Friday, March 22, 2013

Clinical Psychology in the UK – where will we be in 2023?


A talk given to the South East Thames Division of Clinical Psychology AGM Friday 22nd March 2013


Thank you.

Just to introduce myself and to set out my credentials, I have twice now been Chair of the DCP, I’m currently the leader of a large multidisciplinary research group at Liverpool, combining public health, primary care and psychology, and I have myself been a user of mental health services.

So… my title today is “what will clinical psychology look like in 2023…?”

I am hugely optimistic. The future for my profession is bright and positive.

I know that, when I say that these days, audiences tend to be more sceptical. The Health and Social Care Bill, the restructuring and even privatization of the NHS … the recession, cuts in Local Authority funding… These financial constraints and re-organisations put pressures on the employment prospects of clinical and other applied psychologists. And with a Conservative Government, we see a lurch to the right – in our case leading to the danger of old-fashioned and disadvantageous forms of care provision. Clinical psychologists, it’s argued, are facing cuts and downgrading … and our positive vision for care is equally under threat.
But… I’m really sorry… I’m just much more positive than that. I think we have a fantastic, even transformational, message. And I think that, in 2023, we’ll see a robust, effective, authoritative profession.

First, a little history and context.

In 1989, as I was training to be a clinical psychologist, the MAS - Management Advisory Service – wrote a report on the future of what they called ‘healthcare psychology’; what we’d now call applied psychology. Clinical, health, forensic psychology.
This was, in truth, an inside job… it was psychologists making recommendations about their own profession. But it’s still worth quoting their recommendations:
“In order to realise the desirable staffing patterns, it will be necessary to aim ultimately for ...a minimum of 4,000 healthcare psychologists ... To achieve this target it would be necessary to establish at least 300 training posts...”
Now … there are at least 9,600 members of the Division of Clinical Psychology alone, and we’re training 650 new graduates from the D.Clin.Psych doctorates per year… 650 versus the 300 recommended. We have achieved double what we aspired to achieve.
Just think about that. Our own psychologists, arguing for investment in clinical psychology, challenged the Department of Health to invest in our profession… and they responded by giving us twice what we asked for.
I do understand that there are difficulties at present. I think, to be candid, that many working people are finding the present period difficult. But clinical psychology is hardly in crisis. We have seen major policy and legislative support for our work. I am fully aware that there are tensions over the development of NICE guidelines and IAPT services.  But let’s take a step backwards and get some perspective.

NICE and IAPT

I do think that the general principle of the NICE guidelines is great – we systematically review the evidence and an expert practitioner committee makes recommendations about best cost-effective care.
I understand the criticisms of this system – it’s cost-effective care, not necessarily gold-standard care; the system is heavily weighted on RCTs – randomised controlled trials – and diagnostic categories. I am also aware that many of my colleagues feel that CBT has its limitations. But a proportionate look at NICE guidelines should, I think, make you very confident. Again and again, the evidence points to the effectiveness of straightforward psychosocial interventions.
Similarly, when we look at IAPT, while I absolutely see the difficulties, I do think that the picture is hugely positive.
I understand that CBT is not the only fruit. I’m less sympathetic with the idea that CBT therapists are taking clinical psychologists’ jobs; IT consultants have replaced typewriter engineers, and that’s just the way it is. But I do agree that we shouldn’t tolerate sticking plaster solutions and poor-quality care. Some of the aspects of IAPT concern me.
But, again, the general principle of the IAPT programme is wonderful – since psychosocial approaches are effective, let’s invest in them. And… although we’ve not seen a fantastic process of implementation… the basic idea was to see thousands of new CBT therapists (mainly recruited from existing mental health care staff) and thousands of extra clinical psychologists supervising them.

Vision

We also have a positive vision for care…  Back in 1948, the World Health Organisation defined health as “... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, and mental health as: “... a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”
These – hugely attractive – definitions were, in my opinion, improved upon by the EU who defined mental health as “... a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life.”... and also – just to make things nearly perfect – added that: ““The mental condition of people is determined by a multiplicity of factors including biological (e.g., genetics, gender), individual (e.g., personal experiences), family and social (e.g., social support) and economic and environmental (e.g., social status and living conditions).”
That is, of course, great for clinical psychologists. We’re helping people fulfil their potential as human beings, not treating illnesses. This means linking to the wider Government well-being agenda – which has significant but very positive consequences for our profession, and our relationship with other professions.
Of course, of course, there should be one-to-one psychotherapy. But we should also be offering more fully holistic services. We should be linking with Jobcentre Plus employment advisers who are delivering what are effectively wellbeing interventions for people. We should be working with the education services.  And we should be working with the physical health services. We should be working with employers, there’s plenty of evidence that interventions aimed at improving people’s wellbeing - not curing their mental illnesses but improving people’s wellbeing - is productive for employers. We should be working with 3rd Sector organisations and the wider civil society. 
And for me, this means that our employers need to be supportive of that way of working.  We need to be remunerated and employed and contracted and commissioned to deliver the sort of services that people say they want.

