Impact case study database
The “Elephant in the Ward”: Combatting Boredom in Hospital
1. Summary of the impact
The Hidden Persuaders project, led by Professor Daniel Pick, has influenced and inspired Dr Lizzie Burns’ Anti-Boredom Campaign, leading up to and following Burns’ appointment as Public Engagement Consultant on Hidden Persuaders. The Campaign has gone on to change attitudes and approaches to tackling boredom in clinical settings, and succeeded in getting boredom recognised as a major issue in hospitals. The Royal College of Pathologists launched Burns’ colouring book, Incredible You, as a therapeutic resource in 2019. It was given as a Christmas gift to every in-patient at University College Hospital that year. Burns produced a leaflet to inspire and teach patients how to make origami (initial print run 25,000) which was sent to ten NHS Hospital Trusts across the UK; the print run is both far-reaching and easily replicable. Burns has conducted over 2,000 one-to-one origami sessions with NHS patients at UCH and has conducted 200 further sessions through Origami Pulse. Of the patients that completed feedback, all wished the service to continue while the majority reported improvements in mood.
The Oxford Health Charity promoted Burns’ origami tutorials to support service users during Covid-19 self-isolation. Arts packs with Burns’ origami instructions were sent to NHS patients; similar packs were also distributed in December 2018. Finally, a ‘Boredom Busting’ paper with a print run of 60,000 and inspired by Burns’ work was sent to hospitals across the UK in 2020.
2. Underpinning research
Daniel Pick is one of the leading authorities on the history of the psychological professions and has explored the means by which governments, agencies, movements and organizations have used psychological means to influence human behaviour, emotions and thinking (REFS 1, 2, 3). The Hidden Persuaders project, which Pick led and developed from its inception in 2014, has examined the causes, challenges, contexts and consequences of psychologists’ and clinicians’ participation (real and imagined) in mind control projects in and after the Cold War. Pick (in addition to his six-strong research team) has produced original innovative research that has reshaped popular and academic understandings of the history of brainwashing (REFS 1, 2, 3) .
Taking as the starting point fears of ‘brainwashing’ in the 1950s, Hidden Persuaders has forged new lines of inquiry; it has helped understand how concepts and practices in mental health shaped and were influenced by Cold War culture and politics; and mapped legacies of these models of mind and theories of human relations, in the new millennium (REFS 1, 2).
The research shows how brainwashing fears were disseminated in diverse societies, analysed in the human sciences and taken up by the psychiatric, psychoanalytic and psychological professions in myriad ways. With his team, Pick examined the involvement of clinicians in political and commercial behavioural modification experiments ( https://wellcomecollection.org/series/W1boEyYAACgAqwfw), in ideas of re-education, and counter-insurgency strategies, as well as in critical analyses of such indoctrination programmes and practices, and in a plethora of popular dramas. Hidden Persuaders showed how fears of psychological coercion informed crucial debates about freedom and totalitarianism in the history of political thought.
Over seven years, Hidden Persuaders built an international, cross-disciplinary forum for informed inquiry into this vexed history; considered what can be learned from the past in order to combat the dangers of ‘hidden persuasion’ in the twenty-first century, and encouraged policy reflection on the problems of covert influence and indoctrination techniques. The project has provided a panoramic, comparative investigation of theories and technologies of ‘brainwashing’ and cognate processes. It brings the story of mind control experiments into dialogue with urgent concerns now regarding education, mental health therapies, cults, conspiracy theories, covert advertising, detainees’ treatment in captivity, psychological torture and interrogation, and the effects of chronic sensory deprivation and/or overload in modern penal, clinical and hospital settings.
Alongside their continuing programme of research and publication, Pick and the Hidden Persuaders group developed numerous public engagement activities, funded by a substantial additional grant from the Wellcome Trust in 2017. This included a school film project, led by Pick and Dr Sarah Marks, and facilitated by Burns, over 2 years, which enabled up to 80 teenagers in Camden to produce their own short films about brainwashing ( http://www7.bbk.ac.uk/hiddenpersuaders/outreach/). Hidden Persuaders was awarded first prize in the culture section of the International Psychoanalytical Association 2021 awards for Psychoanalysis in the Community ( https://www.ipa.world/IPA/en/Communities2/IPA_in_the_Community/Community_awards_2020.aspx), the schools project was shortlisted for the Learning on Screen Awards 2021 ( https://learningonscreen.ac.uk/awards/shortlist/, outcome pending), and a Birkbeck award for public engagement( http://www.bbk.ac.uk/downloads/research/public-engagement-awards-2019.pdf)
3. References to the research
REF1) Psychoanalysis in the Age of Totalitarianism, eds. Matt ffytche, Daniel Pick (Routledge, 2016). Including Pick, D and ffytche M. Introduction, ibid, 3-19.
