet it is obvious to any observer that increasing fear is the primary target of governmental interventions to control the public’s responses to the pandemic.

Here I republish the Abstract of a significant article concerning the Fear of COVID-19 Scale. It provides a valuable tool for the assessment of this fundamental driver of human behaviour and the authors are to be congratulated.

Int J Ment Health Addict. 2020 Mar 27 : 1–9.doi: 10.1007/s11469-020-00270-8 [Epub ahead of print]PMCID: PMC7100496PMID: 32226353

The Fear of COVID-19 Scale: Development and Initial Validation

Daniel Kwasi Ahorsu,1Chung-Ying Lin,1Vida Imani,2Mohsen Saffari,3Mark D. Griffiths,4 and Amir H. Pakpour5,6

Author informationCopyright and License informationDisclaimerCopyright © Springer Science+Business Media, LLC, part of Springer Nature 2020This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.This article has been cited by other articles in PMC.Go to:



The emergence of the COVID-19 and its consequences has led to fears, worries, and anxiety among individuals worldwide. The present study developed the Fear of COVID-19 Scale (FCV-19S) to complement the clinical efforts in preventing the spread and treating of COVID-19 cases.


The sample comprised 717 Iranian participants. The items of the FCV-19S were constructed based on extensive review of existing scales on fears, expert evaluations, and participant interviews. Several psychometric tests were conducted to ascertain its reliability and validity properties.


After panel review and corrected item-total correlation testing, seven items with acceptable corrected item-total correlation (0.47 to 0.56) were retained and further confirmed by significant and strong factor loadings (0.66 to 0.74). Also, other properties evaluated using both classical test theory and Rasch model were satisfactory on the seven-item scale. More specifically, reliability values such as internal consistency (α = .82) and test–retest reliability (ICC = .72) were acceptable. Concurrent validity was supported by the Hospital Anxiety and Depression Scale (with depression, r = 0.425 and anxiety, r = 0.511) and the Perceived Vulnerability to Disease Scale (with perceived infectability, r = 0.483 and germ aversion, r = 0.459).


The Fear of COVID-19 Scale, a seven-item scale, has robust psychometric properties. It is reliable and valid in assessing fear of COVID-19 among the general population and will also be useful in allaying COVID-19 fears among individuals.

Keywords: COVID-19, Fear, Iran, Psychometrics, Fear of COVID-19 Scale


Fear of Coronavirus

COVID-19 Milestone Series

Original article published in: J Anxiety Disorders 2020 Aug; 74:102258. doi: 10.1016/j.janxdis.2020.102258. Epub 2020 Jun 10.

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020

Gaëtan Mertens 1Lotte Gerritsen 2Stefanie Duijndam 3Elske Salemink 2Iris M Engelhard 2


Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R2 = .37). Furthermore, 16 different topics of concern were identified based participants’ open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people’s fear of the coronavirus.

Keywords: Coronavirus; Fear; Health anxiety; Intolerance of uncertainty; Media.


The Fear Motive – Missing from the Model

Capability, opportunity, and motivation to enact hygienic practices in the early stages of the
COVID-19 outbreak in the United Kingdom

COVID-19 Milestone Series

Extract from the originally published article in the British Journal of Health Psychology (2020), 25, 856–864. Authors: Jilly Gibson Miller et al.

Open Access. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
These few extracts from the published article indicate that all is not well with the COM-B model. The level of empirical support is weak, with only three of six factors showing the predicted positive association with hygienic practices. The most significant factor, ‘reflective motivation’, includes habits and intentions and is difficult to interpret. Many other studies indicate that the strongest predictor of health protective behaviours is the fear motive, notably missing from the COM-B model. Replacing Motivation with Fear Homeostasis, and removing Capability and Opportunity yields a more basic ‘Fear-Homeostasis- Behaviour’ (F-H-B) model, which already receives significant empirical support (e.g. Tannenbaum et al, 2015). As one would predict, in a recent Brazilian study, fear was significantly higher among those practicing protective measures against COVID-19 (facial mask, alcohol gel, and hand hygiene) and respecting social distancing (Giordani 2020).


Objectives. The COVID-19 pandemic is one of the greatest global health threats facing
humanity in recent memory. This study aimed to explore influences on hygienic practices,
a set of key transmission behaviours, in relation to the Capability, Opportunity,
Motivation-Behaviour (COM-B) model of behaviour change (Michie et al., 2011).

Design. Data from the first wave of a longitudinal survey study were used, launched in
the early stages of the UK COVID-19 pandemic.

Methods. Participants were 2025 adults aged 18 and older, representative of the UK
population, recruited by a survey company from a panel of research participants.

Participants self-reported motivation, capability, and opportunity to enact hygienic
practices during the COVID-19 outbreak.

Results. Using regression models, we found that all three COM-B components
significantly predicted good hygienic practices, with motivation having the greatest
influence on behaviour. Breaking this down further, the subscales psychological capability,
social opportunity, and reflective motivation positively influenced behaviour. Reflective
motivation was largely driving behaviour, with those highest in reflective motivation
scoring 51% more on the measure of hygienic practices compared with those with the
lowest scores.

Figure 1:

Conclusions. Our findings have clear implications for the design of behaviour change
interventions to promote hygienic practices. Interventions should focus on increasing and
maintaining motivation to act and include elements that promote and maintain social
support and knowledge of COVID-19 transmission. Groups in particular need of
targeting for interventions to increase hygienic practices are males and those living in
cities and suburbs.

What does this study add?
This study provides insight into the factors influencing UK citizens’ hygienic practices during the early stages of the COVID-19 pandemic.
We found that reflective processes were largely driving hygienic practices – these involve making plans to enact the behaviour and supporting the belief that the behaviour is a good thing to do.
Behaviour change interventions to improve and maintain hygienic practices throughout the lockdown and beyond should contain behaviour change techniques that focus on self-regulatory processes involving planning and goal setting.

Jilly Gibson Miller et al. (2020).

Commentary by DFM

The article contains a series of red flags suggesting that all is not well with the COM-B model.

  1. Only three of the six COM-B variables were positively associated with hygienic practices. Two COM-B variables were negatively associated with hygienic behaviours (opportunity – physical and motivation – automatic) and one COM-B variable (capability -physical) was not associated with hygienic behaviours.
  2. It is notable that the measures were self-reported capabilities, opportunities and behaviours. (see Appendix 1).There is no objective evidence that any of the COM-B variables were associated with actual behaviour change.
  3. The majority of the studies are cross‐sectional in design so that inferences about causality are impossible.
  4. Measurement of the psychological constructs was heterogeneous. The measures need to be simplified and more cohesive.
  5. Measurement of motivation needs to include wants as well as needs and including feelings as well as cognitive judgment to improve the prediction of behaviour (Weinstein et al., 2007).
  6. The studies relied on self‐reports which are open to reporting bias from socially desirability.
  7. Self‐report measures of hand‐washing practices have poor validity (e.g., Curtis, Danquah, & Aunger, 2009Curtis et al., 1993).
  8. The use of intention is limited by the ‘intention–behaviour gap’ such that reported intentions may not in fact translate into behaviour in the event of an actual pandemic (Orbell & Sheeran, 1998).
  9. The COM-B model accounted for only 17% of the variance in self-reported hygienic practices leaving 83% of the variance unexplained. This is typical of models in health psychology which rarely account for more than 20-25% of the variance in behaviour.
  10. The strongest association was between ‘reflective motivation’ and self-reported hygienic practices. However, the items used to define reflective motivation are diverse and include both intentions and habits, which themselves are problematic.
  11. According to the authors “reflective processes were driving hygienic practices” – making plans to enact the behaviour and supporting the belief that the behaviour is a good thing to do. However ‘reflective processes’ are cognitive not motivational processes and these have been mislabelled by the investigators as ‘motivational’.
  12. There is no evidence of a causal connection between self-reported reflective processes and hygienic practices, only a statistical association. Thus words such as ‘driving’ are inappropriate and misleading.
  13. A truly motivational process – fear – is omitted from the COM-B model yet multiple studies indicate functional fear to be of primary importance in motivating hygienic and other protective behaviours in attempts to minimise the risk of COVID-19 infection.
  14. Interventions must address the primary motive of COVID-19 behaviour change, which is fear.
  15. Indoor air quality and improved ventilation are key requirements in the fight to reduce SARS-CoV-2 infections, neglected factors in a neo-liberal policy of placing responsibility on citizens who are expected to conform to mandates and programmes of vaccination.
  16. Governmental policies for public health protection based on the COM-B model remain unsupported by empirical investigations.

Appendix 1

Table A1. Descriptive data for survey items used to measure hygienic practices and COM-B

Hygienic Practices (3-point scale)Mean
B1“Washed your hands with soap and water more often.”2.72
B2“Used hand sanitising gel if soap and water were not available.”2.38
B3“Used disinfectants to wash surfaces in your home more frequently.”2.22
B4“Covered your nose and mouth with a tissue or sleeve when coughing or sneezing.”2.64
B5Touching eyes and mouth (5-point scale)3.62
COM-B items (5-point scale) 
 Psychological Capability 
C1“I knew about why it was important and had a clear idea about how the virus was transmitted.”4.21
C2“I knew about how and when to do it.”4.21
C3“I was able to overcome the physical and/or mental barriers that might have stopped me from doing it.”3.92
 Physical opportunity 
O1“I had the necessary time to do it.”4.20
O2“It was easy for me to do it.”4.21
 Social opportunity 
O3“People were doing it around me.”3.81
O4“I had reminders that prompted me.”3.46
O5“I had support from others.”3.55
O6“I felt like doing it was normal and expected.”4.15
 Reflective motivation 
M1“I intended to do it.”4.18
M2“I felt that I wanted to do it.”4.17
M3“I believe that it was a good thing to do.”4.31
M4“I developed a specific plan for doing it.”3.36
M5“I developed a habit of it in my everyday routine.”3.95
 Automatic motivation 
M6“It made me feel anxious.”  R2.68
M7“It made me feel disgusted.” R2.14
M8“I felt like I could control my emotional reactions so I could do it.”3.42

Notes: Higher scores relate to higher compliance/agreement with that measure. R indicates item is reverse-coded.


Tannenbaum M. B., Hepler J., Zimmerman R. S., Saul L., Jacobs S., Wilson K., et al. (2015). Appealing to fear: a meta-analysis of fear appeal effectiveness and theories. Psychol. Bull. 141 1178–1204. 10.1037/a0039729


Functional Fear Predicts Public Health Compliance in the COVID-19 Pandemic

COVID-19 Milestones Series

Authors: Craig A. Harper, Liam P. Satchell, Dean Fido & Robert D. Latzman

Originally published in the International Journal of Mental Health and Addiction (2021) 19:1875–1888: https://doi.org/10.1007/s11469-020-00281-5 “Functional Fear Predicts Public Health.

Here I republish the first page (p. 1875) only.


In the current context of the global pandemic of coronavirus disease-2019 (COVID-19), health professionals are working with social scientists to inform government policy on how to slow the spread of the virus. An increasing amount of social scientific research has looked at the role of public message framing, for instance, but few studies have thus far examined the role of individual differences in emotional and personality-based variables in predicting virus-mitigating behaviors. In this study, we recruited a large international community sample (N = 324) to complete measures of self-perceived risk of contracting COVID-19, fear of the virus, moral foundations, political orientation, and behavior change in response to the pandemic. Consistently, the only predictor of positive behavior change (e.g., social distancing, improved hand hygiene) was fear of COVID-19, with no effect of politically relevant variables. We discuss these data in relation to the potentially functional nature of fear in global health crises.


Lead author: Craig A. Harper craigaharper19@davidfmarks2018

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.



Covid-19: Omicron may be more transmissible than other variants and partly resistant to existing vaccines, scientists fear

COVID-19 Milestone Series

Originally published by the BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2943 (Published 29 November 2021)

Cite this as: BMJ 2021;375:n2943

Author: Ingrid Torjesen

Omicron, the SARS-CoV-2 variant responsible for a cluster of cases in South Africa and that is now spreading around the world, is the most heavily mutated variant to emerge so far and carries mutations similar to changes seen in previous variants of concern associated with enhanced transmissibility and partial resistance to vaccine induced immunity.

Daily case numbers in South Africa had been fairly low but then rose rapidly from 273 on 16 November to more than 1200 by 25 November, more than 80% of which were in the northern province of Gauteng, where the first cases were seen.

Europe’s first case of the variant was confirmed in Belgium on 26 November in a person who tested positive for covid-19 on 22 November. By 29 November cases had been reported in the Netherlands, France, Germany, Portugal, and Italy. The UK had recorded nine cases by the morning of 29 November, six of them in Scotland.

Elsewhere in the world cases have been reported in Botswana, Hong Kong, Canada, and Australia, which has had extremely tight border controls through the pandemic.

Some countries, including Japan and Israel, were quick to close their borders to all foreign travellers, while others, such as the UK and EU countries, enforced quarantine for travellers from South Africa and neighbouring countries after the World Health Organization designated omicron an official variant of concern on 26 November.

To slow the spread of the variant the UK government has announced that masks are again to become compulsory on public transport and in shops and schools, all contacts of people with a case of omicron will be required to isolate for 10 days, and all travellers entering the country will have to take a PCR test two days later and to self-isolate until they receive a negative result. On 29 November the government was expected to announce that the vaccine booster programme would be expanded to people under 40, after a recommendation from the Joint Committee on Vaccination and Immunisation.

Chaand Nagpaul, chair of council at the BMA, said that mandatory mask wearing should be extended to all public indoor and closed settings, including for staff in the hospitality industry, such as restaurants, and beauty salons. “This addition to government measures will have minimal economic and social impact, but evidence tells us that it will help to further reduce the spread of the virus,” he said. “We only have a small window of opportunity to get this right to ensure that we don’t lose control of this new variant, which has the potential to have a devastating impact on the health service. The government must act now, or we risk seeing even more unnecessary deaths.”