Commissioning

I think that GPs share these aspirations. GPs, for many years, have seen their role as incorporating the protection of public health. GPs see the whole person, across the lifespan. That means GPs have a natural affinity for the type of care we also want.
This is important as the CCGs – the clinical commissioning groups – get to work. Important because it is GPs, who share this vision, who will dominate CCGs. And important, also that the Local Authority Health and Well-being Boards will have such a significant role.


The social and political context

Our health and well-being are intimately related to social, economic and even political issues.
My colleagues Ben Barr and David Taylor-Robinson in Liverpool have demonstrated how 1000 deaths here in the UK can be specifically attributed to the economic crisis. Ben and David have also revealed that the cuts in local authority spending are falling hardest on the poorest – with central government funds withdrawn most severely from the most deprived communities.
This matters, because our research starts in the social and human realities of our clients’ lives. We therefore understand that our core business is much less about treating illnesses and much more about promoting well-being. That’s why psychological contribution to the Office for National Statistics programme to measure national well being, and approaches such as the now ubiquitous 5 ways to well-being, developed in part by my colleague Sam Thompson, are so important.
And it’s why the Health and Well-Being Boards could be so significant and positive for our profession.

Added value

So… the future is, I think, very positive. But... what we need to do is demonstrate the value of our work.
There’s a hackneyed phrase of Kennedy – JFK “ask not what your country can do for you, ask what you can do for your country”. I’m less interested in the navel-gazing of clinical psychologists and much more interested, to be honest, in what we have to offer.
On September 1st 1967, the Nobel Prize-winning civil rights leader Martin Luther King Jr. delivered a speech entitled “the role of the behavioral scientist in the civil rights movement” to the American Psychological Association.
With eloquence and passion, Martin Luther King championed the civil rights struggle … and spoke about how people like me could and should support the civil rights movement.  This speech is particularly relevant today.
Most powerfully, Martin Luther King said: “There are some things in our society, some things in our world, to which we … must always be maladjusted if we are to be people of good will. …”
If there were a Martin Luther King for 2013, he or she would call on us to speak out, to identify and to condemn those things that should be condemned. We should refuse to tolerate the unacceptable and to act accordingly.
In 1967, Martin Luther King identified a number of key issues that should be the focus for behavioural scientists; urban riots, the Vietnam war, unemployment and civil disobedience.
It’s remarkable how well these issues have persisted over two generations. We have seen urban riots on the streets of major UK cities in the very recent past, we have military adventures in Iraq, Afghanistan and Mali, we have mass unemployment and we have civil disobedience – today in the shape of the ‘Occupy’ movement.
We would add social and economic inequalities, the credit crisis, with its lethal impact on citizens’ well-being, and climate change. I would add humane care for people with disabilities and mental health problems. And the social circumstances that determine – more than any biological factors and more than any therapy – the well-being and mental health of our clients.

Diagnosis

In 2006 I published a very simple paper with Erika Setzu, Fiona Lobban and Peter Salmon. It was simple because all we did, in essence, was interview people about how they had ended up in mental health care. One quote is worth repeating at length:

Client: “I started to hear voices, but they were not nice voices, they were horrible.”
Interviewer: “Did you recognise them?”
Client: “It was the man that abused me … I met this man that was a builder, in construction, you know? And he said that he wanted to give me a job, but they were all lies, he was trying to con me. He took me back to his house, he locked the door and he had sex with me. … And then other voices as well. I went to … hospital and the nurses were very good to me.”
Interviewer: “When you went to hospital what did they say it was wrong with you?”
Client: “Schizophrenia, paranoid schizophrenia.”
Interviewer:  “What do you think personally?”
Client: “What do you mean?”
Interviewer: “Do you think it is what you’ve got?”
Client: “Oh yes, that’s what I have got.”

We should be ‘creatively maladjusted’ to this creeping medicalization of human distress. Right now, the American Psychiatric Association is preparing to publish the latest version of its diagnostic manuals – DSM-5. It seems clear that this manifestation of the medicalization of human distress will be more paradoxically illogical, more invalid, more stigmatising, and more pervasively likely to pathologise normal human reactions than ever before.
So, please, join me, Anne and Richard and others in the audience, in registering our concern. You can do this by going to our website – dsm5response.com – and adding your voice.