REF2) Pick, D., and Christie, I, ‘Hidden in Plain Sight: Uncovering the Secret History of Brainwashing - A Dialogue’, in Where Is History Today?: New Ways of Representing the Past, ed: Ian Christie et al, Palacký University Olomouc, (2015), pp. 55-69.
REF3) Pick, D., Psychoanalysis: A Very Short Introduction (Oxford University Press, 2015)
REF4) Pick, D., The Pursuit of the Nazi Mind: Hitler, Hess and the Analysts (OUP 2012)
REF5) with C. Hall and D. Pick, ‘Thinking about Denial’, History Workshop Journal, Autumn 2017, vol 84, pp. 1-23. Online at https://academic.oup.com/hwj/article/doi/10.1093/hwj/dbx040/4092871
REF6) Holmes, M and Pick, D, ‘Voices off: Stanley Milgram’s cyranoids in historical context’, in History of the Human Sciences September, 2019. https://doi.org/10.1177/0952695119867021
4. Details of the impact
Elizabeth Burns, a science-based artist and creative specialist in oncology, began the Anti-Boredom campaign in 2017 after identifying lack of stimulation and tedium as an under-researched and under-treated social problem, raising ‘awareness’ and acknowledging that ‘prolonged boredom is a suffering’. Recognition that boredom can cause acute distress is particularly crucial in vulnerable groups such as long-stay hospital patients, the elderly, individuals in care homes and the terminally ill, whose sufferings can often be exacerbated by extended periods of sensory and psychological deprivation.
Despite the gravity of this issue, the Anti-Boredom Campaign is the only nationwide UK campaign of its kind, addressing this problem in diverse settings including psychiatric care facilities and hospitals. The widespread isolation imposed by the Covid-19 crisis has highlighted this issue. The Anti-Boredom Campaign has gained substantial attention through national media such as The Daily Telegraph, The Times, the BBC, and The Daily Mail.
Burns’ interest in Pick’s research developed while applying to join the Hidden Persuaders team as the project’s Public Engagement Consultant in 2017. As she read more about Pick’s research (for instance his dialogue with the film historian Ian Christie, ‘Hidden in Plain Sight: Uncovering the Secret History of Brainwashing’; published in Where is History Today?) she ‘was amazed and delighted to find unexpected links’. As Burns states, before she read work by the Hidden Persuaders team “this historical perspective (of research into boredom) had been missed by me, and has added depth and gravitas to what I do. In science there's an emphasis on keeping up to date with research, [an assumption] that the latest papers will be the most accurate understanding on a topic - and so historical perspective is lost very quickly.”
Through developing an innovative Schools Project, enabling dozens of London teenagers to make video essays on brainwashing, Pick and Burns collaborated through sharing historical papers relating to boredom, leading to a formal working partnership. In 2018, whilst employed on the project, Burns published a letter in the British Medical Journal Supportive and Palliative Care, entitled “Elephant in the Ward”, on patient boredom and palliative care, later encouraging a patient to write about boredom directly, published in the BMJ.
In contrast to Burns’ earlier work on boredom in clinical settings, “Elephant in the Ward” draws on what she had learnt from Pick and makes reference to archival research, citing a study undertaken in 1957. In the article, Burns describes the aims of that 1957 paper to study deprivation “as one of the most effective ways to break the human mind”, and considers the unintentional sensory deprivation so often endured by patients in modern clinical environments. Earlier sinister experiments on human isolation and sensory deprivation invited reconsideration of the experience of being confined to a hospital, often in stressful situations, and with little to no stimulation. Pick’s work, on post-war brainwashing, and on the uses of psychology in the interwar period and the Second World War, and furthermore the emergence of new approaches to creating therapeutic communities and promoting practices of group therapy after 1945, had already explored related questions about the unconscious impact on prisoners and patients of captivity, or immobility, with its attendant anxiety, stress and potential isolation. As Burns notes, “patients have described being in bare hospital rooms with nothing to do as torturous”. It was through engaging with Pick’s research and through working with him to gain familiarity with how to use archival sources that Burns was able to make new links between the past and present. She credits the project with her expanded focus. In addition to Pick’s work, Burns’ highlights the encouragement of this project to delve into archives and history, hence leading her back to an archival research paper by Woodburn Heron (“The Pathology of Boredom.” Scientific American, vol. 196, no. 1, 1957, pp. 52–57., www.jstor.org/stable/24941856) which fundamentally transformed her thinking. Without Hidden Persuaders, she would not have made this link between boredom, mind control and torture.
The links that Burns made through Hidden Persuaders and working with Pick are important because despite the endemic problem of boredom in hospitals, very little modern research assesses the effects or how best to tackle it. Burns has subsequently effected significant change in clinical approaches to boredom using the refined understanding that Hidden Persuaders afforded her.