Novel mutations

Lawrence Young, a virologist and professor of molecular oncology at Warwick Medical School, said, “This new variant of the covid-19 virus is very worrying. This variant carries some changes we’ve seen previously in other variants but never altogether in one virus. It also has novel mutations that we’ve not seen before.”

In total, the variant’s genome has around 50 mutations, including more than 30 in the spike protein, the part that interacts with human cells before cell entry and that has been the primary target for current vaccines.

David Matthews, professor of virology at the University of Bristol, said that there have been several variants of concern that have turned out not to be as worrying as first thought but that it was important to be cautious at this stage. “There is also the risk that the variant might be better at spreading than the delta variant, and then you speed up the rate at which people are fed into the NHS or any healthcare system, particularly the unvaccinated, which makes it harder and harder for any healthcare system to cope,” he said.

Sharon Peacock, director of the COG-UK Genomics UK Consortium and professor of public health and microbiology at the University of Cambridge, said that the effects of the detected mutations on the omicron variant’s functionality were unknown. “Studies are being rapidly conducted in South Africa to look at antibody neutralisation of this variant, as well as interactions with T cells, but these studies are going to take several weeks to complete,” she said.

Even if current vaccines proved to be less effective against omicron, they were likely to still provide some protection, said Wendy Barclay, leader of the G2P-UK National Virology Consortium and research chair in virology at Imperial College London, and she urged the general public to take up all vaccine shots offered. “If we have a variant that is antigenically distant and isn’t neutralised at a certain level of antibody, there is something we can do: we can boost the overall antibody levels, because sometimes quantity can compensate for the lack of match,” she said. “I would strongly urge people to take the opportunity to give their immune systems the best quantitative chance that they have by getting booster doses and the full course of vaccination.”

Scientists praised South African authorities for their quick action in identifying the variant and putting the world on alert.

Investigation of a similar rise in cases last winter in Kent had also led to the quick identification of the alpha variant.

In contrast, lack of sequencing capability in India meant it took many weeks before the delta variant was found to be behind a rise in cases there. “By that point, delta had already seeded itself in many parts of the world,” said Jeffrey Barrett, director of the Covid-19 Genomics Initiative at the Wellcome Sanger Institute, at a Science Media Centre briefing.

One of the omicron variant’s mutations leads to “S gene target failure” (or “S gene dropout”), meaning that one of several areas of the gene that are targeted by PCR testing gives a false negative. This can be used as a “surrogate marker,” allowing genome sequencing to be targeted, Peacock said, particularly where circulating strains are predominantly S gene positive, as is the case with the delta variant.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.https://bmj.com/coronavirus/usage


Pfizer’s Vaccine Trial Questioned

COVID-19 Milestone Series

Covid-19: Researcher blows the whistle on data integrity issues in Pfizer’s vaccine trial

Originally published in the BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2635 on 02 November 2021 by Paul D Thacker, investigative journalist

This post republishes an article about “Revelations of poor practices at a contract research company helping to carry out Pfizer’s pivotal covid-19 vaccine trial raise questions about data integrity and regulatory oversight. “

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. https://bmj.com/coronavirus/usage

Author: Paul D Thacker 

In autumn 2020 Pfizer’s chairman and chief executive, Albert Bourla, released an open letter to the billions of people around the world who were investing their hopes in a safe and effective covid-19 vaccine to end the pandemic. “As I’ve said before, we are operating at the speed of science,” Bourla wrote, explaining to the public when they could expect a Pfizer vaccine to be authorised in the United States.1

But, for researchers who were testing Pfizer’s vaccine at several sites in Texas during that autumn, speed may have come at the cost of data integrity and patient safety. A regional director who was employed at the research organisation Ventavia Research Group has told The BMJ that the company falsified data, unblinded patients, employed inadequately trained vaccinators, and was slow to follow up on adverse events reported in Pfizer’s pivotal phase III trial. Staff who conducted quality control checks were overwhelmed by the volume of problems they were finding. After repeatedly notifying Ventavia of these problems, the regional director, Brook Jackson, emailed a complaint to the US Food and Drug Administration (FDA). Ventavia fired her later the same day. Jackson has provided The BMJ with dozens of internal company documents, photos, audio recordings, and emails.

Poor laboratory management

On its website Ventavia calls itself the largest privately owned clinical research company in Texas and lists many awards it has won for its contract work.2 But Jackson has told The BMJ that, during the two weeks she was employed at Ventavia in September 2020, she repeatedly informed her superiors of poor laboratory management, patient safety concerns, and data integrity issues. Jackson was a trained clinical trial auditor who previously held a director of operations position and came to Ventavia with more than 15 years’ experience in clinical research coordination and management. Exasperated that Ventavia was not dealing with the problems, Jackson documented several matters late one night, taking photos on her mobile phone. One photo, provided to The BMJ, showed needles discarded in a plastic biohazard bag instead of a sharps container box. Another showed vaccine packaging materials with trial participants’ identification numbers written on them left out in the open, potentially unblinding participants. Ventavia executives later questioned Jackson for taking the photos.

Early and inadvertent unblinding may have occurred on a far wider scale. According to the trial’s design, unblinded staff were responsible for preparing and administering the study drug (Pfizer’s vaccine or a placebo). This was to be done to preserve the blinding of trial participants and all other site staff, including the principal investigator. However, at Ventavia, Jackson told The BMJ that drug assignment confirmation printouts were being left in participants’ charts, accessible to blinded personnel. As a corrective action taken in September, two months into trial recruitment and with around 1000 participants already enrolled, quality assurance checklists were updated with instructions for staff to remove drug assignments from charts.

In a recording of a meeting in late September2020 between Jackson and two directors a Ventavia executive can be heard explaining that the company wasn’t able to quantify the types and number of errors they were finding when examining the trial paperwork for quality control. “In my mind, it’s something new every day,” a Ventavia executive says. “We know that it’s significant.”

Ventavia was not keeping up with data entry queries, shows an email sent by ICON, the contract research organisation with which Pfizer partnered on the trial. ICON reminded Ventavia in a September 2020 email: “The expectation for this study is that all queries are addressed within 24hrs.” ICON then highlighted over 100 outstanding queries older than three days in yellow. Examples included two individuals for which “Subject has reported with Severe symptoms/reactions … Per protocol, subjects experiencing Grade 3 local reactions should be contacted. Please confirm if an UNPLANNED CONTACT was made and update the corresponding form as appropriate.” According to the trial protocol a telephone contact should have occurred “to ascertain further details and determine whether a site visit is clinically indicated.”

Worries over FDA inspection

Documents show that problems had been going on for weeks. In a list of “action items” circulated among Ventavia leaders in early August 2020, shortly after the trial began and before Jackson’s hiring, a Ventavia executive identified three site staff members with whom to “Go over e-diary issue/falsifying data, etc.” One of them was “verbally counseled for changing data and not noting late entry,” a note indicates.

At several points during the late September meeting Jackson and the Ventavia executives discussed the possibility of the FDA showing up for an inspection (box 1). “We’re going to get some kind of letter of information at least, when the FDA gets here . . . know it,” an executive stated.Box 1

A history of lax oversight

When it comes to the FDA and clinical trials, Elizabeth Woeckner, president of Citizens for Responsible Care and Research Incorporated (CIRCARE),3 says the agency’s oversight capacity is severely under-resourced. If the FDA receives a complaint about a clinical trial, she says the agency rarely has the staff available to show up and inspect. And sometimes oversight occurs too late.

In one example CIRCARE and the US consumer advocacy organisation Public Citizen, along with dozens of public health experts, filed a detailed complaint in July 2018 with the FDA about a clinical trial that failed to comply with regulations for the protection of human participants.4 Nine months later, in April 2019, an FDA investigator inspected the clinical site. In May this year the FDA sent the triallist a warning letter that substantiated many of the claims in the complaints. It said, “[I]t appears that you did not adhere to the applicable statutory requirements and FDA regulations governing the conduct of clinical investigations and the protection of human subjects.”5

“There’s just a complete lack of oversight of contract research organisations and independent clinical research facilities,” says Jill Fisher, professor of social medicine at the University of North Carolina School of Medicine and author of Medical Research for Hire: The Political Economy of Pharmaceutical Clinical Trials.

Ventavia and the FDA

A former Ventavia employee told The BMJ that the company was nervous and expecting a federal audit of its Pfizer vaccine trial.

“People working in clinical research are terrified of FDA audits,” Jill Fisher told The BMJ, but added that the agency rarely does anything other than inspect paperwork, usually months after a trial has ended. “I don’t know why they’re so afraid of them,” she said. But she said she was surprised that the agency failed to inspect Ventavia after an employee had filed a complaint. “You would think if there’s a specific and credible complaint that they would have to investigate that,” Fisher said.

In 2007 the Department of Health and Human Services’ Office of the Inspector General released a report on FDA’s oversight of clinical trials conducted between 2000 and 2005. The report found that the FDA inspected only 1% of clinical trial sites.6 Inspections carried out by the FDA’s vaccines and biologics branch have been decreasing in recent years, with just 50 conducted in the 2020 fiscal year.7RETURN TO TEXT

The next morning, 25 September 2020, Jackson called the FDA to warn about unsound practices in Pfizer’s clinical trial at Ventavia. She then reported her concerns in an email to the agency. In the afternoon Ventavia fired Jackson—deemed “not a good fit,” according to her separation letter.

Jackson told The BMJ it was the first time she had been fired in her 20 year career in research.

Concerns raised

In her 25 September email to the FDA Jackson wrote that Ventavia had enrolled more than 1000 participants at three sites. The full trial (registered under NCT04368728) enrolled around 44 000 participants across 153 sites that included numerous commercial companies and academic centres. She then listed a dozen concerns she had witnessed, including:

  • Participants placed in a hallway after injection and not being monitored by clinical staff
  • Lack of timely follow-up of patients who experienced adverse events
  • Protocol deviations not being reported
  • Vaccines not being stored at proper temperatures
  • Mislabelled laboratory specimens, and
  • Targeting of Ventavia staff for reporting these types of problems.

Within hours Jackson received an email from the FDA thanking her for her concerns and notifying her that the FDA could not comment on any investigation that might result. A few days later Jackson received a call from an FDA inspector to discuss her report but was told that no further information could be provided. She heard nothing further in relation to her report.

In Pfizer’s briefing document submitted to an FDA advisory committee meeting held on 10 December 2020 to discuss Pfizer’s application for emergency use authorisation of its covid-19 vaccine, the company made no mention of problems at the Ventavia site. The next day the FDA issued the authorisation of the vaccine.8

In August this year, after the full approval of Pfizer’s vaccine, the FDA published a summary of its inspections of the company’s pivotal trial. Nine of the trial’s 153 sites were inspected. Ventavia’s sites were not listed among the nine, and no inspections of sites where adults were recruited took place in the eight months after the December 2020 emergency authorisation. The FDA’s inspection officer noted: “The data integrity and verification portion of the BIMO [bioresearch monitoring] inspections were limited because the study was ongoing, and the data required for verification and comparison were not yet available to the IND [investigational new drug].”

Other employees’ accounts

In recent months Jackson has reconnected with several former Ventavia employees who all left or were fired from the company. One of them was one of the officials who had taken part in the late September meeting. In a text message sent in June the former official apologised, saying that “everything that you complained about was spot on.”

Two former Ventavia employees spoke to The BMJ anonymously for fear of reprisal and loss of job prospects in the tightly knit research community. Both confirmed broad aspects of Jackson’s complaint. One said that she had worked on over four dozen clinical trials in her career, including many large trials, but had never experienced such a “helter skelter” work environment as with Ventavia on Pfizer’s trial.

“I’ve never had to do what they were asking me to do, ever,” she told The BMJ. “It just seemed like something a little different from normal—the things that were allowed and expected.”

She added that during her time at Ventavia the company expected a federal audit but that this never came.

After Jackson left the company problems persisted at Ventavia, this employee said. In several cases Ventavia lacked enough employees to swab all trial participants who reported covid-like symptoms, to test for infection. Laboratory confirmed symptomatic covid-19 was the trial’s primary endpoint, the employee noted. (An FDA review memorandum released in August this year states that across the full trial swabs were not taken from 477 people with suspected cases of symptomatic covid-19.)

“I don’t think it was good clean data,” the employee said of the data Ventavia generated for the Pfizer trial. “It’s a crazy mess.”

A second employee also described an environment at Ventavia unlike any she had experienced in her 20 years doing research. She told The BMJ that, shortly after Ventavia fired Jackson, Pfizer was notified of problems at Ventavia with the vaccine trial and that an audit took place.

Since Jackson reported problems with Ventavia to the FDA in September 2020, Pfizer has hired Ventavia as a research subcontractor on four other vaccine clinical trials (covid-19 vaccine in children and young adults, pregnant women, and a booster dose, as well an RSV vaccine trial; NCT04816643,  NCT04754594,  NCT04955626,  NCT05035212). The advisory committee for the Centers for Disease Control and Prevention is set to discuss the covid-19 paediatric vaccine trial on 2 November.


