A presentation to the Division of Clinical Psychology 2009

1. Grasp the future – it’s bright out there
A 15 minute update on the future for clinical psychology as seen through the eyes of Derek
Mowbray presented to the Division of Clinical Psychology December 11th 2009 Annual Conference.
Background
My love affair with Clinical Psychology started at University where during my final year I
frequently supported patients at our local Psychiatric Institution – Winterton Hospital, and later I
joined Bill Revesley as his assistant in the psychology department at that hospital. I gave this up
after almost a year in favour of
NHS management, but in 1989, as
My relationship with Clinical Psychology
director of the Management
Advisory Service to the NHS, I
won the contract to review
Review of Clinical Psychology 1989
Clinical Psychology, a study
sponsored jointly by the BPS and A College of Healthcare Psychology 1990
the Department of Health. As I
had a very strong applied The Development of a Role of
research background I was
MAS Associate Clinical Psychologist 2003
particularly concerned about the New Ways of Working for Applied Psychologists 2007
evidence of effectiveness of
psychological interventions; a
concern that translated into the
first review of effectiveness of psychological interventions conducted for me by Fraser Watts,
and included as an appendix to the MAS Report. The MAS review conclusions were predicated
on behaviour as one of three principal influences on health and wellbeing – the others being
genetics and nutrition. It was, therefore, important to me to elevate the significance of
psychological theories and principles in relation to issues of health and healthcare. I devised the
different levels of psychological skill, knowledge and experience, concluding that level 3 skills
were those that are unique to psychologists and draw on all the available theories and principles
and apply these to the complex issues of health and healthcare. Effectively this amounted to
eclectic skills, knowledge and experience to be acquired over a period of time and not easily
taught. Level 2 skills were those needed to apply psychological interventions that could be
described by protocol. You didn’t need to be a psychologist to do this. Level 1 skills are those that
we all possess in some form and are based on common sense.
In 1990 at a joint conference of the BPS and Royal College of Psychiatrists I proposed the
formation of a College of Healthcare Psychology. The aim was to draw together psychologists
with eclectic skills, knowledge and experience to focus on the issues of health and healthcare.
Another aim was to raise the profile of psychology and for the College to be a focus for research
and its application to practice – the exemplar of the scientific-practitioner idea.
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2. Realising that my definition of level 3 practitioner wasn’t working in practice (the idea of level 3
practitioner was virtually universally accepted, but decisions to introduce a doctorate level entry,
and a failure to market psychological practice at this level meant most continued to practice at
level 2) something needed to be done to a) capitalise on the 12,000 psychology graduates from
universities each year, most of whom were not going into clinical psychology and b) to shift the
expensive doctorate level psychologists from working at level 2 to work at level 3. With the
support both intellectually and financially from Northgate and Prudhoe Trust I undertook a study
to establish if it was going to be feasible to create an associate role in clinical psychology focused
on providing service at level 2 thus freeing existing doctorate level psychologists to fulfil their
potential of working at level 3. The result was interesting. About half of the trainees waiting to
enter training didn’t want to be a level 3 psychologist preferring instead to be a therapist
practising at level 2. The result of the study eventually translated into pilot training programmes. I
was struck, once again, at the difficulty of gaining BPS support for this initiative, even after the
DoH was lending its support. Soon after the start of the pilots the IAPT initiative emerged and
was implemented at a pace that was breathtaking to watch from the sidelines – a demonstration
of project management at its best, and interestingly, hardly involving the BPS in its progress and
implementation.
In 2006/7 I was invited to help with the New Ways of Working initiative and was asked to prepare
a vision for the future of applied psychology to health. Some of this work is featured in the final
report.
My message has been consistent – the application of the unique level 3 skills to the complex
issues of health and healthcare.
My impact has also been consistent – I have failed to persuade sufficient numbers of the
appropriate people that my ideas have legs.
Observations and conclusions from 2009.
I have been profoundly disappointed that clinical psychologists haven’t realised the potential
presented to them in 1989 and subsequently. I believe the path that has been followed has
resulted in the profession being in a
Observations and conclusions from 2009 worse state than in 1989, principally
by being over and inappropriately
qualified for the work that clients
expect from them. This has been
•Professional in a non-professional world
•Lost level 3 skills, knowledge and experience made worse recently by the failure
•Out of step with key issues
•Missed opportunities to persuade the Health Professions
•Lost identity
•Not pack animals – more like cats that want to follow Council that eclectic psychological
•Depressed
skills, knowledge and experience is
what is required to meet the
complex challenges of health and
healthcare. This failure has
consequences for psychology as a
science and for applied psychology.