Crucially, working with Pick and the Hidden Persuaders team allowed Burns to incorporate her understanding of historical approaches, and its archive-based practices, into the Anti-Boredom Campaign. Moreover, Burns notes that the historic perspective that Pick’s research helped her formulate added ‘gravitas’ to her campaign; she would never have discovered ‘The Pathology of Boredom’ and other rich historical materials, if not for Hidden Persuaders. Burns’ approach to boredom as something that should be thought of and treated as pathological derives from the historicist and inter-disciplinary perspectives that Hidden Persuaders provided, and helped her to see how a major issue was marginalised or entirely occluded in the modern scientific and clinical literature (1 ( http://www7.bbk.ac.uk/hiddenpersuaders/blog/the-pathology-of-boredom/)).
Following Burns’ work with Hidden Persuaders, the Anti-Boredom Campaign has significantly impacted on attitudes and approaches to tackling patients’ experience and opportunities in clinical settings, firstly through her work with London College Hospitals NHS Trust (UCLH), and secondly through her Community Interest Company, Origami Pulse.
University College London Hospital NHS Foundation Trust
UCLH has been at the centre of this systemic change in creating new resources for patients. Burns work has inspired other Trusts including Oxford University Hospitals trust (OUH). The ‘Anti-boredom' boxes that Burns developed are being used at the OUH, funded by the League of Friends volunteer organisation. In January 2020, 40 boxes were delivered to the Trust’s four hospitals, costing GBP3,000 in total (2). Meanwhile, the community charity Oxford Hub recruited ‘anti-boredom’ volunteers in their Hospital Volunteering pilot. The charity partnered with the OUH NHS Trust and, inspired by the Anti-Boredom Campaign, used Burns’ origami technique in hospitals (3). Additionally, a 2018 Justgiving campaign raised over GBP121,000 for UCLH which part-funded Burns’ anti-boredom work at the hospital. Furthermore, the campaign witnessed impacts during the Covid-19 crisis: the Oxford Health Charity promoted the Anti-Boredom Campaign’s origami tutorials to support service users during Covid-19 self-isolation (3).
The Arts Co-ordinator at Creating with Care at Oxford Health Foundation Trust subsequently organised arts packs to be sent to patients at the OUH Trust during the crisis. As of 20 March 2020, they have been sent to patients at the Witney Community Hospital. These packs include origami instructions that Burns designed (4). Similar packs were also sent to Witney Community Hospital in December 2018.
Nottingham University Hospital NHS Trust
In 2020, an Occupational Therapist at Nottingham University Hospital NHS Trust was inspired by Burns’ Anti-Boredom work to create her own resource, a booklet to help alleviate boredom for older patients on wards who couldn’t access newspapers, books, or other activities. The quality of Burns’ booklet encouraged her to aim high and to get booklets printed professionally. Moreover, the creativity led her to think of ways to encourage this as part of the booklet and to come up with easily accessible creative activities which could be enjoyed by older people who may have a cognitive impairment such as dementia or delirium (5). After the initial 150-strong print run was distributed to inpatients on a ward for older people, feedback was extremely positive (5).
Boredom Busting paper
Inspired by Burns’ work, an arts coordinator created a ‘boredom busting’ newspaper to distribute to hospital inpatients (6). Featuring work from globally-acclaimed artists Anthony Gormley and Banksy, as well as contributions from Burns, the initial 60,000-strong print run of the paper was distributed to hospitals across the UK. Such was the success of the initial run that she is currently working on a second edition of the paper.
Origami Pulse
Stating that ‘Origami is the closest I’ve come to a single answer to help people with boredom’, Burns notes the key role that Hidden Persuaders played in driving her to develop origami as a therapeutic practice with patients. After working on Hidden Persuaders, she was struck by the suggestion that techniques used in sensory deprivation are remarkably similar to hospital environments, so often characterised by blank surfaces devoid of patterns. Origami relieves pattern deprivation by providing pattern-based stimulation to occupy chronically bored patients’ minds.
Hidden Persuaders ‘crystallised how detrimental deprivation and boredom are for mental health’, adding ‘richness’ to Burns’ understanding. She repeatedly acknowledges the importance of Hidden Persuaders for her own work:
‘Reading [the archival studies] has changed my approach [and has given] me more drive […] The point in one study about pattern-deprivation was very important to my appreciation of origami. I wouldn’t have accessed that study or even been aware of it without the Hidden Persuaders project […] Reading this work informed my understanding of boredom which then informed my approach to anti-boredom and origami. ‘Elephant in the Ward’ discussed the idea that hospitals encourage pattern deprivation with blank spaces. It’s hard to say whether I would have pursued origami as strongly if I hadn’t worked with Daniel – it certainly gave me a push and clarity to develop work.’ (1)
Using origami as a basis for patterned stimulus to alleviate boredom has subsequently become a cornerstone of Burns’ practice, so much so that she co-founded and is now a company director of Origami Pulse CIC. Promoting therapeutic origami, Origami Pulse’s successes have been remarkable, building partnerships with OpenMaker, the Big Lottery Community Fund, Community Foundation for Merseyside, Groundwork Tesco Bags for Help, Postcode Community Trust, and The Beautiful Ideas Co.