  • Provenance and peer review: commissioned; externally peer reviewed.
  • Competing interests: PDT has been doubly vaccinated with Pfizer’s vaccine.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.https://bmj.com/coronavirus/usage


  1. Bourla A. An open letter from Pfizer chairman and CEO Albert Bourla. Pfizer. https://www.pfizer.com/news/hot-topics/an_open_letter_from_pfizer_chairman_and_ceo_albert_bourla.
  2. Ventavia. A leading force in clinical research trials. https://www.ventaviaresearch.com/company.
  3. Citizens for Responsible Care and Research Incorporated (CIRCARE). http://www.circare.org/corp.htm.
  4. Public Citizen. Letter to Scott Gottlieb and Jerry Menikoff. Jul 2018. https://www.citizen.org/wp-content/uploads/2442.pdf.
  5. Food and Drug Administration. Letter to John B Cole MD. MARCS-CMS 611902. May 2021. https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/jon-b-cole-md-611902-05052021.
  6. Department of Health and Human Services Office of Inspector General. The Food and Drug Administration’s oversight of clinical trials. Sep 2007. https://www.oig.hhs.gov/oei/reports/oei-01-06-00160.pdf.
  7. Food and Drug Administration. Bioresearch monitoring. https://www.fda.gov/media/145858/download.
  8. FDA takes key action in fight against covid-19 by issuing emergency use authorization for first covid-19 vaccine. Dec 2020. https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19.

Competing interests: DFM has been triply vaccinated with Pfizer’s vaccine.


Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries

COVID-19 Milestone Series

Panic stations! UK deaths of 750 a day predicted and rising. The paper that threw the entire world into disarray. But were our fears justified? Only history will tell. But the consequences have been severe.

The full report is 35 pages. Here I repost only the Summary, pages 1-2.


Revisiting the initial COVID-19 pandemic projections

COVID-19 Milestone Series

In previous posts I republished early attempts to project fatalities: here and here. In their milestone paper here, Adam T Biggs and Lanny F Littlejohn explain how interventions to protect the public were founded on exaggerated claims about the likely fatalities from the pandemic. One study from Imperial College, London on 16 March 2020 estimated that in the US there could be 2.35M deaths and in the UK, close to 600,000 deaths. To date, total numbers of deaths in these countries have been 769,769 and 144,433 respectively, 32% and 24% respectively of the projections. Will the projected numbers of deaths ever be reached? Nobody can say. For now the estimates appear pessimistic, some might say, grossly inflated.

The societal, economic and psychological burdens resulting from governmental actions to suppress the pandemic will be felt for decades. Whether the governmental actions will ultimately be viewed as justifiable is for future historians to decide. The jury is still out, but I, for one, remain skeptical.

Authors: Adam T Biggs and Lanny F Littlejohn

Open Access Originally Published: March, 2021


Early projections of the COVID-19 pandemic prompted federal governments to action. One critical report, published on March 16, 2020, received international attention when it predicted 2 200 000 deaths in the USA and 510 000 deaths in the UK without some kind of coordinated pandemic response.1 This information became foundational in decisions to implement physical distancing and adherence to other public health measures because it established the upper boundary for any worst-case scenarios.However, the authors derived these projections from best available estimates at the time. The evolving nature of empirical knowledge about COVID-19 provides current estimates with more accurate information than what would have been available merely weeks after first discovery of the virus—plus the benefit of hindsight. For example, asymptomatic transmission has been said to be the Achilles’ heel of public health strategies to control the pandemic,2 and several factors about asymptomatic cases remained uncertain during the early days. The report assumed that asymptomatic individuals were 50% as infectious as symptomatic cases,1 whereas the current US Centers for Disease Control and Prevention (CDC) estimates suggest a 75% infectiousness rate for asymptomatic individuals.3 A more important difference is the infection fatality ratio as originally projected in the Imperial College London (London, UK) report1 versus current estimations. A high ratio of asymptomatic individuals might have inflated the perceived mortality of the disease given the limited testing supplies and attention to symptomatic cases.

Age 0–19 yearsAge 20–49 yearsAge 50–69 yearsAge >70 yearsTotal
Population83 267 556126 429 14471 216 11727 832 721308 745 538
Projected deaths
Imperial College London report273389 358725 2321 532 0442 349 367
CDC estimations202320 482288 4251 217 4031 528 333
Seroprevalence135948 638259 2351 070 3811 379 612
Population15 098 00026 193 00014 533 0007 359 00063 183 000
Projected deaths
Imperial College London report49318 744159 069402 318580 624
CDC estimations367424358 859321 883385 351
Seroprevalence25010 18456 653279 548346 637

Data are from the initial Imperial College London report1 and two more recent parameter estimations from the CDC3 and a retrospective study with data from 45 countries (seroprevalence).4 CDC=US Centers for Disease Control and Prevention.

This simplified assessment arrives at a comparable approximation of the original report—2 349 367 projected deaths in the USA and 580 624 deaths in the UK. Applying age-adjusted infection fatality ratio rates to the census population values reveals a striking difference from CDC estimates and seroprevalence reporting. CDC estimates place total deaths at 1 528 333 in the USA and 385 351 deaths in the UK, whereas seroprevalence estimates total deaths at 1 379 612 in the USA and 346 637 deaths in the UK. For the US estimates, the differences produce a 54–70% overestimation of approximately 1 million deaths. For the UK estimates, the differences produce a 51–68% overestimation of approximately 200 000 deaths.Such overestimations remind us of several lessons learned over the course of the pandemic. First, the initial projections were never going to be 100% accurate with a novel coronavirus. Initial projections built worst-case scenarios that would never happen as a means of spurring leadership into action. This upper boundary of possibility then demonstrates a functional value of modelling efforts for unmitigated pandemic progression. Second, asymptomatic cases inflated perceived mortality ratios in addition to complicating any containment challenges. Third, consensus predictions underscore the value of public health coordination—especially early in a novel outbreak. When information is scarce, information sharing from multiple sources becomes crucial to attaining the clearest prediction possible. Last, in democracies, these public health crises will be politicised, and it is incumbent upon guardians of the public trust in health-care institutions and services to remain apolitical—to remain focused on scientific knowledge and the needs of public health, just as the US Department of Defense remains apolitical and focused on the needs of national defence.Ultimately, the relative value of mask wearing and physical distancing, and the economic consequences of lockdowns will be analysed retrospectively. These evaluations will use worst-case scenarios of unmitigated progression as the measuring stick to describe the merit of different public health interventions. Still, initial projections were commendable efforts that brought about public action despite more than 2 million deaths in the USA and more than 500 000 deaths in the UK being a significant overestimation.

We declare no competing interests. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, the US Department of Defense, or the US Government. The authors are military service members or employees of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.


  1. Ferguson NM et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand.https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf Date: March 16, 2020Date accessed: December 1, 2020View in Article Google Scholar
  2. Gandhi M et al. Asymptomatic transmission, the Achilles’ heel of current strategies to control Covid-19.N Engl J Med. 2020; 382: 2158-2160View in Article Scopus (504)PubMedCrossrefGoogle Scholar
  3. Centers for Disease ControlCOVID-19 pandemic planning scenarios.https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.htmlDate: Sept 10, 2020Date accessed: December 1, 2020View in Article Google Scholar
  4. O’Driscoll M et al. Age-specific mortality and immunity patterns of SARS-CoV-2.Nature. 2020; (published online Nov 2.)https://doi.org/10.1038/s41586-020-2918-0View in Article PubMedGoogle Scholar
  5. Hauser A  et al. Estimation of SARS-CoV-2 mortality during the early stages of an epidemic: a modelling study in Hubei, China and northern Italy.medRxiv. 2020; (published online July 12.) (preprint).https://doi.org/10.1101/2020.03.04.20031104View in Article Google Scholar

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Lessons From the SARS-Cov-2 Pandemic

COVID-19 Repost Series

In a series of republished articles, I recount a catastrophic sequence of errors made in our dealings with the COVID-19 pandemic. In attempting to explain the errors – many of them seeming too obvious to be accidental – it is easy to jump to a conspiracy theory. However, there is a valuable little rule of thumb that states “never attribute to malice that which is adequately explained by stupidity”. In the cases to be presented, stupidity beats conspiracy every time and there are valuable lessons to be learned, if only we pay attention.

Throughout the SARS-Cov-2 pandemic, basic errors have occurred on a regular basis. The analysis of these errors provides a counterweight to what otherwise tends to be captured by a conspiracy narrative. I do not say that we can conclusively disprove all of the many conspiracy theories about the COVID-19 pandemic, but a good place to start is to explore multiple examples of what boils down to human error or plain stupidity. When these examples are taken on board, we can arrive at a more simple account of events. At their best, we humans can be wonderful problem solvers. At our worst, we can say and do some stupid things.

In this first post, Ronald Brown explains how US lawmakers formulated a pandemic control strategy using a ten-fold overestimate of the likely fatalities.

Ronald B Brown (2020): Public health lessons learned from biases in coronavirus mortality overestimation. Disaster medicine and public health preparedness14(3), 364-371. © Society for Disaster Medicine and Public Health, Inc. 2020. I thank the author, the author’s institution and sponsors for placing this article on Open Access.

Public Health Lessons Learned From Biases in Coronavirus Mortality Overestimation

Published online by Cambridge University Press:  12 August 2020

Ronald B. Brown


In testimony before US Congress on March 11, 2020, members of the House Oversight and Reform Committee were informed that estimated mortality for the novel coronavirus was 10-times higher than for seasonal influenza. Additional evidence, however, suggests the validity of this estimation could benefit from vetting for biases and miscalculations. The main objective of this article is to critically appraise the coronavirus mortality estimation presented to Congress. Informational texts from the World Health Organization and the Centers for Disease Control and Prevention are compared with coronavirus mortality calculations in Congressional testimony. Results of this critical appraisal reveal information bias and selection bias in coronavirus mortality overestimation, most likely caused by misclassifying an influenza infection fatality rate as a case fatality rate. Public health lessons learned for future infectious disease pandemics include: safeguarding against research biases that may underestimate or overestimate an associated risk of disease and mortality; reassessing the ethics of fear-based public health campaigns; and providing full public disclosure of adverse effects from severe mitigation measures to contain viral transmission.


case fatality ratecoronavirus mortality overestimationCOVID-19infection fatality ratesampling bias

TypeConcepts in Disaster MedicineInformationDisaster Medicine and Public Health Preparedness , Volume 14 , Issue 3 , June 2020, pp. 364 – 371DOI: https://doi.org/10.1017/dmp.2020.298[Opens in a new window]Creative Commons

Creative Common License - CC
Creative Common License - BY

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.Copyright© Society for Disaster Medicine and Public Health, Inc. 2020

On September 23, 1998, the US National Aeronautics and Space Administration (NASA) permanently lost contact with the $125 million Mars Climate Orbiter. 1 A simple miscalculation, failure to convert English measurements to metric measurements, doomed the Mars space mission. Reference Isbell and Savage2 A later investigation found that backup quality assurance procedures were not in place at NASA to catch and correct this simple miscalculation. Fast forward 22 years to another crisis involving a US government agency: On March 11, 2020, the US Congress House Oversight and Reform Committee received information from the National Institute of Allergy and Infectious Diseases (NIAID) concerning the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and coronavirus-disease 2019 (COVID-19). Reference Fifer3 Based on the data available at the time, Congress was informed that the estimated mortality rate for the coronavirus was 10-times higher than for seasonal influenza, which helped launch a campaign of social distancing, organizational and business lockdowns, and shelter-in-place orders.

Previous to the Congressional hearing, a less severe estimation of coronavirus mortality appeared in a February 28, 2020 editorial released by NIAID and the Centers for Disease Control and Prevention (CDC). Published online in the New England Journal of Medicine (NEJM.org), the editorial stated:

“…the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%).”Reference Fauci, Lane and Redfield4

Almost as a parenthetical afterthought, the NEJM editorial inaccurately stated that 0.1% is the approximate case fatality rate of seasonal influenza. By contrast, the World Health Organization (WHO) reported that 0.1% or lower is the approximate influenza infection fatality rate, 5 not the case fatality rate. To fully appreciate the significance of discrepancies in fatality rate usage by NIAID, the CDC, and the WHO, brief definitions of relevant epidemiological terms follow.

Case fatality rates (CFRs), infection fatality rates (IFRs), and mortality rates are used by epidemiologists to describe deaths during and after an infectious disease outbreak. The CDC defined a mortality rate as the frequency of deaths within a time period relative to the size of a well-defined population. Reference Dicker, Coronado and Koo6 Patients may be classified as having an influenza-like illness (ILI) such as COVID-19 according to standard criteria in a case definition. 7 A CFR is defined as the proportion of deaths among confirmed cases of the disease. CFRs indicate the disease severity, while an IFR is defined as the proportion of deaths relative to the prevalence of infections within a population. Reference Bui, Sanger-Katz and Kliff8 IFRs are estimated following an outbreak, often based on representative samples of blood tests of the immune system in individuals exposed to a virus. Estimation of the IFR in COVID-19 is urgently needed to assess the scale of the coronavirus pandemic. Reference Mallapaty9

Because different types of fatality rates can vary widely, it is imperative to not confuse fatality rates with one another; else misleading calculations with significant consequences could result. As of late spring 2020, a search of the keyword term “infection fatality rate” on the CDC website returned no matching results or similar terms, nor was the epidemiological term located in the 511-page CDC publication, Principles of Epidemiology in Public Health Practice. (The CDC eventually introduced the Infection Fatality Ratio (IFR) on July 10, 2020 “as a new parameter value for disease severity.” 10 ) This terminology omission, in conjunction with questionable use of fatality rate terminology in the NEJM editorial, raises red flags, warning of possible inaccuracies in the coronavirus mortality estimation presented to Congress. Similar to the need to vet for miscalculations that might have rescued NASA’s 1998 Mars mission, vetting the coronavirus mortality estimation for miscalculations and biases may benefit the validity of mortality conclusions. Therefore, the purpose of this article is to present an ad hoc critical appraisal of the coronavirus mortality estimation presented to US Congress on March 11, 2020.