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3. The training for clinical psychology does not equate to the role I set out for level 3 psychologists
in 1989. The move to pigeon hole clinical psychology removes the prospect of these
psychologists acquiring the skills, knowledge and experience to tackle the complex issues of
health and healthcare, which depends on the integration of theories and principles from across
the spectrum of psychological science. Level 3 practice is about the ability for consultant
psychologists to draw on their broad but detailed skills, knowledge and experience to address
complex issues. This is about applying discretion in what are, essentially, chaotic situations. This is
the core of professional practice, and if it was ever established it is now being lost.
The psychological challenges
There are three types of
challenge facing clinical The psychological challenges today – part 1
psychologists. The first is the
challenge of becoming engaged
•Groupthink
in the complex issues affecting •Communication
•Interaction
health and wellbeing, and •Social networking
•Poverty and deprivation
addressing these from the •Compliance with change
•Demographics •Wellbeing
perspective of promoting •Lifestyle
•Environment •Performance
wellbeing and performance. •Scientific knowledge and advances
•Technology
•Expectations
Health policy determinants are •Disease
•People
listed in the slide. Psychologists
have a role to play in researching
and applying research in each of
these areas, by identifying the triggers that influence wellbeing and performance. Clearly there is
need to work closely with others in the top level activities, as well as at the community level to
mitigate the impact of some of the issues on general and individual wellbeing and performance.
There is huge scope for psychologists to contribute positively in this arena, and to advise on
policy content as well as being engaged in delivering appropriate interventions on the ground.
The second challenge is to create a
The psychological challenges today – part 2 psychological culture which focuses
on wellbeing and performance that
influences the ways in which leaders
Psychological culture- focused on wellbeing and performance
in society deliver their own agendas.
Psychological language – neither too–simple nor too complicated
The psychological challenges today part 1
Currently the UK daily cultural signals
are coloured by extensive negative
Delivery – ensuring appropriateness, efficacy, effectiveness, and efficiency language displayed in behaviours of
threat and intimidation. The cultural
language of support, encouragement
and engagement for a virtuous
purpose appears lost.
There is the problem of psychological language – either it is psychobabble that anyone speaks
and is too simple or it’s the use of complicated words that convey meaning only to those with a
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4. psychology dictionary. There is a need for a new language that helps people communicate
positive messages and display behaviours related to cultural foundations of virtuous intent.
Marketing specialists seem to be brilliant at creating new language, and ensuring it is spoken.
There is the challenge of delivering psychology in a way that demonstrates impact. The closeness
of clinical psychology to the medical model and its paraphernalia such as NICE means being
sucked into adopting the same type of effectiveness rigour that medicine requires. This is a
mistake. Psychologists deal with chaos of a different kind to medicine. The infinite variation of
individual and collective response to context and their own physiology is such that a different
kind of effectiveness criterion is required that reflects individual differences rather than
similarities.
The third set of challenges relates
to the National Health Service
(NHS). Currently the NHS is the The psychological challenges today – part 3
major client for clinical
psychology. It is an organisation The clients (commissioners):
that is characterised by the need those wanting a ‘quick fix’ – executives and patients
those wanting to change the world - champions
for rapid solutions to complex The culture:
problems, is target driven, target driven quick fixers culture – transactional
paranoid in places
responsive to a controlled market,
and has a management culture of The organisation:
bullying and harassment. The ambiguous
stress inducing
trend of using only evidence based
interventions may be appropriate,
but not necessarily suitable to the
interventions that psychologists provide for the more complex cases. Therefore the focus on
using CBT and variants is in line with the quick fix approach, but has limitations when matched
with the huge range of complex issues that require psychological attention.
Strategic framework for applied psychology
With a rather dismal assessment of the state of clinical psychology and the context in which it is
applied, I now turn to the positive and the actions that I think are needed to enable applied
psychology to thrive in the future.
Step 1 – establish the purpose of psychology applied to health
I present a strategic framework for applied psychology. This has five purposes:
To prevent psychological distress, and to facilitate psychological wellbeing and
performance.
To prevent anyone from deteriorating from the point they require psychological
interventions.
To restore people back to, and beyond, their normal level of independent life, wellbeing
and performance.
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5. To maintain the highest quality of life, wellbeing and performance, for those with chronic
conditions who naturally deteriorate towards death.
