[Clinical Psychology Forum, no. 80, 3-6, 1995]

Clinical psychology: liberatory practice or discourse of power?

DAVID SMAIL, Nottingham Community Health NHS Trust

THE ARGUMENT I WISH to make is that clinical psychology has up to now embodied in its core practice an ethic which is quite sharply differentiated from that of other mental health related professions, but which would not be readily inferred from the professional discourse in which it has been couched. Up to now this has been more an inconvenience than a fatal contradiction. In an essentially political context which has, as far as professional public health provision is concerned, changed radically over the past 16 years from benign to malign, the pressure on clinical psychology to adopt the ruling discourse of business may force its ethical practice into an entirely new shape which, apart from anything else, would deprive it of its distinctiveness.

I think one must acknowledge at the outset that no intellectual or, more particularly, professional practice, however altruistic its aim, can with impunity step outside the field of social power which shapes its interests. All such practices must, if for no other reason than the economic survival of their practitioners, pay careful attention to the ideological requirements of the forces which control them. Professionals, in other words, have to pay heed to the "discourse of power" and make sure that their own discourse conforms closely to it.

As it has developed along with the NHS since the end of World War II, clinical psychology, having no immediately compelling ideological powerbase of its own (as has medicine, for example) has had to be particularly careful to make sure that its justificatory rhetoric accorded with the ruling discourse and threatened no more powerful interests. It has done this so far by adopting in turn the scientistic rhetorics of psychometry and behaviourism and, in the rather safer climate of the 1970s, the more liberal professionalism of cognitive behaviourism. It has at various points tended also to seek legitimation by attaching aspects of its practice to theoretical positions expected to lend it credibility with those who control, consume, or in some cases compete with its services, for example, by invoking the academic rigour of experimental psychology or the authority (in some circles!) of psychoanalysis, "humanistic" theories such as that of Carl Rogers's and so on.

What clinical psychology has not done, I would submit, is develop a consistent theoretical position of its own, i.e. one which accurately reflects its practice within the particular context in which it is carried out, namely a large, essentially free public health service. I think that was a mistake, and very probably one we are about to pay for dearly. For in a virulently anti-professional climate in which we have lost control of our own "management" (and may if we are not careful soon lose control of our own training) we are about to find ourselves competing in a deregulated market with other professions and groups of "providers" who can no less legitimately than we claim allegiance to the same justificatory discourses. This situation is reflected, for example, in the anxious scurrying of clinical psychologists to work out their position in relation to counsellors, health psychologists and so on.

The temptation in this predicament, particularly under the sway of the current ruling discourse of Business, is to attempt to solve the problem by some kind of advertising or PR technique; to produce, so to speak, the ultimate glossy brochure saying why clinical psychologists have the special credentials and the extra blue whitener that competitors cannot aspire to. If Baudrillard is right about the essentially imaginary nature of postmodern hyperreality, then maybe effective slogans and powerful propaganda are all we need. But I doubt it. It still really is a real world (and always will be), and if we can identify, elaborate and hang on to the reality of clinical psychological practice, we may yet be able to offer people something they both want and need without entirely losing either our integrity or our sanity.

For clinical psychology is distinctive in its practice. Not, I must say, through any intellectual virtue of its own, nor through the excellence of its practitioners, excellent though they may be. Let me first say what I think is distinctive about clinical psychology, and then suggest what the origins of this distinctiveness might be.

The distinctiveness of clinical psychology

In its core practice clinical psychology is unlike any other mental health profession in that practitioners tend to side with their patients or clients without, on the one hand, exercising coercive power over them (as do psychiatrists and social workers) or, on the other, attempting to normalize them through recourse to some form of moralistic critique (as do many counsellors). We do not interfere with our patients' bodies through restraint, drugs or the legal process, we do not separate them from their children, and we do not on the whole have much truck with ideas which link emotional distress to personal responsibility and will power.

Of course, clinical psychologists have at times been involved at least indirectly with all these things, mainly precisely because of our failure to articulate what we are "really" about. And I have to concede that my evidence for claiming that such activities are not central to our role is in some ways informal, if not impressionistic. Furthermore, one must acknowledge that clinical psychology covers a whole range of activities with a whole range of clients in a whole range of institutional as well as community settings, and cannot therefore easily be treated as one neatly homogeneous entity.