Findings from a comparative analysis of selected video and texts are used in this article to critically appraise the validity of coronavirus mortality calculations presented in US Congressional testimony. Critical appraisal is a process that judges the validity of scientific research evidence. Reference Mhaskar, Emmanuel and Mishra11 Comparative analysis is a tool used in a grounded theory methodology to investigate an unexplored area through logical induction of coherent themes and explanations that are grounded in empirical evidence. Reference Chun Tie, Birks and Francis12 Text from the February 2020 NEJM.org editorial and video of Congressional testimony are compared with reliable informational texts from the WHO and CDC. Inconsistencies, inaccuracies, biases, utilization, and consequences of the coronavirus mortality estimation are discussed.

In NIAID testimony before the House Oversight and Reform Committee Hearing on Coronavirus response, Day 1, Reference Fifer3 the Committee learned that mortality from seasonal influenza is 0.1%. Additionally, it was reported to Congress that the overall coronavirus mortality of approximately 2-3% had been reduced to 1% to take into account infected people who are asymptomatic or have mild symptoms. The adjusted mortality rate from coronavirus of 1% was then compared with the 0.1% mortality rate from seasonal influenza, and the conclusion was reported to the House Committee that the coronavirus was 10-times more lethal than seasonal influenza.

In a comparative analysis with WHO and CDC documents, the coronavirus mortality rate of 2-3% that was adjusted to 1% in Congressional testimony is consistent with the coronavirus CFR of 1.8-3.4% (median, 2.6%) reported by the CDC. 13Furthermore, the WHO reported that the CFR of the H1N1 influenza virus (1918) is also 2-3%, 14 similar to the unadjusted 2-3% CFR of the coronavirus reported in Congressional testimony, with no meaningful difference in mortality. As previously mentioned, the WHO also reported that 0.1% is the IFR of seasonal influenza, 5 not the CFR of seasonal influenza as reported in the NEJM editorial.


Confusion between CFRs and IFRs may seem trivial, and it is easy to overlook at first, but this confusion may have ultimately led to an unintentional miscalculation in coronavirus mortality estimation. IFRs from samples across the population include undiagnosed, asymptomatic, and mild infections, and are often lower compared with CFRs, which are based exclusively on relatively smaller groups of moderately to severely ill diagnosed cases at the beginning of an outbreak. Due to host defense mechanisms and autoimmunity provided by innate and adaptive immune responses, Reference Aoshi, Koyama and Kobiyama15 asymptomatic infections are often prevalent in influenza. Reference Furuya-Kanamori, Cox and Milinovich16With many asymptomatic infections already identified in COVID-19, Reference Gao, Xu and Sun17 it appears unlikely that the IFR in an ILI like COVID-19 would approximate the disease’s CFR. Presymptomatic infections can also lower the proportion of asymptomatic infections. For example, a CDC report found that asymptomatic individuals identified through reverse transcriptase-polymerase chain reaction (RT-PCR) testing developed symptoms a week later, and those individuals were re-classified as having been presymptomatic at the time of testing. Reference Kimball, Hatfield and Arons18

In Figure 1, 4 cases grouped in the dotted-line box are also included among 7 infections, illustrating that all cases are infections but not all infections are cases, a potential point of confusion in media reports of COVID-19. For example, a high number of coronavirus infections were discovered in US meat-packing plants in Iowa, Reference Leys19 but these infections were reported as cases in the media, Reference Maddow20 potentially causing a type of information bias known as misclassification. Reference Althubaiti21 Misclassification refers to “the erroneous classification of an individual, a value, or an attribute into a category other than that to which it should be assigned.” Reference Porta22 This type of information bias in epidemiological research can lead to underestimates or overestimates of associated disease and mortality risks. Reference Althubaiti21

FIGURE 1 CFR and IFR. 1 fatality / 4 cases = 25% CFR. 1 fatality / 7 infections = 14.28% IFR.

CFRs and IFRs represent different segments of a targeted population and contain widely different proportions of nonfatal infections; therefore, misapplying findings or generalizing inferences between these 2 groups can cause a type of selection bias known as sampling bias Reference Johnson, Beaton and Murphy23 or ascertainment bias. Reference Delgado-Rodriguez and Llorca24 In this type of bias, people do not represent segments of the population to whom findings apply. Furthermore, “…comparisons of the CFR of 1 disease with the IFR of another are mostly useless,” Reference Roth, Clausen and Mueller25 and sampling bias can lead to serious inaccuracies, as when Congress was informed that the coronavirus is 10-times more lethal than seasonal influenza.

A comparison of coronavirus and seasonal influenza CFRs may have been intended during Congressional testimony, but due to misclassifying an IFR as a CFR, the comparison turned out to be between an adjusted coronavirus CFR of 1% and an influenza IFR of 0.1%. Had the adjusted coronavirus mortality rate not been lowered from 3% to 1%, fatality comparisons of the coronavirus to the IFR of seasonal influenza would have increased from 10-times higher to 20- to 30-times higher. By then, epidemiologists might have been alerted to the possibility of a miscalculation in such an alarming estimation.

Quality Assurance

Most people rely on trusted public health experts from organizations like the CDC to disseminate vital information on infectious diseases. Reference Fingerhut26 Unfortunately, even experts can make simple miscalculations that can lead to catastrophic results. In the example of NASA’s lost Mars Climate Orbiter, the NASA board investigating the failed mission recognized that mistakes happen on projects, “However, sufficient processes are usually in place on projects to catch these mistakes before they become critical to mission success.” Reference Isbell and Savage2 The NASA board also recognized the importance of quality assurance procedures to prevent future failures. Of relevance, in 2018, the National Institute of Neurological Disorders and Stroke (NINDS) provided an exemplary definition of quality assurance (QA) in clinical and health sciences:

“The objectives of QA procedures are to assure the accuracy and consistency of study data, from the original observations through the reporting of results and to ensure that study results are considered valid and credible within the scientific and clinical communities.” 27

Similar to NASA’s quality assurance problems in 1998, quality assurance procedures at US national public health organizations in 2020 may benefit from review and revision to prevent crucial mortality miscalculations of infectious diseases in the future. As a safeguard against misuse of fatality rates, and protection in the event of nonstandardized or inter-organizational discrepancies in terminology, every fatality rate should clearly define the denominator of the rate as the specific group to whom fatalities apply, either to the total population in mortality rates, confirmed cases of a disease in CFRs, or individuals exposed to a viral infection in IFRs.

Mitigation Measures

As the campaign to mitigate coronavirus transmission was implemented from March into May, 2020, expected coronavirus mortality totals in the United States appeared much lower than the overestimation reported in Congressional testimony on March 11. Compared with the most recent season of severe influenza A (H3N2) in 2017-2018, 28 with 80,000 US deaths reported by CDC officials, 29 US coronavirus mortality totals had just reached 80,000 on May 9, 2020. 30 By then, relative to the 2017-2018 influenza, it was clear that the coronavirus mortality total for the season would be nowhere near 800,000 deaths inferred from the 10-fold mortality overestimation reported to Congress. Even after adjusting for the effect of successful mitigation measures that may have slowed down the rate of coronavirus transmission, it seems unlikely that so many deaths were completely eliminated by a nonpharmaceutical intervention such as social distancing, which was only intended to contain infection transmission, not suppress infections and related fatalities. Reference Ferguson, Laydon and Nedjati Gilani31 Also in early May, 2020, a New York State survey of 1269 COVID-19 patients recently admitted to 113 hospitals found that most of the patients had been following shelter-in-place orders for 6 wk, which raised state officials’ suspicions about social distancing effectiveness. Reference Matthews, Villeneuve and Hill32 Still, polls showed the public credited social distancing and other mitigation measures for reducing predicted COVID-19 deaths, and for keeping people safe from the coronavirus. Reference Benzie33,Reference Chappell34

Surprisingly, disproportionate mortality increases in Italian and American health-care facilities during the height of the COVID-19 outbreak were not unique; similar health-care facility crises occurred during the 2016-2017 influenza season in Italy, Reference Rosano, Bella and Gesualdo35and during the 2017-2018 influenza season in the United States. Reference Macmillan36 Yet, these earlier outbreaks did not appear to receive the same intensive media coverage as COVID-19. Although media reports of new coronavirus infections reinforced the public’s belief that the virus was continuing to spread, greater levels of testing may have increased detection of infections that were already prevalent throughout the population. In addition, the accuracy of coronavirus tests rushed into production during the pandemic were unknown. Reference Perrone37 RT-PCR testing has been in use since the detection of the A (H5N1) influenza virus in 2005, 38 but a serious limitation of RT-PCR testing is that nucleic acid detection is not capable of determining the difference between infective and noninfective viruses. Reference Joynt and Wu39 Moreover, the CDC modified criteria to record coronavirus mortality by including “probable” and “likely” deaths in the International Classification of Diseases code (ICD) for COVID-19. Reference Schwartz40

By June 21, new daily deaths from the coronavirus dropped to 267 in the United States, a 90% decrease from 2693 daily deaths reported on April 21. 30 However, confirmed cases in some areas increased as lockdowns lifted, Reference Cohen41 and total US infections had reached 1,254,055 by June 21. 30 Several reasons in addition to increased viral transmission could account for case increases. For example, ill people may no longer fear going to hospitals as society reopens, Reference White42 and coronavirus testing may also result in greater differential diagnosis of SARS-CoV-2 infections from other common respiratory viral infections. Reference Singhal43 With more reported cases of COVID-19 in younger people following reopening, Reference Samore44 CFRs could actually decline due to lower associated mortality risk in this age group. Furthermore, country comparisons of coronavirus CFRs are often confounded by numerous factors, Reference James45 including health-care differences in case definitions, access to quality treatment and reliable testing, compliance with mitigation measures, and underlying health conditions; demographic differences in age, race, socioeconomic status, and population density; and geo-political differences including climate, seasonality, environmental pollution, social inequities and unrest, personal liberties, public health policies, reliability in reporting valid government statistics of disease, and lifestyle customs that affect physical and mental health, public sanitation, and personal hygiene. Ultimately, with a myriad of uncontrolled confounding factors, a serosurvey of representative samples of a population is a more reliable method to determine the true prevalence of coronavirus infections.

Emerging confounding factors in the United States have also contributed to a rising mortality trend in ILIs such as COVID-19. For example, each year surviving members of the ageing Baby-Boomer cohort of 76 million people born between 1946 and 1964 enter the high-risk category for ILIs, increasing the burden placed on health-care systems. Reference Henderson, Maniam and Leavell46 Also, research shows that a warming trend in the Artic can lead to more extreme winter weather conditions, especially in the Eastern United States, Reference Cohen, Pfeiffer and Francis47 which may play a role in rising mortality rates from ILIs during the influenza season.

As health authorities responded to the COVID-19 pandemic by implementing lockdowns and other mitigation measures with minimal supporting evidence, scientists warned of “a fiasco in the making,” Reference Ioannidis48 Caution was also raised against violations of fundamental principles of science and logic, such as the mistaken assumption that correlation implies causation. Reference James45 For example, the public’s belief that mitigation measures were responsible for reducing coronavirus mortality may be a post hoc fallacy if lower mortality was actually due to the overestimation of coronavirus deaths. Furthermore, implementing the unconfirmed hypothesis that mitigation measures save lives in vulnerable populations, and rejecting the null hypothesis that assumes no life-saving effect exists, is a type I error in hypothesis testing. Reference Randolph49 The null hypothesis does not assume a priori knowledge. Therefore, before implementing mitigation measures that incur severe costs, the onus is on mitigation proponents to formally reject the null hypothesis by justifying claims of life-saving benefits. Additionally, education in principles of basic research methods is essential for consumers of public health research, and there is a need to increase instruction in the science and logic of research methods in general education curricula. Reference Aguado50 More research of nondrug mitigation interventions is also urgently needed to prevent COVID-19, especially in vulnerable populations. Reference Glasziou, Sanders and Hoffmann51

Scientists also warned of public health decisions made without reliable data of infection prevalence within the population. Reference James45,Reference Ioannidis48 Lacking valid input data due to insufficient testing for disease prevalence, statistical modeling methods often relied on speculative assumptions, producing fearful predictions of increased mortality, which have often proved unreliable. Reference Begley52 A systematic review found that most diagnostic and predictive models for COVID-19 lack rigor, have a high risk of selection bias, and are likely to have lower predictive performance in actual practice compared with optimistic reports published in the research literature. Reference Wynants, Van Calster and Bonten53

A revised version of a non–peer-reviewed study on COVID-19 antibody seroprevalence in Santa Clara County, California, found that infections were many times more prevalent than confirmed cases. Reference Bendavid, Mulaney and Sood54 As more serosurveys are conducted throughout the country, a nationally coordinated COVID-19 serosurvey of a representative sample of the population is urgently needed, Reference McClellan, Gottlieb and Mostashari55 which can determine if the national IFR is low enough to expedite an across-the-board end to restrictive mitigating measures. Plans for a national US serosurvey were announced in April 2020 by the National Institutes of Health, to be conducted by NIAID and the National Institute of Biomedical Imaging and Bioengineering (NIBIB), with the assistance of the National Center for Advancing Translational Sciences (NCATS) and the National Cancer Institute (NCI). 56 Of relevance, nationwide mitigation measures, such as lockdowns, social distancing, and shelter-in-place orders, were not implemented during the 2017-2018 influenza with 45 million US illnesses reported by the CDC. 57 Neither were mitigation measures implemented during the 2009 influenza, with reported estimates adjusted for underreported hospitalizations of approximately 60.8 million US cases, ranging between 43.3 million to 89.3 million cases. Reference Shrestha, Swerdlow and Borse58

Fear and Collateral Damage

Psychological adverse effects, such as anxiety, anger, and posttraumatic stress, have been linked to restrictive public health mitigation measures due to isolation, frustration, financial loss, and fear of infection. Reference Brooks, Webster and Smith59,Reference Hoof60 A June 8, 2020, survey from the Association for Canadian Studies found that fear of contracting the coronavirus affected 51% of the Canadian population, compared with 56% of the US population.61 Venturing out into public during the reopening phase of the lockdown was stressful to 50% of Canadians compared with 56% of Americans. A second wave of the virus was also expected by 76% of Canadians and 64% of Americans. Furthermore, the possibility exists that yet another novel virus could emerge, potentially reigniting a perpetual process of unfounded fear and unnecessary lockdowns if mortality estimations are not properly vetted.

