First post

Dr Bould’s first post in psychiatry in Bristol was with Dr Jonathan Evans, who at the time was a senior lecturer in the University of Bristol.

“He had a split role: half his week was clinical practice and half his week was academic in the University. He was really enthusiastic and genuinely curious and interested in patients’ experiences, and I interpreted this as being partly because he wasn't in clinic all the time and partly because he was conscious that we don't know everything: we’re on a journey of understanding - and I thought to myself, I want to have his job! That was the point where I decided to pursue academic psychiatry.”

The road to research

However, getting into research proved difficult, at first. Helen met with Professor Glyn Lewis, who was then a professor of psychiatric epidemiology in Bristol, who helped her get involved with a few small projects including analyses and writing up the research for publication, as well as continuing with her clinical training.

In February 2014, Helen wrote an application for the Elizabeth Blackwell Institute Clinical Primer Scheme.

“The Elizabeth Blackwell Institute interview process was a very positive experience. I had a really good conversation with interested academics and I came away thinking, ‘well I think that went quite well!’ Luckily I was correct and was offered the post.”

Clinical Primers

The Clinical Primer Scheme was a program from the Elizabeth Blackwell Institute designed to let clinicians experience academic research, and consider whether it might be a suitable career path. Helen’s project, titled ‘Body Dissatisfaction, Eating Disorders & Schools’, was conducted in the School of Social and Community Medicine with Dr Evans and Prof Lewis.

The project involved working with record-linkage data from Sweden regarding eating disorders in girls born in Stockholm in 1984 to 1995. This clinic data was linked with data on which schools the children went to (from 15 to18 years old), and the study aimed to see if some schools had more female pupils with eating disorders than others.

Helen found that schools with a higher proportion of female students, and schools with a higher proportion of highly educated parents, had higher rates of girls with eating disorders, even once individual student characteristics were taken into account. This suggests that there may be differences in the cultural milieu the students experience in different schools, or that eating disorders could be socially contagious.

The work may help clinicians to reduce the risk of eating disorders by identifying schools where young people are at more risk and intervening early. Helen presented the study at the European Society for Child and Adolescent Psychiatry Congress 2015 in Madrid, and published it in the International Journal of Epidemiology.

She was also collaborating extensively with epidemiologists in the Medical School. “The statistics and epidemiology departments in Bristol are amazing; I learned a huge amount from them”.

As well as establishing relationships with cross-disciplinary researchers in Sweden, the project proved beneficial in other ways, as Helen explained. “The Elizabeth Blackwell Institute project was the first time I'd had time to do academic work without having to fit it in around any clinical responsibilities. I was able to work on a standalone project which I finished off during my doctorate, and I also started another project which became the first chapter in my PhD.”

Relocation to Oxford

Helen submitted a DPhil application to Oxford University, which was successful so immediately after the Clinical Primer, Helen relocated to Oxford to study for her doctorate, which was born from a talk given by Bristol University’s experimental psychologist Marcus Munafò, about shifting people's interpretation of different facial expressions - something he was exploring with young offenders at the time.

“I was working in an inpatient unit with people with eating disorders, and I wondered if you could change people's perception of their body size in a similar way: a large proportion of people with eating disorders are very concerned about their body size, their shape and their weight, and may misperceive their size. When I explained this idea, Marcus he was really supportive of me investigating it. So that became an interdisciplinary piece of work with Marcus and Professor Ian Penton Voak at Bristol.”

Professor Munafò put Helen in touch with Prof Catherine Harmer at Oxford University, who was investigating mood and emotion recognition -  Helen’s project was parallel to her interests, but in a different field. Prof Harmer became one of her supervisors.

“During the Clinical Primer I had Professor Glyn Lewis and the epidemiologists and statisticians helping with Swedish record linkage data and the ALSPAC data, and I was also working with Marcus and Ian designing experiments around body image. Marcus and Ian, alongside Dr Andy Skinner, a methodologist who was working in their group at the time, remained involved in my PhD work and are co-authors on most of the outputs from my PhD.”

Back in Bristol

Following the completion of her PhD, Helen returned to Bristol and in March 2019 she, alongside her Bristol colleagues, was awarded an MRC/MRF grant for a project called ‘Emotional Dysregulation, self-harm and eating disorders: a mechanistic investigation’.