To prevent carers and supporters from impaired wellbeing, performance and
psychological distress
Applying this framework to my own area of interest, wellbeing and performance in controlled
communities, such as organisations, it can be seen that there is a need for a broad application of
psychological theories and principles, from those required to build positive work cultures,
building resilience and tolerance within people, to the provision of individual focused support
services for those who do suffer psychological distress.
A Positive Work Culture
Applied Psychology strategic framework based on wellbeing and performance
Strategic framework Focus Purpose
Prevention Culture To promote a Positive Work Culture based
Prevention on wellbeing and performance
To manage threats to wellbeing and
performance
Next Prevent
Generation deterioration
Prevent deterioration Self To prevent personal deterioration
in wellbeing and performance
Restoration Support services To restore people back to their normal level
of independent life and beyond
Palliation To support people with chronic
Palliation Restoration psychological distress
Next generation To prevent psychological distress
in support workers/carers © Derek Mowbray 2009
Step 2 – establish a framework for building and sustaining psychology applied to health.
This step brings together the purpose of psychology applied to health, determinants of health
and healthcare, the culture, language and
delivery processes with the identification
A framework for the future of Applied Psychology
of primary clients. Secondary clients are
agents who commission services on behalf Clients Communities
Organisations (controlled communities)
of the primary clients. With respect to the Challenges Individuals
•Groupthink
•Communication
NHS the secondary clients are •Interaction
•Social networking
Wellbeing
•Poverty and deprivation
commissioners. •Compliance with change
and •Demographics
•Lifestyle Strategies
•Environment
•Scientific knowledge
Performance Prevention
The overall purpose of applied psychology Prevent deterioration
and advances
•Technology
Restoration
•Expectations
Palliation •Disease
within this framework is to facilitate one of The ‘next generation’. •People
the five strategic purposes regarding
wellbeing and performance in
communities and individuals, in relation to each of the health determinants.
This is clearly a massive agenda for psychology applied to health and necessitates the
incorporation of psychologists with specialist expertise in a broad range of psychological theories
and principles. It does, however, provide a basis for a detailed strategic development for applied
psychology that addresses the key issues that affect wellbeing and performance of the
population.
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6. Step 3 – identifying the ingredients required to populate the strategic framework
The strategic framework should appeal to a broad range of psychological interests. In addition,
there will be a requirement to blend together the ingredients that make a complete service.
These include:
Research
Regulation
Quality assurance processes
Marketing
Organisation, leadership and management
Training and development
There is a requirement to include other functions, such as financial procurement, media
communications and consideration of further psychological specialisation to address specific and
growing areas of concern and interest.
Some ingredients of the applied psychological cake More ingredients of the applied psychological cake
Quality assurance
Psychology
Organisation and Psychological scientific Money rock’n’roll psychology
Management development
Strategic direction sleep psychology pop psychology
Marketing
Cultural development
? Regulation
Applied psychology
obese psychology
Wellbeing
and Performance
psychology
service
community psychology
vacation psychology
demographic psychology
ego therapy
Training and baby psychology
Academic psychology
Development
travel
Psychological therapies Media communications
psychology
Step 4 – Building sustainable organisations to deliver psychology applied to health
The British Psychological Society is a member organisation established to serve the interests of
its members.
What is required is an organisational arrangement or arrangements that marry the requirements
of clients to those of the science and delivery of psychology applied to health.
The approach is to work through the organisation development model from the perspective of
creating a new organisation. This model requires clarity of purpose, an architecture that
promotes commitment, trust and engagement; rules of how the organisation should work in
practice that also promotes commitment, trust and engagement in the workforce, and training
and development of those working in the organisation so that they may effectively achieve its
purpose.
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7. An Institute of Psychology Applied to Wellbeing and Performance
There is a requirement to bring together the psychological theories and principles relevant to the
issues of health and healthcare with a focus on wellbeing and performance. This means drawing
together the existing results from research as well as experiences from practitioners from across
the spectrum of psychology. There is a
requirement to undertake research into
Architecture – national level
aspects of the agenda that will inform
practitioners of effective psychological
Challenges Money
approaches and interventions. Clients Management
Culture Media
Strategies Marketing
There is, also, a requirement to raise the Institute of
Psychology Applied to
profile of psychology applied to Wellbeing and Performance
wellbeing and performance, and to Support to Prevention
Prevent deterioration
create and sustain a ‘power house’ of Quality assurance
Centres for Psychological
Health and Restoration
Regulation Wellbeing Palliation
influence on health policy development Next generation
and application, focusing on the
performance of organisations,
communities and their constituent
individuals.