Fear, in contrast to moral civic duty and political orientation, was shown to be a more powerful predictor of compliance with mitigating behavior in response to a viral pandemic, but with decreasing well-being and poorer decision-making. Reference Harper, Satchell and Fido62Studies have shown that fear impairs performance of cognitive tasks through debilitating anxiety and worry. Reference Zhuang, Wang and Tang63 Even if a threat ceases to exist, prolonged fearful avoidance of threats is maladaptive and restricts a return to normal social interaction and productivity. Reference Sangha, Diehl and Bergstrom64 For example, after the outbreak of SARS had ended in 2004, avoidance behavior continued to restrict people’s social interactions and prevented people from returning to work. Reference Usher, Bhullar and Jackson65

Exaggerated levels of fear were driven by sensationalist media coverage during the COVID-19 pandemic. Reference James45,Reference Oprysko66,Reference Budrick67 And yet, while the public was ordered to lockdown, overall costs and benefits to society from severe mitigation measures had not been assessed. Reference James45 Fear of infection also prevented people from seeking needed health-care services in hospitals during the pandemic. Reference McFarling68 The ethics of implementing fear-based public health campaigns needs to be reevaluated for the potential harm these strategies can cause. Reference Bayer and Fairchild69 Dissemination of vital health information to the public should use emotionally persuasive messaging without exploiting and encouraging overreactions based on fear.

In addition, legal and ethical violations associated with mitigation of pandemic diseases were previously investigated by the Institute of Medicine in 2007. Reference Gostin and Berkman70 People should have the right to full disclosure of all information pertinent to adverse impacts of mitigation measures during a pandemic, including information on legal and constitutional human rights issues, Reference James45 and the public should be guaranteed a voice in a transparent process as authorities establish public health policy.

Last, severe mitigating measures during the COVID-19 pandemic caused considerable global social and economic disruption. Reference Nicola, Alsafi and Sohrabi71 Enforced lockdowns increased domestic violence, closed businesses and schools, laid off workers, restricted travel, affected capital markets, threatened the security of low-income families, and saddled governments with massive debt. Between February and April 2020, US unemployment rose from 3.5%, the lowest in 50 years, to 14.7%. Reference Davidson72 A recession in the United States was also officially declared in June 2020 by the National Bureau of Economic Research, ending 128 months of historic economic expansion. Of relevance, economic downturns are associated with higher suicide rates compared with times of prosperity, and increased suicide risk may be associated with economic stress as a consequence of severe mitigation measures during a pandemic. Reference Reger, Stanley and Joiner73 Relapses and newly diagnosed cases of alcohol use disorder were also predicted to increase due to social isolation, and harmful drinking in China increased 2-fold following the COVID-19 outbreak. Reference Da, Im and Schiano74 As a global natural experiment, psychological outcomes from restrictive interventions in the COVID-19 pandemic require further investigations. Reference Patrick and Cormier75

Public health lessons learned during the COVID-19 pandemic contribute knowledge and insights that can be applied to prevent future public health crises. Reference Secchi, Ciaschi and Spence76 Figure 2shows a flow chart that summarizes biases and potential effects of viral mortality overestimation observed in a pandemic. Failure to intervene at the source of the problem, at the upstream levels of information bias and sampling bias, can allow fear to rapidly escalate and may cause an overactive response that produces severely harmful collateral damage to society.

FIGURE 2 Biases and Potential Related Effects of Virus Mortality Overestimation.


Sampling bias in coronavirus mortality calculations led to a 10-fold increased mortality overestimation in March 11, 2020, US Congressional testimony. This bias most likely followed from information bias due to misclassifying a seasonal influenza IFR as a CFR, evident in a NEJM.org editorial. Evidence from the WHO confirmed that the approximate CFR of the coronavirus is generally no higher than that of seasonal influenza. By early May 2020, mortality levels from COVID-19 were considerably below predicted overestimations, a result that the public attributed to successful mitigating measures to contain the spread of the novel coronavirus.

This article presented important public health lessons learned from the COVID-19 pandemic. Reliable safeguards are needed in epidemiological research to prevent seemingly minor miscalculations from developing into disasters. Sufficient organizational quality assurance procedures should be implemented in public health institutions to check, catch, and correct research biases and mistakes that underestimate or overestimate associated risks of disease and mortality. Particularly, the denominator of fatality rates should clearly define the group to whom fatalities apply. Public health campaigns based on fear can have harmful effects, and the ethics of such campaigns should be reevaluated. People need to have a greater voice in a transparent process that influences public health policy during an outbreak, and educational curricula should include basic research methods to teach people how to be better consumers of public health information. The public should also be fully informed of the adverse impacts on psychological well-being, human rights issues, social disruption, and economic costs associated with restrictive public health interventions during a pandemic.

In closing, nations across the globe may fearfully anticipate future waves of the coronavirus pandemic, and look bleakly toward outbreaks of other novel viral infections with a return to severe mitigation measures. However, well-worn advice from a famous aphorism by the poet philosopher George Santayana should be borne in mind, which is relevant to public health lessons learned in this article: “Those who cannot remember the past are condemned to repeat it.” Reference Santayana77


Smearing MECFS Patients in the Name of Science

A previous post reviewed the SMC’s ‘expert reactions’ concerning MECFS between 2011 and 2017.

Here I review the Science Media Centre’s continued smearing of MECFS patients in a set of carefully curated ‘expert reactions’ to MECFS research between 2017 and 2020,

I expose here further evidence of a deliberate smear campaign of a vulnerable patient group. This campaign has been steered by the director of the SMC, Fiona Bernadette Fox OBE, with the willing assistance of medical and psychological scientists at prestigious institutions such as Oxford University and King’s College London.

The SMC describes itself as: “an independent press office helping to ensure that the public have access to the best scientific evidence and expertise through the news media when science hits the headlines.” Far from being independent, the SMC is funded to well over £500,000 by companies such as: GlaskoSmithKline and Wellcome and Universities such as King’s College London and Oxford.

All for the good of science and humanity, one might expect, but is it really? Not only is this not good science, it is not good journalism either. It is nothing more than pseudoscience verging on a cult. I review the evidence on this in a paper published elsewhere.

Ask a patient with MECFS and you might be surprised that all is not well with the SMC’s view of the condition. The SMC chooses to review a narrow band of researchers allied to a particular, contentious view that MECFS is a psychosomatic disorder based on the unscientific ‘Biopsychosocial Model’.

Curiously for an organisation claiming to represent science, there is almost zero mention of any proper scientific research on the biological basis of the disorders.

What exactly has the SMC been up to? Why has the SMC adopted the peculiar cause of a few researchers from its member institutions at the expense of the wellbeing of patients?

Below, the text of the experts’ reactions on MECFS research is examined with the author’s annotations in [square brackets].

NOVEMBER 10, 2020

expert reaction to NICE draft guideline on diagnosis and management of ME/CFS

Prof Michael Sharpe, Professor of Psychological Medicine, University of Oxford, [WS member, no conflicts of interest declared] said:

“As the NICE report says, it is paramount that patients are listened to and their symptoms and concerns taken seriously. It is also essential that evidence-based rehabilitative treatments (graded activity/exercise and cognitive behaviour therapy) are given only to those patients who want them and then given in a personalized expert fashion in partnership with them. It is to be hoped that these new guidelines improve the quality of delivery of these treatments. It is also to be hoped that the strongly stated concerns about the effect of badly delivered [badly delivered or inappropriate?] treatments do not make it even harder for patients to access the well delivered, evidence-based treatments.” [This statement is distracting spin. The NICE guidelines reject the use of CBT and GET. The issue is not about quality of delivery of treatments, it is about the appropriateness of the treatments in the first place.]

Prof Trudie Chalder, Professor of Cognitive Behavioural Psychotherapy, Institute of Psychiatry Psychology & Neuroscience (IoPPN), King’s College London, [ PACE investigator, no conflicts of interest declared] said:

“Cognitive behaviour therapy (CBT) and graded exercise therapy (GET ) are evidence-based treatments for chronic fatigue syndrome (CFS) in that they facilitate reductions in fatigue [measured by the Chalder Fatigue Scale, with all of its flaws] and improve people’s quality of life if delivered by a qualified therapist. Previous reviews of the science provide the evidence [which the NICE (2020) report finds to be of low or very low quality]. Our clinics are full of patients who are very keen to receive these evidence-based treatments and our patient reported outcomes support their use. My concerns are a) that patients should be offered these treatments to avoid a situation in which their condition stays the same or worsens [which is exactly what the NICE (2020) report suggests happens with GET] b) that health professionals will stop offering evidence-based treatments.” [NICE (2020) recommends against the use of GET and Lightning Process and so if health professionals stopped offering these treatments, that would be a desirable outcome.]

Prof Sir Simon Wessely, Regius Chair of Psychiatry, King’s College London, [no conflicts of interest declared] said:

“As someone who has been treating patients with ME/CFS for over 30 years [e.g.  Ean Proctor] I am in no doubt of the importance of continuing to treat CFS patients with empathy and respect, and offering individualised patient centred care. [Empathy and respect? Dropping them into swimming pools, scaring them on ghost trains and with vigorous wheel chair projection to the amusement of the staff?]  This was in the previous NICE guidelines in 2007, and it is depressing that this still needs to be said today. [Especially for hundreds of thousands of MECFS patients.] If even one patient feels that they are not been taking seriously, there is more work to be done. [There is a huge amount of work to be done because there are hundreds of thousands of MECFS patients who feel that they have not been taken seriously and many attribute this to the BPS psychosomatic approach that claims the symptoms are psychological rather than neurological or immunological.]  13 years ago there were only two treatments with clinical trial support, namely graded exercise therapy (GET) or cognitive behavioural therapy (CBT), and that has not changed over the years. In the new guidelines NICE has again emphasised that these approaches should not be fixed or set in stone, [A gross distortion of what NICE report actually says : the guidance clearly states that GET should not be used and CBT should have only a supportive role] which is already the case for those few centres with proper supervision and expert leadership that do provide such services at present. Such services will agree that “unstructured exercise that is not part of a supervised programme” [forms of GET] should be avoided.  There is a lot of helpful detail as to how such programmes should be implemented, but still some odd inconsistencies.[Innuendo without substance.]  Finally, sufferers should rightly beware any claims of miracle cures from any quarter, [e.g. the Lightning Process which theresearch team has promoted in three publications including a clinical trial] but be reassured that existing programmes that take a cautious, collaborative, clinically supervised approach, backed by evidence from randomised controlled trials, [none of the trials run bythe research team were controlled for placebo or attention effects] the gold standard of assessing effectiveness, offer some hope [to whom? patients?] of meaningful improvement in what remains a complex, little understood and still sometimes misunderstood condition.”

Prof Peter White, Emeritus Professor of Psychological Medicine, Queen Mary University of London, [WS member, no conflicts of interest declared] said:

“NICE is usually commended by being led by the science. It is therefore a great surprise that this guideline proscribes or qualifies treatments for CFS/ME for which there is the best evidence of efficacy, namely graded exercise therapy (GET) and cognitive behaviour therapy. [A great surprise? There has been a huge amount of criticism of GET and CBT for MUS/MECFS patients over the last 10 – 20 years.]

“It is also remarkable that the committee use the symptom of post-exertional fatigue as a reason for not providing GET, when the largest ever trial of GET showed that it significantly reduced this symptom more than staying within one’s energy envelope. [Misleading]. Should this guideline be adopted as suggested, I fear that it will discourage healthcare professionals from offering the two treatments that give patients the best chance to safely improve their health.” [This ‘discouragement’ is based on ‘evidence-based practice’].

APRIL 29, 2019

expert reaction to study investigating a potential biomarker for chronic fatigue syndrome / ME

Prof Sir Simon Wessely, Regius Chair of Psychiatry, Institute of Psychiatry Psychology & Neuroscience, King’s College London (IoPPN), and President, Royal Society of Medicine, [no conflicts of interest declared] said:

“There have been many previous attempts to find a specific biomarker for CFS.  The problem is not differentiating patients with CFS from healthy controls.  The issue is can any biomarker distinguish CFS patients from those with other fatiguing illnesses?  And second, is it measuring the cause, and not the consequence, of illness? This study does not provide any evidence that either has finally been achieved. [Excellent point. However, the same issue applies to the entire research programme of the team at King’s. Multiple occurrences of inappropriate causal language are employed in papers by the King’s team. See Table 2]. It is also regrettable that it is claimed that such a test would give “scientific proof” of the existence of the condition, and prove it is “not imaginary”.  You don’t need a blood test to prove that an illness exists, and nor does the absence of such a test mean that it is “all in the mind”.  Any sub who runs a headline that says ‘new test proves CFS is real and not psychiatric’ should be ashamed of themselves.” [Any sub or Psychiatrist who says CFS is a psychiatric condition and not organic one should be equally ashamed of themselves because this has never been scientifically demonstrated. See section 3.]