“I was in the last two months of writing up my thesis, and the MRC/MRF put out a call for grants in the area of eating disorders and self-harm. The timing was perfect, the subject matter matched perfectly with my field - so I stopped writing up my PhD for a couple of months and instead wrote my first grant application. Like you do. And, in the autumn, we got it!”

The project, which ran through until May 2020, used ALSPAC data to study whether difficulties in regulating emotions in early childhood has an impact on self-harm and eating disorders in later childhood, and if there are links to issues understanding social situations, reading facial expressions or bullying.

As well as this, from November 2019, Helen was working with the local NHS trust as a consultant child and adolescent psychiatrist - the University and the NHS collaborated to create the post, which allowed her to spend part of her time as a clinician, and the remainder as an academic.

Into the virtual

Helen’s present work is very closely aligned to her Clinical Primer and PhD studies - in November 2022 she started a NIHR (National Institute for Health and Care Research) Advanced Fellowship titled ‘Using the Person Based Approach to Design Novel Virtual Reality Treatments for Eating Disorders’.

“This project is informed by the work that I did during my PhD - I was looking to move towards approaches that could potentially become a component of patient care - and I was fascinated by how we might be able to make use of virtual reality as a technology to enable people to experience things that aren't necessarily possible to do in the real world”

The plan for the current research is to develop novel interventions - with another three years to go in the Fellowship, Helen and her team have a suite of three interventions at varying stages of development.

Feasibility trials 

“One of the interventions will be feasibility trialed by the NHS as part of the fellowship. If that trial goes well, we will look to apply for follow-on funding for a randomised control trial. Should the other interventions look similarly promising, Helen would aim to get separate funding to spin them off from the same project in the same way.

But what is it about the application of VR that appeals, from a psychiatric perspective?

“I think there are definitely areas of psychiatry and mental health where virtual reality is making a real difference and really helping people. For patients with PTSD in particular, virtual reality enables people to relive experiences that they've had but with additional support from clinicians - and it seems to be quite effective. The other area which VR can help is with phobias - fear of heights, for example. Virtual Reality lets patients experience incremental stimuli in a controlled and gradual way and thus have exposure and response prevention work. Of course, it’s possible to do this without VR, but the technology makes it easier: it's convenient and you can operate it within the clinic rather than having to go out into the world.

Cafe au fait

The aspect of Helen’s work that the team has progressed most to date is a cafe scenario, where patients with eating disorders, who often find cafes very challenging, can experience a much more controlled environment than they could in a cafe in real life.

“The patient and their clinician will be able to decide on the level of difficulty; how empty, busy, noisy or quiet the cafe should be, and what the interactions they have with other people are going to be like; what the menus are going to be like and so on. I envisage this being used as a sort of stepping stone to help people get back into real world cafes.”

The team is also working on some different VR experiences, focusing on body image interventions, as Helen explains:

“Virtual reality enables you to experience embodying a body that's different to your own. We are in the process of analysing our first sets of focus groups and interviews with people with eating disorders about how they imagine that would be for them, and what therapeutic use we might be able to make of that experience. We’re working out how we can develop an intervention that is safe and that people would want to engage with, that might enable them to feel more positive about their own body and facilitate their journey to recovery.”

“One of the key things I have taken from my experiences in Bristol and working with Marcus and Ian is the importance of open science, and how having transparent and reproducible processes is key. If we work really carefully to discover the ways in which it can be useful, and involve end users throughout to ensure that patients in clinic will engage with what we develop, and use it as part of their treatment, then Virtual Reality has real potential.”

Reflections

Looking back on her journey in research to date, Helen said: “My career path was not without it obstacles and challenges, including several failures along the way (most notably four unsuccessful PhD Fellowship applications and an unsuccessful post-doctoral Fellowship application), and also a considerable amount of juggling around having children.”

“The Elizabeth Blackwell Institute supported me at a pivotal moment of my career, giving me the opportunity to move from working full time as a clinician to training as an academic too. There’s immense value in an institution that supports interdisciplinary research and facilitates collaboration in the way the Elizabeth Blackwell Institute does, helping new researchers explore new angles and consider different perspectives on their own work, and most importantly giving them time in which to do this.”