But talking and debating with clinical psychologists, teaching and supervising them, tends quite consistently (though not, of course, always) to reveal a fairly objective concern for patients which leads to a sympathetic account of their difficulties as arising from a world over which they can be expected to have but little control, but at the same time seeks, with the patient, to formulate an approach which may at least contribute something to the solution of his or her problems. As far as we have a name for this, it might be summed up in the "scientist-practitioner" label we sometimes like to stick on ourselves.

If, however, one had not spent a lot of time talking and debating with clinical psychologists, teaching and supervising them, but had rather limited oneself to the official accounts they give of themselves in "the literature", one might well have arrived at a very different view of them; as hard-nosed behavioural technicians engaged in a coldly distant exercise of Benthamist social control. It is certainly true that as a profession we have done very little to dispel, and far too much to encourage, such a view, not least by allowing our official thinking to be done for us by scientistic gurus who, like Hans Eysenck, have done very little actual clinical work.

How is it, then, that we have developed the kind of benign, pro-patient, scientist-practitioner role that I am arguing for, in the teeth of an official rhetoric which implied practically the opposite?

There are, no doubt, some things about our training in academic psychology which lend a certain distinctiveness to our clinical role. Most psychologists have a respect for and an at least implicit commitment to evidence which marks them off from many colleagues in, for example, social work, counselling and many of what I call the "brand-name therapies" which rely for their "credibility" less on evidence than on exclusive procedures of initiation, accreditation and virtual registration of their trademarks. Medicine, of course also claims scientific credentials, but much medical education, certainly traditionally, lacks the criticalness which psychologists are taught - I hope still - to bring to their subject matter.

It may also be that our close association with behaviourism, particularly in the formative years of our development as a profession, had the benign, if perhaps not entirely intended effect of creating a perspective on our patients' problems which was also unlike that of other mental health professions. For what was distinctive about behaviourism was the emphasis it placed on environmental factors as the explanation for human behaviour and - as far as it admitted the concept - experience. In contrast, medicine naturally focuses on internal biological aspects of people's predicaments and so creates a spurious realm of "mental illnesses". The brand-name therapies concentrate, even if not explicitly, on a kind of unanalysable moral space within individuals which permits "insight", "change", ,acceptance of responsibility", "personal growth" and so on - concepts which social work, rather surprisingly, also appears often to rely on. The trouble with behaviourism was of course that it got side-tracked into an unfortunate enthusiasm for conditioning theories of learning and so failed in the end to give any kind of sensible account of what environmental influences might consist of. I suspect however, that the factors which shape us most powerfully in our clinical approach are ones which have very little to do with our formal training or our self-conscious intellectual history and much more to do with the actual situation in which we have found ourselves having to carry out our work and the characteristics of the people we carry it out with.

It is in fact quite surprising how far clinical psychology has come as a profession in terms of both material benefits and independence, especially when one considers how small the profession is and how brief its existence so far. I would certainly hope that part of the reason for this is that we have something useful to offer, but I have little doubt that another part is that we have not challenged our much more powerful professional neighbours in the health field by laying claim to the kind of statutory powers which underpin their raison d'etre.

Indeed, probably the greatest single factor in shaping our role in the NHS has been precisely our lack of formal power. While many of us saw this lack, particularly perhaps in the earlier days of our professional development, as a serious brake on our status and earning power, what it has in fact meant is that in order to help our patients we have had to rely on little more than the powers of persuasion. While patients wrestled with their difficulties we have had to restrict ourselves to the role of being commentators and accomplices rather than patronizing or oppressing them as superior powers who know what's best for them.

Under the cover of a behavioural rhetoric sufficiently socially controlling to allay any anxieties higher up the "apparatus of power" of which, certainly, we form a part, we have, then, been operating almost subversively to form a kind of solidarity with our patients in resisting their becoming labelled, stigmatized and oppressed, and assisting as far as we could in their attempts to cope with hard times.

Another factor which has, I think, made it difficult for us to become assimilated theoretically into the kinds of account offered by psychoanalysis or the humanistic psychologies is the nature of our clientele. Just as we, in relation to our, so to speak, professional competitors, have very little formal power, so our patients, in relation to the well-resourced clients of the major schools of individual psychotherapy, tend on average to have access to very few of the socio-economic benefits and advantages which make it possible to get a grip on one's circumstances and open up opportunities for oneself. Concepts such as "insight" and "personal growth" appear to have validity only in situations where individuals are enabled through the process of therapy to deploy powers and resources already available to them in such a way as to improve their position in the world.