MARCH 22, 2018

reanalysis of the PACE trial

Comment from three authors of the original PACE trial

Prof Michael Sharpe, Professor of Psychological Medicine, University of Oxford, Prof Trudie Chalder, Professor of Cognitive Behavioural Psychotherapy, Institute of Psychiatry Psychology & Neuroscience (IoPPN), King’s College London, & Dr Kimberley Goldsmith Senior Lecturer in Medical Statistics, Institute of Psychiatry Psychology & Neuroscience (IoPPN), King’s College London, said:

“Wilshire et al have written a critique of several papers reporting on the PACE trial of treatments for CFS/ME, of which we are authors.  They also report a reanalysis of the PACE trial data.  We note that most of the analyses they report have already been published, either in peer reviewed journals or by ourselves on the PACE trial website (https://www.qmul.ac.uk/wolfson/research-projects-a-z/current-projects/pace-trial/). [At the time of going to press, this website was unavailable. On 25 July 2021 it stated: “Sorry, the page you requested could not be found.”]

“They report different results from the original trial. However this is not surprising as their analyses used only part of the trial dataset and followed a preliminary PACE analysis plan, rather than the final approved and published one. Furthermore they do not refer to the many other trials and meta-analyses that have replicated the findings of the PACE trial. [Misleading criticism: Wilshire et al. (2018) aimed to provide a reanalysis of the PACE trial only, not an entire literature review, which was carried out by NICE (2020).]

“In conclusion we find little of substance in this critique and stand by our original reports. These are all available through the trial website [As noted, at the time of going to press, the trial website was unavailable. On 25 July 2021 it stated: “Sorry, the page you requested could not be found.”] The PACE trial found that CBT and graded exercise therapy are safe and moderately effective treatments; a positive message for people who suffer from this otherwise long-term debilitating illness.”

SEPTEMBER 20, 2017

The Lightning Process – a controversial treatment  for children with chronic fatigue

The Lightning Process is a controversial treatment that is sometimes used for children with chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME), a disabling illness that means 1% of UK secondary school children miss a day a week or more of school. Describing itself as “a training course that focuses on the science behind how the brain and body interact”. The Lightning Process has been met with scepticism in the scientific community. [Largely because it is a pseudoscientific, pyramid scheme based on Neurolinguistic Programming, strange rituals and osteopathy.]

Researchers decided to test the robustness of this treatment so, despite activists trying to stop them, [An unfounded ad hominem denigration of critics] they ran its first ever trial – an RCT that looked at the effectiveness and cost-effectiveness in children with CFS/ME. The results are published in the Journal of Archives of Disease in Childhood [twice – the second time with major corrections – after the changed endpoints and ethical shortcomings were exposed.]

SEPTEMBER 20, 2017

expert reaction to controversial treatment for CFS/ME

* ‘Clinical and cost-effectiveness of the Lightning Process in addition to specialist medical care for paediatric chronic fatigue syndrome: randomised controlled trial’ by Crawley et al. published in Journal of Archives of Disease in Childhood on Wednesday 20th September.

Prof. Alastair Sutcliffe, Professor of General Paediatrics, UCL, said:

“A recent systematic review of neurolinguistic programming (NLP) stated “There is little evidence that NLP interventions improve health-related outcomes. This conclusion reflects the limited quantity and quality of NLP research, rather than robust evidence of no effect. [An interesting distinction.  There is currently insufficient evidence to support the allocation of NHS resources to NLP activities outside of research purposes.” [Br J Gen Pract. 2012 Nov; 62(604): e757–e764. Published online 2012 Oct 29. doi:  10.3399/bjgp12X658287, PMCID: PMC3481516]. But now we have this interesting study by Crawley, a well-conducted single blind clinical trial that suggests NLP, in combination with other therapies and described as the ‘Lightning Process’, is effective for some children with the very hard to treat condition of chronic fatigue syndrome (CFS).

“Although in my view the effects described show some benefit and are therefore to be welcomed, this could be due to placebo which would still be GOOD news. Costs are modest [Costs range between £775 and £2500 per patient] and therefore this study is to be welcomed.

“These press releases are accurate, however, there is no reference to the fact that the effect may be due to placebo as this is a single-blind trial. But in a sense this is not so important [most investigators who run clinical trials would be disappointed if the intervention being trialed was shown to be a placebo effect and nothing more] and as the trial shows convincing evidence of benefit [convincing to whom?] and as placebo is impossible to quantify [yes, in any trial that does not include a placebo control group] we are left with the alternative possibility that these children benefited from the package of care per se, rather than the nebulous placebo effect.[It is impossible to reach this conclusion with an RCT design which lacks a control condition.]

“CFS is a difficult to treat and common disorder, so overall I welcome this step in the direction of evidence-based care as, at present in the UK, there is little agreement about what is the best way to treat this illness.” [The Crawley et al. trial is not a step in the direction of evidence-based care nor can it offer any robust conclusions about the best way to treat MECFS because of its many ethical and design flaws. A flawed trial that allows no advancement in scientific understanding is a waste of public research funds, patient goodwill and time.]

Prof. Dorothy Bishop, Professor of Developmental Neuropsychology, University of Oxford, said:

“The gains for patients in this study do seem solid, however, I am still rather uneasy because while the patient allocation and statistical analysis of the trial appear to be done to a high standard, the intervention that was assessed is commercial and associated with a number of warning signs. The Lightning Process appears based on neurolinguistic programming, which, despite its scientific-sounding name, has long been recognised as pseudoscience. [Valid statement.]

“I am sympathetic to the authors’ decision to evaluate the Lightning Process (LP), given that they had patients who had used it and reported favourably on it, and it could be argued that to fail to do so would indicate a degree of closed-mindedness [Absurd statement. Not anything patients have tried should be evaluated in a clinical trial, for example,  hyperbaric oxygen therapy, “chi deficiency”, acupuncture, naturopathy and chiropractic (invented by D. D. Palmer, who took his instructions from a talking ghost) purely to avoid the appearance of a ‘degree of closed-mindedness’? The potential harms, lack of scientific rationale and the wastage of research resources investigating quack practices cannot be entertained for the sake of ‘open-mindedness’.] But the commercial nature of LP really creates problems. We cannot tell which aspect of LP is responsible for the gains in patients who took part.

“I noticed, for instance, that LP involves group sessions, whereas the comparison group undergoing standard medical care were treated individually. So it may be that the benefits derive from interacting with other children with chronic fatigue syndrome/ME, rather than the specific exercises and training. This is, of course, something that could be investigated in future research [This factor could and should have been controlled in this trial] but meanwhile the concern is that this report will in effect act as positive publicity for a programme that is being proposed for a wide range of physical conditions (including chronic pain, low self-esteem, multiple sclerosis, and depression, to name just a few) and has to date been promoted largely through celebrity endorsements.” [The author previously has said that the technique is based on pseudoscience, yet she is suggesting further research should be carried with improved controls and so she is advocating further research on what she has categorised as a pseudoscientific therapy.]

Dr James Thompson, Honorary Senior Lecturer in Psychology, UCL, said:

“The treatment in this study looks like it had an effect, at least by the standard of most clinical trials. To be extra robust I would have liked to see more objective measures, but unfortunately chronic fatigue syndrome is not an objective diagnosis, it is a leftover category and fatigue is subjective. [Misleading criticism. Not having an objective diagnosis does not prevent objective measurements of improvement, e.g. activity measures.]

“One limitation is that self-report scales can be subject to placebo effects, however if the patients feel better in the experimental condition in which they receive extra help, even if everyone knows it, then that is something and the pupils miss less school, which is an objective measure. In this case it may not have been the CBT element of the treatment, but it looks like it.” [It cannot ‘look like it’ because it is impossible to tell without proper control conditions.]

Prof. Michael Sharpe, Professor of Psychological Medicine, University of Oxford, [WS member, no conflicts of interest declared] said:

“Chronic fatigue syndrome (CFS) is a name for an illness with symptoms of long lasting and disabling fatigue. It affects many young people and can interfere with their education. Whilst some people call it myalgic encephalomyelitis (ME) it is not clear if this is the same or a different condition.

“This trial tests the effectiveness of a commercially available brief intensive talking therapy for CFS called the Lightning Process. The treatment has similarities to cognitive behaviour therapy (CBT) and is given in groups. [The treatment also has differences, e.g. CBT does not require participants to: Tell everyone that you have been healed;  Perform magical rituals such as standing in circles drawn on paper with positive keywords inscribed; etc] The treatment was found to be better than usual care in fatigue, physical function and school attendance, with benefit seen as long as a year later. It was also safe. The study does not tell us how it works however. [The study does not even tells us if it works.]

“This is a robust study because patient were allocated to one of the two treatments at random ensuring that any difference seen in outcome between these treatments, is not due to pre-existing differences in the patients. The main limitation is that, as it is not possible to hide which treatment they received from the patients, their self-ratings of fatigue and functioning could potentially be biased by their views on the treatment they received. [These criticisms are true of all trials run by the BPS school including the PACE trial but the author has never acknowledged this fact.] However, differences in the school attendance a year later were also noted; it seems [un?]likely (sic) that these could be due to such a bias.

“Commercially available treatments like this one that are being used by patients should be rigorously tested. This is especially important for an illness like this one about which much misinformation is spread using social media. [And by medical journals that pass defective trials though peer review and refuse to retract them.] We need more studies and less polemic.” [!]


The Science Media Centre and MECFS: Best Scientific Evidence or Biased Opinion?

The Science Media Centre describes itself as: “an independent press office helping to ensure that the public have access to the best scientific evidence and expertise through the news media when science hits the headlines.” (https://www.sciencemediacentre.org/)

Here I examine the SMC’s reports on MECFS-related publications relating to the PACE trial, from 2011 when the trial was published until 2017 when the Journal of Health Psychology published a Special Issue critiquing the trial. What the SMC describes as ‘best scientific evidence’ consists of biased opinions from people with strong vested interests.

My personal take on the experts’ opinions is placed [inside square brackets throughout the text].

The recently published revised guidance on MECFS by NICE (2021) recommends that GET should be dropped and CBT only used in a supportive role in the treatment of people with MECFS. How well does the SMC ‘expert opinion’ stand up to scrutiny in light of that new NICE guidance?

I leave this for readers to decide.

JULY 31, 2017

expert reaction to Journal of Health Psychology’s Special Issue on The PACE Trial

The Journal of Healthy Psychology has published a special issue focusing on the PACE trial – originally published in The Lancet (2011). ‘Special Issue on The PACE Trial’ edited by David Marks published in Journal of Health Psychology on Monday 31st July 2017.

Prof. Malcolm Macleod, Professor of Neurology and Translational Neuroscience, University of Edinburgh, said:

“The PACE trial, while not perfect, provides far and away the best evidence for the effectiveness of any intervention for chronic fatigue; and certainly is more robust than any of the other research cited. Reading the criticisms, I was struck by how little actual meat there is in them; and wondered where some of the authors came from. [Ad hominem]. In fact, one of them [a reputable and well-published family doctor in Amsterdam] lists as an institution a research centre (Soerabaja Research Center) which only seems to exist as an affiliation on papers he wrote criticising the PACE trial. [It is normal practice to consider the quality of a critic’s argument not their institution. For the record, affiliations and the alma mater of other PACE trial critics include University College London, City, University of London, Northwestern University, DePaul University, the University of Hertfordshire, Victoria University of Wellington New Zealand, UC Berkeley, and the ME Association.]

“Their main criticisms seem to revolve around the primary outcome was changed halfway through the trial: there are lots of reasons this can happen, some justifiable and others not; the main think is whether it was done without knowledge of the outcomes already accumulated in the trial and before data lock – which is what was done here. [Evidence on this point remains uncertain.]

“So I don’t think there is really a story here, apart from a group of authors, some of doubtful provenance [a family doctor does not have doubtful provenance]  kicking up dust about a study which has a few minor wrinkles (as all do) but still provides information reliable enough to shape practice. If you substitute ‘CFS’ for ‘autism’ and ‘PACE trial’ for ‘vaccination’ you see a familiar pattern…” [This statement is a shameful ad hominem argument that is unbecoming of any reputable academic.] 

A spokesperson for University of Oxford [where a PACE trial investigator is employed, no conflicts of interest declared] said:

“The PACE trial of Chronic Fatigue Syndrome treatments was conducted to the highest scientific standards and scrutiny. This included extensive peer review from the Medical Research Council, ethical approval from a Research Ethics Committee, independent oversight by a Trial Steering Committee and further peer review before publication in high-impact journals such as The Lancet. 

“The allegation that criteria for patient improvement and recovery were changed to increase the reported benefit of some treatments is completely unfounded. As the study authors have repeatedly made clear, the criteria were changed on expert advice and with oversight committee approvals before any of the outcome data was analysed.

“Oxford University considers Professor Sharpe and his colleagues to be highly reputable scientists whose sole aim has been to improve quality of life for patients with ME/CFS. While scientific research should always be open to challenge and debate, this does not justify the unwarranted attacks on professionalism and personal integrity which the PACE trial team have been subjected to.” [It does not justify vilification of patients, citizen scientists and scholars who have criticized very poorly done trials such as the PACE trial.]

OCTOBER 28, 2015

expert reaction to long-term follow-up study from the PACE trial on rehabilitative treatments for CFS/ME, and accompanying comment piece

A paper published in The Lancet Psychiatry reports results of a long-term follow-up study to the PACE trial for CFS/ME. The study has assessed the original trial participants’ health in the long-term, and asks whether their current state of health, two and a half years after entering the trial, has been affected by which treatment they received in the trial.

‘Rehabilitative treatments for chronic fatigue syndrome: long-term follow-up from the PACE trial’ by Michael Sharpe et al. published in the Lancet Psychiatry on Wednesday 28 October 2015.

