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I have spent some time over the past month attending various DCP events
(Branch and Faculty meetings, Trust CPD events, etc.) as well as national cross-professional events. It’s clear that the change in government, the reforms to the NHS, the efficiency savings imposed on health and
social care services, the developments of NICE guidelines and IAPT are all unsettling clinical psychologists.
Which is obviously a challenge for the Chair of DCP. There is a call for ‘something to be done’. And there is some praise for the DCP. There seems to be support for our developing emphasis on well-being rather
than an insular focus on mental health - I’ve contrasted this with the old description of clinical psychologists as people who ‘diagnose and treat mental illness, usually using psychotherapy’, instead focussing on our
clinical application of psychological theory and science to help individuals and communities solve a variety of social problems and improve well-being. There is also support for some of our more distinctive positions -
when members are aware of them. So we have received praise for our quite distinctive (even radical) position on medically-predicated
diagnostic frameworks such as that proposed for DSM-V. As a spin-off, our focus on some of the dangers of misinterpreting the meaning of diagnosis, over-diagnosis and over-medication in children (discussing, in
this context, ADHD, but also social anxiety and the like) appears to be popular. We’ve received praise for our position in respect to the Health and Social Care Bill (from those members who have read it). So there are
some positive responses.
But there remain anxieties. Colleagues are concerned about the impact of efficiency savings on the profession (clinical psychology posts are under threat) and the services we offer to the public. Colleagues are also concerned about IAPT and other initiatives to develop psychological therapies and other psychosocial interventions. These concerns are well-known and quite widely discussed. They include doubts about the evidence-base used to develop, and the emphasis on, NICE guidelines.
Some colleagues feel that emphasis on diagnostic criteria, symptomatic outcome, short-term cost-effectiveness and those forms of therapy that can be manualised and subjected to randomised, controlled, trials are prioritised
(at the expense, perhaps, of therapies from other traditions). Colleagues worry, in principle, about a focus on the ‘stepped care’ policy, and worry, again from principled positions, that some forms of intervention recommended by NICE and developed by IAPT are ‘sticking plasters’. Those colleagues look for support for more fundamental, more psychological alternatives. And colleagues worry about the practical consequences - at least in some Trusts - of developments in IAPT. Those
colleagues argue that, of course, we welcome genuine investment in psychological therapies (that’s our core professional role) but we are
concerned if monies spent on those perceived diagnostic, symptomatic, short-term, frankly lower-quality forms of ‘sticking plaster’ therapy
replace - and this is important - replace other psychological and psychosocial services.
And, for me at least, these are challenges that the DCP needs to address. So; how should we position ourselves? For me, the answer is straightforward but difficult. We should offer a positive vision for psychologically-informed health and social care in which clinical psychology
obviously plays a leading role… but we should avoid negativity and defensiveness.
So that means that I can see the threats, and I wouldn’t want to pretend
they don’t exist. But we need to offer a positive vision (sorry for the Americanised, management consultants’ language) of what we’d like to see and how we can help deliver it.
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 realises 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’. The UK Government’s mental health strategy echoes this: with a strategy to ‘…transform the mental health and well-being of the nation…’ and for
‘…mental health to be "everyone’s business" - all of Government, employers, education, third sector…’. We, I think, have a view of well-being which fully supports this approach. Our focus on the whole person, on the psychological well-being of individuals and communities, clearly fits with this. Of course, junior managers might focus on ersatz quick-fixes… but it’s our responsibility, with our colleagues in the
Department of Health and in the medical Royal Colleges, to realise these more visionary objectives.
For me as a clinical psychologist, I need to focus on my vision for health and social care services. And, of course, I’d want genuinely psychological services. They haven’t been there in the past, and they clearly aren’t there yet. So we need to help the government increase the availability of psychological approaches. Leaving aside the exponential rise in clinical psychology as a profession, this means, in simple terms, Improving Access to Psychological Therapies… I.A.P.T. More precisely, as a profession
based on psychological science, what kinds of psychological services, psychological therapies, would we prioritise? Clearly, I think, those with a sound evidence-base. That looks perilously close to IAPT to me. And finally… would I, if I were advising government, advise that the best way to
deliver those hugely valuable psychological perspectives that form the basis of my profession merely by employing consultantlevel clinical psychologists? Frankly, no. My vision for psychologically appropriate health and social care does not mean that the middle-class residents of Tunbridge Wells (sorry Tunbridge Wells, but I thought Hampstead was too frequently
stigmatised in this context) could have access to substantial numbers of clinical psychologists (who might, in any case, use techniques that have a relatively poorer chance of effectiveness) but that the vast bulk of the UK citizens who need psychological approaches to help ‘realise his or her own abilities, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to his or her community…’ in the wide variety of settings from health and social care, employment, education, etc. would have to rely on medical prescription by GPs. So, if I imagine
- envision - a massive expansion of psychological expertise, I must have a vision of clinical psychologists (and other welltrained professionals) assessing, formulating and offering clinical leadership to multidisciplinary teams in which there are many more colleagues offering a range of
more limited, more specific, interventions. These interventions would, in my vision, include CBT (to be honest, I think CBT is great - transformatively excellent) but also a wide range of other interventions supported by evidence and recommended by NICE. Importantly, it is possible to deliver
these therapies though relatively shorter training periods than the lead-in times for consultant psychiatrists or consultant clinical psychologists, they perhaps require a less focused academic background on the part of the practitioners, the therapies can be incorporated into the working practices
of other staff members and, important for managers, the practitioners would command lower levels of remuneration than consultant clinical psychologists.
The point is that this vision is positive - it’s a vision for how psychological
approaches could be developed and delivered. And I don’t think it should threaten any clinical psychologist… Of course, I’m not naive. I do realise the world out there isn’t always sympathetic. But we’ve got a difficult
time ahead. I simply believe that we should offer a positive vision for what should be developed, not a negative defence of a system that, to be honest, was never capable of democratic expansion.
Peter Kinderman
Chairs update - November 2011
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