One cannot work for long as a clinical psychologist in the NHS without becoming very aware of the limited room for manoeuvre most of our clients have for dealing with their difficulties. No amount of "insight" or emotional determination makes it possible to achieve improvements to one's lot if one does not have the wherewithal to make them. The combination of a respect for evidence plus experience of working with a population in which social deprivation is widespread thus tends to introduce a societal perspective to our understanding which, even if it remains largely tacit, at least inhibits us from over-involvement in the individualistic mystifications of many of the "brand name" approaches. And in the field of "community psychology", I should add, this societal perspective is at last beginning to find explicit formulation.

If I am right that our practice so far has been shaped by our situation rather than by our rhetoric, we need to pay very serious attention to the fact that the situation is changing radically, and it may therefore be extremely important to formulate a guide to our future development by articulating a theoretical understanding of our activity which actually reflects and elaborates what we do rather than merely provides us with acceptable excuses for doing it.

Almost out of desperation, but entirely consistently with these individualistic times, I have made a kind of home-spun attempt at sketching out what the principal features of such a theory might look like. In the hope that I am not only talking to myself, this was published a few months ago in a book called The Origins of Unhappiness, the reactions to which so far suggest that there are at least ten other people in whom it strikes a chord.

What we need to do above all, I suggest, is reaffirm the scientific nature of our undertaking and distinguish it from the normative, moralizing and ideological enterprises which characterize so much of the broad "mental health" field. And by "science" I certainly do not mean the threadbare dogmatism of the various versions of behaviourism and methodological objectivism which most clinical psychologists - even now - find themselves exposed to in their training, but rather a much more broadly defined project to reach unconstrained agreement with others on the basis of an appeal to experience and reason.

I do not think it is our business to tell people how they ought to be, nor even to lecture society on what it should be doing (if for no other reason than that we obviously do not know). I do not think we should be dismayed if we should discover, as in my view we are bound to, that the extent to which we can improve either people or their lives is extremely limited. In other words, I do not think that we should feel that the justification of our profession must be in its therapeutic success.

What we should in my view be doing, on the other hand, is working towards explanations of emotional and psychological distress which are as valid and accurate as it is scientifically possible to show them to be. To achieve this, I have no doubt, would require us to make explicit aspects of our undertaking which at present are mostly implicit. It would mean, for example, that we would have to work out a satisfactory analysis of the structure and functioning of social power, and many of us would have to redirect our gaze from an (in fact non-existent) interior moral space (in which, for example, "decisions" are supposedly made and "attitudes" formed and changed) to a much more tangibly existent exterior social space-time in which powers and resources are deployed for, against and by people as they struggle with their environments.

In advocating that we uncouple our role as scientists -as being focused, that is, on explanation - from the moral-ideological enterprise of therapeutic perfectibility, I certainly do not mean to suggest that we give up a clinical role or that our activity should or could be value-free.

A surveyor commissioned to give a report on a house is unlikely to criticize his client's taste or evaluate the building according to his or her own aesthetic predilections, or compare it with some unattainable ideal of architectural virtue, but will limit himself or herself to giving as accurate an account as possible of what, if anything, is wrong with it, and what needs to be done to put it right. I would not want to suggest that the clinical psychologist's role is quite as cut and dried as that. Nor do I think it is all that different. We may, it is true, find ourselves giving our patients explanations of their difficulties which refer less to what is wrong with them than with the world they are and have been inhabiting. In view of the nature of the distress they are likely to be in (unlike, one hopes, the average house-buyer) we should perform our task with a degree of kindness and compassion not usually called for from surveyors.

Apart from that there is no obvious reason I can see why we should do much more than explain what the nature of the person's difficulties are and what courses of action, if any, are available to him or her to effect change. Indeed, if we really could do that, we would be doing pretty well. And if we cannot do that, we certainly should not be implying that we can by embarking on courses of "treatment" or "therapy".

Ethically, it seems to me, this would be to treat our patients, or clients, as moral equals who have good reasons for being the way they are, though they may be confused about the nature of those reasons - such confusion being, in fact, their main reason for consulting us. It would above all allow people to be free to he the people they are, to liberate them from the riveting clinical gaze analysed so well by Michael Foucault, and turn their, our, and everyone else's attention to the real causes of their problems, i.e. the world we live in.