‘Chronic fatigue syndrome: what is it and how to treat?’ by Steven Moylan et al. published in the Lancet Psychiatry on Wednesday 28 October 2015.

Prof. Rona Moss-Morris, Professor of Psychology as Applied to Medicine, King’s College London, said:

“I think this is a robust study with some limitations that the authors have been clear about. [The authors have not been ‘clear about’ the limitations and refuse to acknowledge the many methodological flaws in the PACE trial. ] The original PACE trial published in 2011 showed that at one year people with CFS/ME who received either graded exercise therapy (GET) or cognitive behavioural therapy (CBT) in addition to standard medical care were significantly less fatigued than those who received standard care alone or those who received adapted pacing therapy. The authors concluded GET and CBT were moderately effective treatments for CFS. Now, moderately effective may not sound all that impressive until you consider that many of our commonly used pharmaceuticals for medical conditions have similar moderate treatment effects. When using pharmaceuticals as treatment, maintaining these effects may mean taking ongoing medicines. This study shows that even two years or more after treatment has completed, patients receiving GET and CBT sustain their clinical benefits. A small percentage of these patients accessed some further treatment, but even so, these sustained effects are impressive. [In light of re-analyses, the effects practically disappear and are fully consistent with a placebo effect].

“Despite these impressive results [hype], this isn’t time for complacency. Some patients do not benefit from the treatment. [The majority of patients do not benefit from the treatment.] We need to do more to understand why. [A critical review of the underlying theory would be a good place to start.]  We also need to develop and tailor existing treatment to get larger effects. It is also important to note that the CBT and GET protocols used in PACE were developed specifically for CFS. They are not the same as CBT for depression and anxiety or the exercise training you may receive at a local gym. The therapies are based on a [non-scientific] biopsychosocial understanding of CFS and the health care professionals in PACE received specific training and supervision in these approaches. This is an important note for commissioners as not all CBT and exercise therapies are equal. Specialist knowledge and competence [and a failure to control for placebo effects] in these therapies is needed to obtain these sustained [contentious and unrecommended by NICE, 2020] treatment effects.”

 Declared interests

Prof. Rona Moss-Morris: “Two authors of this study, Trudie Chalder and Kimberley Goldsmith, are colleagues of mine at King’s College London. I work with Trudie on other CFS work and with Kimberley on different work. I published a small study on GET in 2005. I am a National Advisor for NHS England for improving access to psychological therapies for long-term conditions and medically unexplained symptoms. Peter White (another author of the present study) is Chair of trial steering committee for an HTA NIHR-funded RCT I am working on with people with irritable bowel syndrome.” [Multiple conflicts of interest declared.]

FEBRUARY 17, 2011

expert reaction to Lancet study looking at treatments for Chronic Fatigue Syndrome/ME.

Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial, by Peter White et al, published in the Lancet at 00.01hr UK time Friday 18 February 2011.

The study made the first definitive comparison of various treatments for CFS/ME to deduce the most effective treatments.

Dr Alastair Miller, Consultant Physician at Royal Liverpool University Hospital, Clinical lead for CFS services in Liverpool, Independent assessor of trial safety data for PACE trial and Principal Medical Advisor, Action for ME, [Action for ME was one of the PACE trial sponsors and Dr Miller has an undeclared conflict of interest] said:

“Although NICE have previously recommended graded exercise and CBT as treatments for ME/CFS, this was on the basis of somewhat limited evidence in the form of fairly small clinical trials. This trial represents the highest grade of clinical evidence – a large randomized [uncontrolled] clinical trial, carefully designed, rigorously conducted and scrupulously analysed and reported [A totally false description of the PACE trial which contained 14 design and ethical flaws.] It provides convincing evidence that GET and CBT are safe and effective and should be widely available for our patients with CFS/ME.

“It is clearly vital to continue our research into biological mechanisms for ME/CFS but recent ‘false dawns’ for example, over the role of retroviruses (XMRV) have shown how difficult this can be. In the current absence of a biomedical model for the causation and the absence of any pharmacological intervention, we have a pragmatic approach to therapy that works and we should use it.” [even if it is only a small placebo effect?]

Dr Derick Wade, Consultant and Professor in Neurological Rehabilitation and Clinical Director, Enablement Directorate, Oxford Centre for Enablement, said:

“CFS is common, and it is vital to know whether treatments proposed and/or used are safe and are effective. Randomised controlled trials provide the best and only reliable evidence on safety and effectiveness of any intervention in any condition. The trial design in this study was very good, [but it was not a controlled trial and there are more than a dozen objective flaws] and means that the conclusions drawn can be drawn with confidence. [A patently untrue statement.]

“This is a very significant finding. It identifies that one commonly used intervention is not effective (and therefore should not be used), and it confirms the effectiveness of two treatments, and their safety. The study suggests that everyone with the condition should be offered the treatment, and every patient who wishes to be helped should be willing to try one or both of the treatments. It also means that we can allocate resources to treatments that will benefit patients and, more importantly, stop allocating treatments that do not have proven efficiency. Further research should identify ways that treatments derived from these may deliver greater benefits. [All of this paragraph is spin.]

“Research needs to investigate both treatments and factors that increase the risk of developing CFS. However, it is probably more effective to research treatments, and proving a treatment is effective starts to give clues about causative factors.”

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said:

“We welcome the findings of the PACE trial, which further support cognitive behavioural therapy and graded exercise therapy as safe and effective treatment options for people who have mild or moderate CFS/ME. These findings are in line with our current recommendations on the management of this condition.

“We will now analyse the results of this important trial in more detail before making a final decision on whether there is a clinical need to update our guideline. Until then, healthcare professionals should continue to follow our existing recommendations, especially as this latest research appears to endorse them as best practice for the NHS.”

[NICE, 2021, reported its revised guidance that GET should be dropped and CBT only used in a supportive role.]

Dr Esther Crawley, Consultant Paediatrician and Clinical Lead for the Bath Specialist Paediatrics Chronic Fatigue Syndrome/ME Service, [research associate with no conflicts of interest declared] said:

“All children with chronic fatigue syndrome and their parents are desperate for new research to understand how to treat this condition. The next step is to do a study like this for children to find out if these treatments work.” [Promoting her SMILE trial grant application.]

Prof Willie Hamilton, GP in Exeter and Professor of Primary Care Diagnostics, Peninsula College of Medicine and Dentistry, said:

“At least half of patients improved with CBT or GET. The study also allays fears that CBT or GET may be harmful. [Not among patients who are at the receiving end.] There are a minority of patients who didn’t see improvement so the next step must try and find treatments to help them.

“This study matters: it matters a lot. CFS/ME is common, and causes a lot of suffering. Up until now we have known only that CBT and GET work for some people. We didn’t know if pacing worked. This caused a real dilemma – especially for those in primary care. We didn’t know whether to recommend pacing, or to refer for CBT or GET. Worse still, not all GPs have access to CBT or GET, so ended up suggesting pacing almost by default. This study should solve that dilemma.

“At a patient level, I now know what to suggest to my patients. Almost as important, it sends a powerful message to PCTs – and the soon-to-be-formed GP consortia – that they must fund CBT or GET. NICE proposed that before this study came out – the evidence is even stronger now.”

[With the exception of AfME who sponsored the trial, and later apologised, patient advocacy organisations have not accepted the PACE trial evidence. CBT and GET continue to fail to meet patients’ needs. The NICE (2021) guidance changed recommendations on both GET and CBT and neither therapy is recommended as a treatment for MUS/MECFS.]          


Think again Dr Paxton. Do your job. Or resign.

In previous posts here, here and here, I have discussed the apparent xenophobia of The Psychologist‘s twitter account.

In a bizarre turn of events, however, it is revealed that any alleged misconduct of psychologists working for the British Psychological Society is not dealt with by the Society’s Ethics Committee. This elite group includes Jon Sutton, the managing editor of The Psychologist, who can apparently tweet to his heart’s content in the name of the British Psychological Society. The majority of the Society’s employed officers are managers, not psychologists. If anybody wishes to complain about the conduct of this elite group, they must do so using an arcane ‘Complains Procedures’ described on the Society’s website.

According to the Complaints Procedures, members are required not to “act in a way that damages, or is likely to damage, the reputation of the British Psychological Society or is contrary to the object of the Society as set out in the Royal Charter.” However, the Chair of the Society’s Ethics Committee, Dr Roger Paxton, informed me that the conduct of staff employees falls under the Complaints Procedures, not the Ethics Committee.

Psychologists employed by the Society apparently have a permanent ‘get out of jail free’ card because cases of alleged misconduct are not dealt with by the Ethics Committee.

What a bizarre system: one set of rules for rank and file members and another set of rules for the elite at head office.

An Email sent on behalf of Dr Roger Paxton dated 10 August 2021 states:

Dear Professor Marks,

Thank you for copying me into your email of 3 August to Diane Ashby.  

Dealing with complaints is not within the terms of reference of the Ethics Committee. If you wish to make a complaint about any BPS staff member the complaints process is readily available on the Society website. 

Kind regards,

Dr Roger Paxton

“Dealing with complaints is not within the terms of reference of the Ethics Committee”


This is absurd. Jon Sutton is a practising psychologist and member of the BPS. If his conduct is alleged to be unethical, surely this conduct falls under the purview of the BPS Ethics Committee.

Writing in The Guardian on 13 September 2020, Paxton stated:

Morality has been stripped from public life. Here’s a four-step plan to revive it

Moral Wellbeing

Paxton talks about physical, mental and moral well-being. According to Paxton:

For moral wellbeing there is a similar framework that could be useful: the psychological model developed by James Rest, outlining the four components of moral reasoning.

This is a framework for improving thoughtfulness and clarity about moral matters. The first stage is moral sensitivity – recognising when an issue is one of morality, rather than a personal preference or practicality. The second component is moral reasoning. Having identified that a question is one of right and wrong, you then decide what the right thing to do would be. Third comes moral motivation – acknowledging other interests and motives that influence your thinking about the issue, and then weighing up the conflicting motives. The fourth and final stage is moral implementation, which means bringing moral reasoning and moral motivation together to make and act on a decision

Put theory into practice and think again Dr Paxton. Do your job, or resign.


Xenophobia – What Xenophobia?

Sharing Xenophobia a Collection of Resources

The Little Englander series continues. Following episode 2, ‘Little Englander’: Diane Ashby to the Rescue, we take up the story as Diane Ashby’s Rescue Mission Continues. Her latest email receives a rapid riposte.

Dear Professor Marks

In response to your email of 24 July, I can reassure you that high standards are indeed expected of both staff and members. The purpose of Jon’s tweets around Euro 2020 – including referencing Wales and Scotland when they were in the tournament – was to share a collection of resources on Psychology and football. I believe that, and the spirit in which they were intended, will be apparent to the vast majority of people.

Similarly, I think that an ordinary reasonable person is likely to interpret your ‘Little Englander’ tweet as implying that Jon holds xenophobic attitudes. As noted by Wikipedia, this is a common interpretation of the ‘derogatory’ term. Therefore I must repeat my request that you delete the tweet, by10 August 2021 or we will need to consider further action.

I also kindly request that you refrain from copying Jon in to any reply, as I am aware he has already appealed to you regarding the impact of this. To continue regardless could be interpreted as harassment.

Kind regards

Diane Ashby

Deputy Chief Executive

Dear Diane Ashby,

I acknowledge receipt of today’s email.

Your claim that the purpose of Jon Sutton’s tweets around Euro 2020 “was to share a collection of resources on Psychology and football” appears naive, highly implausible and beside the point. Even if it were true, the impression given by Jon Sutton’s tweet  is of an entirely different nature. 

I refer you to the BPS Guidance on the use of social media where it states: 

■ “Keep your professional and personal life as separate as possible. This may be best achieved by having separate accounts, for example Facebook could be used for personal use and LinkedIn or Twitter used for professional purposes.”

Jon Sutton’s views on ‘football coming home’ etc were personal and should never have been published on the BPS Psychologist Twitter account. Quite clearly, Jon Sutton has broken the rules specified in the social media guidance. By defending Jon Sutton, you are complicit is an unethical, xenophobic and antisocial act against the BPS Code of Ethics and Conduct.

If, as you say, an “ordinary reasonable person is likely to interpret [my] ‘Little Englander’ tweet as implying that Jon holds xenophobic attitudes”, that’s exactly my point. Please note Code of Ethics and Conduct paragraph 3.4 which states: “Integrity Acting with integrity includes being honest, truthful, accurate and consistent in one’s actions, words, decisions, methods and outcomes. It requires setting self-interest to one side and being objective and open to challenge in one’s behaviour in a professional context.”  Also please note paragraph 3.1 which states: “3.1 Respect Respect for the dignity of persons and peoples is one of the most fundamental and universal ethical principles across geographical and cultural boundaries, and across professional disciplines. It provides the philosophical foundation for many of the other ethical Principles. Respect for dignity recognises the inherent worth of all human beings, regardless of perceived or real differences in social status, ethnic origin, gender, capacities, or any other such group-based characteristics. This inherent worth means that all human beings are worthy of equal moral consideration.” Neither Jon Sutton nor you are showing integrity or respect. 

According to the principles of Integrity and Respect, Jon Sutton’s public expression of xenophobia is open to challenge as is your defence of his conduct. I defend my right as a Fellow of the BPS and Chartered Psychologist working within the Code to criticise Jon Sutton for what I perceive to be his xenophobia. There have been multiple occasions where xenophobia and racism, codified or overt, have been evident in BPS publications. I am discussing these issues in a book edited by Professor David Pilgrim and will not go into them here. However I am willing to elaborate if called to do so by any investigating organisation such as the Charity Commission.