Still further, there is a requirement for an arrangement that co-ordinates the results of research
conducted throughout the world, so that psychologists have access to and can apply the cutting
edge science that is relevant to issues of health and healthcare with a focus on wellbeing and
performance.
There is, also, a role to be played in training and development of psychologists with an interest in
the wider issues of health and healthcare, and a need to dovetail training with existing and
planned programmes in clinical and health psychology, together with the relevant training
programmes from other psychological disciplines, particularly social and occupational
psychology.
One element of the proposed Institute is the formation of a National Institute of Psychological
Excellence, based on the idea of NICE but applied to psychology.
Centres for Psychological Health and Wellbeing
At the local level there is a requirement to draw together psychologists with different special
interests to focus on wellbeing and performance within local communities, organisations and
individuals.
There is a massive agenda to address in relation to local communities, and the role of psychology
in helping other agencies address societal issues, such as obesity, teenage pregnancy, crime,
unemployment, isolation, corporate and community depression and many other topics of
concern.
Centres for Psychological Health and Wellbeing should be established as social enterprise
franchise organisations, owned by the psychologists themselves. It would be expected that a
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8. wide mix of skills would practice from
these centres, including psychological Architecture – local level
Social enterprise franchise
therapists, alternative therapists with a
psychological focus, and nutritionalists Positive Work Cultures
People in work
whose practice impacts of psychological Research and development
Positive community cultures
Centres for
wellbeing and performance. Community economic Psychological
Health and People at home
development and
growth Wellbeing Personal development
These Centres need to be established in as Prevent, prevent deterioration,
Community wellbeing
Restoration, palliation
many communities as possible, being a and ‘next generation People in education
parallel chain of Centres to general medical money management media marketing
practice.
Step 5 – establishing rules
The following slide shows the rules that I suggest be established to help psychology to be
appropriately applied and delivered.
Rules
Custodian and leader of psychological science, its
development and its application
Incorporation of all psychological theories and
principles to health
Focus on wellbeing and performance, including the
prevention of ill health
Complementary to medicine where applicable
Graded levels of expertise
Educate, train and supervise psychological applications
In addition, there are other rules that might be necessary, those that enable commitment, trust
and engagement of psychologists with the profession of psychology. The possible subject areas
are listed in the slide, and the rules will need to be formulated with a view to developing and
sustaining a cohesive workforce situations where individuals may become isolated as a result of
changes in working practices.
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9. In the red box in the following slide are
the topics that influence commitment, Other rules
trust and engagement, and which form
the criteria against which any rules need Portfolio careers
‘rules’ that build commitment:
to be assessed to achieve a cohesive and Flexibility The job
Recruitment
committed workforce. Independent Professional Practitioners
Pay
Challenges
Security
Career opportunity
Citizenship
Marketing expertise Training
Development
Team working
Psychological businesses Life balance
Step 6 – how to play the game Networking facility
Work experience CPD and supervision specialists
allowances
The final aspect of building a new
organisation is ‘how to play the game’ or Support services Mothership
the training, development and personal
focused activities that need to be in place to enable the new organisation to work in practice.
The assumption here is that psychologists
How to play the game will migrate from the security of a single
employer to being independent
practitioners wishing to engage with
Join a Mothership – a Centre for Psychological Health and Wellbeing
others in the delivery of the strategy
Join an independent family of psychologists - PsychologistsDirect
outlined earlier.
Join a Network – Strictly Psychology
Establish an Institute of Psychology Applied to Wellbeing and Performance
Don’t rely on the taxpayer for income
There are four elements of this game –
working from a Centre for Psychological Health and Wellbeing as the basic Mothership
for psychologists
working with the Institute of Psychology Applied to Wellbeing and Performance
joining together with other independent practitioners and offering independent services
through PsychologistsDirect
joining a network of psychological support called Strictly Psychology – a place where all
professional and many social needs of psychologists will be met.
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10. In 2012.................................
Psychologists will have a development strategy
based on wellbeing and performance needs of the UK
Psychologists will have an Institute of Psychology
Applied to Wellbeing and Performance
Families of Psychologists will be practising from
Centres of Psychological Health and Wellbeing
Psychologists will be getting their needs met
from PsychologistsDirect and Strictly Psychology
Derek Mowbray is visiting Professor of Psychology at Northumbria University and Director,
OrganisationHealth, the Stress Clinic and PsychologistsDirect.
www.orghealth.co.uk
www.the-stress-clinic.net
www.derekmowbray.co.uk
email: derek.mowbray@psychologistsdirect.org
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