Treatment

And when it comes to treatments, there are again things to which we should be maladjusted.
We must refuse to tolerate the cruel, inhuman and degrading treatment of people in psychiatric care. This includes the appalling inhumanity described – correctly – by the United Nations as "akin to torture".
But such extremes are also supported by everyday inhumanity – and by the inadequate, cruel and uncaring treatment experienced every day and in many (if perhaps not all) settings. On the same day I read the UN report, a man wrote to me describing his experiences of psychiatric 'care'. The whole incident is traumatic; from the initial involuntary admission (in handcuffs, by the police) to discharge. I was particularly struck, however, by the everyday inadequacy of the inpatient stay. This won't be terribly surprising to people working in mental health care... but the fact that this account will be recognised speaks to its truth.

My correspondent reported; "... Rather than engaging with the patients on the ward, the staff instead shepherded them around like sheep with bullying commands, threats of ‘jabs’ (injections), and removal to an acute ward elsewhere in the hospital, if they did not co-operate. The staff also stressed medication rather than engagement as a way of controlling the patients.
And the staff closeted themselves in the ward office, instead of being out and about on the corridors and in the vestibule where they should have been. The staff wrote daily reports on each patient on the hospital’s Intranet system; these reports were depended upon by the consultant psychiatrists for their diagnoses and medication prescriptions, but were patently fabricated and false, because the staff had never engaged or observed properly the patient they were writing about in their reports. The psychiatrists themselves were rarely seen on the ward, and only consulted with their patients once a week."

I certainly recognise this account. It doesn't represent absolutely all psychiatric units... but it isn't bizarre or unrepresentative. It reflects - in psychiatric rather than acute medical care - the findings of the Francis Report into uncaring and inhumane treatment in the Mid-Staffordshire NHS scandal. And we should absolutely refuse to accept it. I don't want to accept this as the status quo. And we should absolutely refuse to accept it. I don't want to accept this as the status quo.

Conclusion

In the words of the European Union, good mental health is: “a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life. For societies, good mental health of citizens contributes to prosperity, solidarity and social justice”.
Psychologists are – now – and will in the future be key to delivering this vision. In 2023 it will be recognised that clinical psychologists are a key profession in helping people fulfil their potential as human beings, not treating illnesses. Outcomes will be driven by real people – service user’s – definitions of what they need as real-world outcomes. And psychological therapies will be designed and commissioned to that end.
For us as psychologists, we will be offering a broader, more holistic service. Yes, of course, because we’re experts in psychological therapies, we’ll offer one-to-one therapy. But, as we’ve always wanted to, we’ll offer more fully holistic services – linking with employment advisors, working with education services, physical health services, with employers, with community services.
This means rather different professional links – as much with the Royal College of GPs as with the Royal College of Psychiatrists. And it means better links with the other applied psychologist groups. Since a genuine view of well-being integrates clinical psychologists’ interest in mental health with occupational psychologists’ interest in employment, educational psychologists’ interest in education, health psychologists, forensic psychologists etc.
Addressing the full range of a person’s well-being means coordinating services across a wide range of domains, across many different services – education, health, employment. A multi-disciplinary service. 
And it strikes me as pretty obvious that, within those multi-disciplinary services, we’ll see the judicious use of colleagues trained, rapidly, in mono-modal therapies... .
But, in 2023, clinical psychologists will be coordinating the higher-level case formulations within which those mono-modal therapies will be delivered.
So we should be upfront and positive. Good mental health and well-being is a consequence of how we make sense of and understand the world, primarily our social world. And how we make sense of and understand the world is largely determined by our experiences and upbringing.
I believe that the future lies in helping policy-makers, the media and commissioners realise the potential benefits of our skills, and in integrating our work with a much wider program of improvement of health and well being across a number of Government Departments. That requires us to be confident and imaginative as we look to the future.

But… it’s all good news.
Thank you very much.



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  2. I saw your talk at this year's LAPG conference, and I just want to say that I thoroughly enjoyed it. I only hope I can be as confident a public speaker one day as you are now!

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  3. I do believe that clinical psychology is an essential profession and cannot be compared to other psychological therapies. Simply put, we sre more than therapists. We have systemic skills, managerial and supervisory roles, research knowledge and applied skills on a range of therapy. I find truly unfair and disrespectful the downgrading of clinical psychology, mostly because of the intensity training we are required to do but also because on a balance of probabilities our presence in health care is more essential than psychiatry. I know I'm a dreamer but the only way for psychology not to loose it's hegemony is by having honest psychologists going into power, even government snd legislative positions.

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