Xenophobia about England and English football is widely recognised. It is associated with yobbism, violence, nationalism, racism and right wing politics.  Xenophobia is not an attitude that is becoming of an Editor of The Psychologist. It is my considered opinion that Jon Sutton should delete his tweet and apologise, and that you and other BPS officers should distance yourselves from it and other forms of xenophobic behaviour, not defend it with unsubstantiated and implausible speculations. Hence you are as culpable as Jon Sutton for xenophobia which is out of keeping with the Code of Conduct. 

As stated above I will be willing to clarify in more detail why I consider Jon’s conduct and your support of it detrimental to the public standing and reputation of the Society. To give an example, one of the phrases Jon used: “It’s coming home” may not be as innocent as it sounds. I refer you to the paper: “‘Football’s coming home’ but whose home? And do we want it? Nation, football and the politics of exclusion” by Ben Carrington (2002) in A. Brown (Ed.) Fanatics (pp. 121-143). Routledge available at: http://ndl.ethernet.edu.et/bitstream/123456789/34991/1/Adam_Brown.pdf#page=122

The following quotation from Ben Carrington’s paper seems especially apposite:

“Racism manifests itself in plural and complex forms. In this situation the logic of racism needs to be appraised in what we shall call metonymic elaborations. This means that racisms may be expressed through a variety of coded signifiers…. Contemporary racisms have evolved and adapted to new circumstances. The crucial property of these elaborations is that they can produce a racist effect while denying that this effect is the result of racism.” (Solomos and Back 1996:27). 

As a xenophobic, codified signifier of racism, Jon Sutton’s tweet should be removed without further delay and Jon Sutton should be reprimanded and warned not to use the Society’s Psychologist Twiiter account to make personal, xenophobic remarks. For this reason, I am making a formal complaint to the Society Ethics Committee about Jon Sutton’s conduct and your conduct by being complicit with it.

As requested, I have not copied Jon Sutton into this email to avoid what you describe as ‘harassment’. Equally, any further emails from you to me about this matter will also constitute ‘harassment’, by your definition, and I request that you do not write any further emails to me about this matter.

Herewith I am lodging a formal complaint to the Ethics Committee about your and Jon Sutton’s conduct. Any further communication about this matter should be through the offices of the Chair of the BPS Ethics Committee, to whom I am copying this email.

Kind regards,

David F Marks PhD FBPsS  CPsychol


‘The Martians could land in the car park, and no one would care’



My friend Dave Pilgrim over at BPSWatch writes:

In 1988, the Board structure agreed by the then leaders of the BPS set the scene for the norms of misgovernance and corruption – which we have reported at length on this blog – to grow and thrive.  Two years later Margaret Thatcher had gone, but neoliberalism and managerialism were finding their symbiotic balance and were being embedded in British public organisations, as they became both more bureaucratized and more marketized (Dalingwater, 2014).  The compromise was the New Public Management approach, which was to find a particularly dysfunctional expression in the BPS, as recent events have demonstrated.

In 1989, Del Amitri released their insistently hypnotic Nothing Ever Happens. Good protest songs are enduring; really good ones can be prophetic, hence the title above, which is one of its many spikey lines. To signal the frenetic passivity of recent times, its chorus repeats its own lament of futile repetition: ‘nothing ever happens, nothing happens at all, the needle returns to the start of the song, and we all sing along like before’.  Good lyricists, like good whistle-blowers, are the canaries in our coalmines.

The BPS AGM on the 26th of July 2021 was rigged to celebrate the oligarchy in a feast of scripted mutual backslapping. Another incipient President was confected, in the wake of the show trial, biased appeal, and public disparagement of the expelled whistle blower, Nigel MacLennan. This illegitimate election symbolised, once more, a contempt for integrity and decency in the BPS. 

The two new Presidents (are they both ‘Elect’ and do these terms actually matter anymore, within this chaotic pretence of democracy?) have got their work cut out. If the SMT say ‘jump’, will they ask, ‘how high?’ Alternatively, will they see what is coming down the line and do their best to hold the cabal to account? When put under pressure to conform obediently, as they will, can they really risk being tarred with the same brush of the old guard? This is the grim context for the newcomers to the party: while the Charity Commission prevaricates, the lawyers and the police are closing in on past crimes and misdemeanours. This is a tricky scenario and so the new duo might do well to seek their own legal advice at this stage. 

Within two days of her ‘election’, Katherine Carpenter was ‘delighted’ to unveil the oven-ready ‘New Strategic Framework’, the goals of which I cite here, with some questions in square brackets; many more come to mind, but these are a sample:

  1. We will promote and advocate for diversity and inclusion within the discipline and profession of Psychology and work to eradicate discriminatory practice. [Will this goal require and permit an open democratic discussion of what is meant by all of these terms and how they will be measured or appraised in practice?]
  2. We will strive to create a vibrant member-centred community with a meaningful membership identity. [Will this mean being open with members and not keeping them in the dark about the workings of the Board and the workings of the SMT, in the light of recent history?]
  3. We will promote the value of and encourage collaboration in interdisciplinary development and engagement. [How will that work in practice in relation to other biological and social sciences and will there be a shared commitment to academic freedom and an unambiguous condemnation of censorship?]
  4. We will be the home for all Psychology and psychologists and uphold the highest standards of education and practice. [Will the ethics and complaints system be overhauled radically in order to turn these fine words into practice, under full compliance with Charity Commission expectations?]
  5. We will increase our influence and impact and advance our work on policy and advocacy [Will this work be inclusive of all policy views and value positions in the Society, rather than those which have been captured contingently by some interest groups in the recent past?]
  6. We will strive to be more innovative, agile, adaptive and sustainable. [Will this include being less secretive and censorious than in the recent past or are these words a form of permission for a continuation of the lack of accountability from those in power in the BPS?]”

All of this Motherhood and Apple Pie stuff is so amorphous that it cannot be gainsaid. It all sounds sensible and progressive, but the devil is in the detail. More importantly, look what has happened in the past, when people have tried to put good intentions into practice. 

A number 7 could have been ‘we will confess to and clear up the scandalous mess the BPS is now in after so many years of misgovernance’. That did not make it into the ‘New Strategic Framework’ for the very reason that the rhetorical line of ‘problem what problem?’ has been held firmly by a defensive cabal, pursuing their own vested interests. However, how can ‘we’, the members, have a better a future without owning the truth of the past?

The broadly good intentions of this document motivated the activity of the President Elect, who note was removed illegitimately and then replaced by Katherine Carpenter. He was concerned to make the Society open, and membership centred. He was concerned to defend a Society that was both learned and learning. He was the one who ensured engagement with the Charity Commission to facilitate such changes, and this was resisted by a reactionary Board hostile to his efforts. 

Earlier attempts at ensuring accountability (for example from another removed President, Peter Kinderman) ended in the same process of systemic resistance, reflecting the norm of misgovernance present since 1988.  And although this is systemic resistance (a description), it has been enacted knowingly at times by a social network that remains shameless and self-congratulatory (a motivational explanation) (McPherson, et al., 2001). If this claim is in doubt, witness the fatuous AGM just held. 

In this context of pretence or bad faith, who does the word ‘We’ actually refer to? Is it the Board, the SMT, the membership, some combination, or other people, such as the non-existent truly independent Trustees? Today, investigative journalists trying to find ‘the BPS’ (and the ‘we’ that supposedly embodies it) are like the perplexed foreign student trying to find ‘the university’, among the Oxford colleges (Ryle, 1949). The convenient imprecision throughout the Framework creates ambiguity and a formula for perpetual unaccountability and political mystification in practice. ‘The needle returns to the start of the song and…… 

‘….we all sing along like before’ – an organisation without a memory

The BPS is the antithesis of a ‘learning organisation’. Indeed, it is an ideal case study in cultural dysfunction and selective amnesia, ripe for teams of researchers, whether historians or from management schools. The very idea of a learning organisation or ‘organisation with a memory’ has proved problematic for the NHS (Pilgrim and Sheaff, 2006) but that does have the excuse of being a vast and complex system, employing around 1.5 million staff (Department of Health, 2000). By contrast, the BPS is a medium-sized charity, with just around a hundred employees and less than 70,000, members. The first is a national treasure but the second is becoming (for those who care about it) a national embarrassment. 

Given the size of the BPS, it does have a fighting chance of being a learning organisation. However, for this to be actualised then a starting responsibility is that those of us who are committed to academic values, including freedom of expression, have to be honest about the mess before us. Evading that empirical picture or pretending that this is merely a passing downturn in the fortunes of an essentially honourable institution, which has been kicking around since 1901, looks like the current tactic of the cabal. They favour the convenient ‘this is has been a challenging year’ rhetorical waffle, in order vaguely to play victim and avoid telling the truth, the whole truth and nothing but the truth about the shambles. (This excuse making was on the pernicious YouTube video from Carol McGuinness about Nigel MacLennan, now belatedly removed by the cabal.)

Who will provide the history of this shameful period?

This blog will be archived in the History of Psychology Centre. However, what will be the story for the record told by the current cabal and the older oligarchy, encouraged in their emergence by the structural false start of 1988?  Will it be the heavily redacted Board minutes of November 2020? Will it describe the policy of censorship operated deliberately in relation to its own publications and how BPS employees were used for that purpose? Will it offer the memo demanding that people should close down discussion? Will there be a silence about the departure of the Finance Director while under investigation? Will it mention non-disclosure agreements and the departures of another CEO and another Finance Director under a cloud before the most recent debacle at the top? Will there be an account of why the current CEO (at the time of writing) is still being paid, while absent from his office, with the membership being offered no transparent proposals about the resolution of this ridiculous impasse? 

The questions keep coming for the very reason that the cabal is secretive, and secrecy provokes curiosity, journalistic and otherwise. And because it is secretive ipso facto it is not inclined to elaborate very much for the historical record. More food for thought for the incoming Presidential duo about how history will judge us all.

Talking of looking back…..

When we sent our dossier to the Charity Commission at the end of 2020, it contained several examples of concern that reflected poor governance in the BPS. One related to the closure of the Memory and Law group announced by the Chair of the Research Board, Daryl O’Connor. At the recent AGM noted above, he was made an Honorary Life Fellow of the BPS. Earlier in the month, the other person involved in the announcement, Lisa Morrison Coulthard (Head of Research and Impact), declared via Twitter that she was leaving the BPS after 25 years of employment to join the NFER. Both were central to the development of the existing and outdated report on memory (British Psychological Society, 2008/2010), which was challenged for a decade by alternative voices in the BPS, particularly those emphasising underreported child sexual abuse and its consequences for adult mental health. 

O’Connor and Morrison Coulthard had a clear vested interest in closing down a much-needed review of the evidence, which note had been agreed publicly and on the record on March 26th 2018, under the watch of the then President Nicola Gale. While public inquiries into child sexual abuse have now published their findings in the Australia and are being released episodically in the UK, the only advice available from the BPS is the 2008/2010 report (now archived). It has a narrow focus on false positive decision making based on closed system methodology and its challenge of extrapolation to open systems. For now, the BPS has permitted no reflection on the public inquiries, the social epidemiology of underreported child abuse, the tendency of sex offenders to glibly deny wrongdoing from private scenarios of the past or the evidence on trauma and dissociation (Pilgrim, 2018; Children’s Commissioner’s Report, 2016). 

This suppression of the production of an agreed new review on this matter of grave public interest is an absolute disgrace. It is (yet) another betrayal of democracy and transparency, to add to the many others we have documented on this blog. What chance the success of the ‘New Strategic Framework’, with these inherited mendacious cultural norms? If, in the future, the BPS is to regain a sense of honourable self-possession as a charity, a membership organisation and a truly learned Society, then people will surely be rewarded for their short-term, not long-term, contributions. Why is hanging around year on year, or being recycled in different leadership roles to exclude new voices, a badge of honour and not of shame in a membership organisation? 

The oligarchy may now be disintegrating by sheer dint of the years passing. This creates the space for a new ethos and for considered reflection on this cultural inertia and its ethically dubious norms of self-perpetuated authority.  After the police, lawyers and Charity Commission have done their work in the coming months, then the BPS still has a fighting chance to regain its credibility and become a learning organisation. 

New people with integrity will be needed for this optimistic scenario. The stitched up and scandalously disparaged ex-President Elect could be their role model. Trustees need to be truly independent to displace the current sham of a Board. The SMT must be accountable to the Board and not dictate to it. Financial matters must be transparent at all times to the Board. The membership must be kept informed, not in the dark. Censorship should have no place in a learned organisation. 

Food for thought indeed for the incoming Presidential duo. I do not envy them their considerable challenge.


British Psychological Society (2008/2010) Guidelines on Memory and the Law Recommendations from the Scientific Study of Human Memory.  Leicester: British Psychological Society.

Children’s Commissioner’s Report (2016) Barnahus: Improving The Response to Child Sex Abuse in England London: UK Children’s Commissioner’s Office 

Dalingwater, D. (2014) Post-New Public Management (NPM) and the Reconfiguration of Health Services in England. Observatoire de la Société Britannique, 16, 51-64.

Department of Health (2000) An Organisation With A Memory: Report of an Expert Group on Learning from Adverse Events in the NHS London: Stationery Office.

McPherson, M. Smith-Lovin, L. and Cook, J.M. (2001) Birds of a feather: homophily in social networks. Annual Review of Sociology 27, 1, 415–444. 

Pilgrim, D. (2018) Child Sexual Abuse: Moral Panic or State of Denial? London: Routledge.

Pilgrim, D. and Sheaff, R. (2006) Can learning organisations survive in the newer NHS? Implementation Science 1, 27, 1-11.

Ryle, G. (1949) The Concept of Mind London: Hutchinson.