Including Burns, the company is comprised of three staff and since its incorporation in 2018 has been funded by three lottery grants worth a total of £30,000. Burns has conducted over 2,000 origami sessions with NHS patients at University College Hospital and has conducted 200 further sessions through Origami Pulse. The psychological benefit that Burns’ origami sessions has had on patients is strong: after the sessions, 58% of participants reported that they felt happier, 42% more relaxed and 38% felt mentally stimulated, compared with 31% feeling down, 28% bored, and 18% anxious prior to the sessions. Patients overwhelmingly felt that the sessions could help with anxiety (78%), mood (81%), boredom (87%), and loneliness (69%). 100% of participants wanted the sessions to continue (7).
In addition to the origami sessions, the company has also commissioned a graphic designer to produce a leaflet targeted at hospital patients. The leaflet had an initial print run of 25,000 and was sent to hospitals across the UK, including Liverpool, York, Bristol, Coventry, London, Cambridge, Oxford (1). Origami Pulse’s latest project partners with the Sefton Borough of Culture campaign on the Red Squirrel Project, which is raising awareness to halt the decline of the iconic British species. They also sell products through the Big Issue shop https://www.bigissueshop.com/vendor/origami-pulse. This is just one example of the cascade of effects of Burns’ work and of the Hidden Persuaders project that has influenced it.
Incredible You and Amazing Body
Further assisting the Anti-Boredom Campaign, the Royal College of Pathologists launched and promoted Burns’ colouring book, Incredible You, as a resource “designed to support learning and relaxation” (8). Incredible You also featured prominently as part of the Royal Institution’s ‘Animal CSI: Predator’ event and exhibition in March 2019, and was given as a Christmas gift to every in-patient at University College Hospital in 2019 (1). The project was aimed at helping patients overcome boredom through learning and creativity.
With funding from The Physiological Society, Dr Burns has been collaborating with scientists across the UK to create drawings and pieces of Origami to stimulate learning and creativity around the human body. The project was inspired by creating resources to help patients combat boredom, and includes support from Nobel Prize winning Sir Peter Ratcliffe’s group ( https://www.physoc.org/supporting-you/public-engagement/outreach-resources/amazing-body/).
Singing in The Rain
Best-selling author, former Times journalist and mental health advocate Rachel Kelly has cited Burns’ 2017 letter to the British Medical Journal, ‘Pass me an anti-boredom pill doctor’ – itself inspired by Pick’s work – as a key research source in her book, Singing in The Rain: 52 Practical Steps to Happiness. Singing in the Rain offers practical solutions for individuals experiencing a range of mental health symptoms. It is currently rated at 5 out of 5 stars at Waterstones and 4 stars on Amazon.co.uk, with customer reviews noting that it empowers ‘everyone to take control of their mental health’, and its advice being based on ‘solid scientific research’. It has been praised by Professor of Biological Psychiatry at Kings College London, Carmine Pariante, and Sir Anthony Seldon, Vice-Chancellor of Buckingham University and co-founder of Action for Happiness. Kelly is also the official ambassador for leading UK mental health charities, SANE, Rethink Mental Illness, The Counselling Foundation, and Head Talks, supporting those with and raising awareness of mental health issues.
5. Sources to corroborate the impact
1) Email: Lizzie Burns; Blog post: Lizzie Burns, ‘The Pathology of Boredom’, Hidden Persuaders
2) ‘“Anti-Boredom Box” Helps Combat Hospital Boredom, Oxford University Hospitals News
3) ‘How YOU can be part of the NHS in Oxford City’, Oxford Hub Blog; Oxford Hub Tweet thanks Lizzie Burns for Hospital work; ‘Staying Positive with Creating with Care’, Oxford Health Charity; ‘Anti-Boredom Volunteers for the John Radcliffe Hospital!’
4) ‘COVID: Arts packs keep boredom and distress at bay’, Oxford Health NHS Foundation Trust
5) Email Occupational Therapist, Nottingham University Hospitals Trust
6) Boredom Buster printed resource (Summer 2020)
7) Origami Pulse CIC: Testimonial and quantitative evidence of patient benefits.
8) ‘Incredible You - A New Colouring-in Pathology Resource’, Royal College of Pathologists