[Clinical Psychology Forum, 119, 22-24, 1998]
I have argued before (Smail, 1993; 1995) that the rhetoric we have chosen to represent our activities as clinical psychologists to the powers that be has always tended to disguise the true nature of our enterprise. That is to say, we have tended to tell our political rulers what we felt they wanted to hear while actually making a pretty reasonable job of serving our clients' interests. We have however, inevitably become somewhat confused by our own duplicity, and at last our strategy has caught up with us. If we do not consider carefully at this stage what we are up to and what our discipline ought to be about, we may, 1 fear, be in real trouble. Even so, there is in my view no need for a crisis of confidence. What we do need is a clear idea of what our contribution has been and how we can continue to make it.
The following remarks are addressed principally to those of us in the broad "mental health" field who agonize about how we are to distinguish ourselves from the armies of counsellors, CPNs and so on who threaten to compete all too effectively with us in the marketplace. How can we justify our existence to managers who understand nothing about psychology and very little about mental health, but are as capable as most at calculating the cost of things?
This I think, is a pit we dug for ourselves during the 1970s, when we made an all-out and at the time pretty successful bid to shake off our "scientific" image and become professional therapists. So here we are, now widely seen (and trained) as professional therapists, but as exposed as everyone else in the field to the evidence (ironically, largely of our own making) that no particular form of therapy is significantly better than any other, and that none are all that brilliant anyway. Who can blame the benighted managers for wondering if we are worth our salt when the only thing they can see as distinctive about us is our relatively inflated salaries?
But we never have been just professional therapists and even now our training recognizes that there is much more to clinical psychology than just the application of "cognitive~behavioural" techniques to clinical problems. In fact, our contribution to the way "mental health" is considered and dealt with has been out of all proportion to our numbers.
Much of what happens in psychotherapy, counselling and even psychiatry is down to us, as is a great deal of the relevant research and the techniques which are used to conduct it, not to mention things we might be less proud of but which are even considered "management tools" by many of those who employ us, for example, psychometric tests for selection, and so on.
Other workers in the field cannot do what we can: psychotherapists (of the "type C" variety) purvey brand-name theologies; to the boredom and frustration of their clients, counsellors nod and reflect feelings, psychiatrists still bandy around meaningless diagnostic labels and, together with social workers, mediate social control. No one but us uses a relevant, critical, empirical knowledge base to try to make sense of our clients' distress, formulate its causes, measure attempts at change, calculate the possibilities of prevention as well as "cure" and provide explanations where neither proves possible. So why are we afraid of going out of business?
Much of our problem obviously, stems from the structure of power in which we find ourselves enmeshed. Power, as is now well known, has its particular apparatuses and discourses, and however inconvenient these may be they tend to get imposed on all those individuals and groups unable to resist them. In our case the language, concepts and principal preoccupations of Business, imposed through the management structures we have come to know so well, are especially unsuitable for the development of what we are about. There are in particular four factors beloved of the Business ideology which militate against our being able satisfactorily and creatively to develop our role.
1. The flattening of professions
Whether to save money or to clip the wings of budding professions, there has clearly been a concerted effort to reverse the trend for clinical psychology departments to develop and operate relatively autonomously. It is surely unnecessary for me to spell out the deleterious effects this has had on our ability to elaborate, teach and convey our understanding of clinical phenomena to others. The prospect of our becoming a collection of A grade practitioners uprooted from any professional structure is a real (and potentially mortal) threat.
We should by every means available resist all further attempts to erode our professional structure. In this as in many other areas we need to develop professional solidarity and a more assertive collective stance at national level. Too often the advice to colleagues of leading clinical psychologists is to use their "professional skills" to manipulate and impress managers locally to look favourably upon them. This not only places an unreasonable burden on clinicians who have a right to expect an adequate structure in which to carry out their work, but also ignores the fact that local managers have no real power. We need to develop our organization centrally in order to negotiate with centralized power.
2. Team working
Collaboration with others is clearly a good idea. However, the concept of "team-working" has become a kind of fetish for NHS management over the past decade or so, and seems mainly to be advocated as a way of breaking down professional identity and development and maintaining Business hegemony.
We certainly do not have to be professionally stand-offish and should welcome collaboration with other professions in the field; indeed for the most part we always have. But we should not be afraid either to proclaim more assertively than we often do what it is we can do that others cannot. We should insist too, on the necessary tools and conditions of our trade such as adequate office accommodation and furniture, privacy, and so on. Once again, we need to establish (or rather revive) national standards in these respects and assert them collectively. Solidarity is a form of power we should make much more use of than we have in the past.
3. The Business view of knowledge
Perhaps the most damaging assumption of the Business mentality (and one whose effects are by no means restricted to the Health Service) is that practices such as ours consist essentially in the application of techniques by suitably trained operatives (this, quite explicitly, has its origin early in this century in the Taylorist principles of production-line manufacture). The knowledge which forms the basis of such practice is seen as if ranged on shelves in convenient packages, which may, for example, be delivered by experts in training (similarly schooled as operatives in their own field). It is simply beyond the comprehension of this mentality that clinical psychology could be a creative discipline which, as well as applying, invents and discovers (and indeed needs to teach) its own subject matter.
We need to use our authority as psychologists to combat this impoverished view of how expertise is acquired and applied. Our tendency has always been to accept the agenda set by authority and then try to work within it. In this case the agenda has to be rejected, as by working within it we simply cancel out our own raison dêtre.
4. Central direction of "R&D"
According to management mythology, knowledge is created at the rational direction of Business interests. In other words, the Board makes a rational decision about what kinds of knowledge are needed for the development of the product, and directives are then sent out to "R&D" operatives to deliver the appropriate goods.
Probably no really significant advance in knowledge has ever been made in this way, and we need to register, and then point out to others, just how impoverished this conception is. Discovery and invention cannot be anticipated, and depend very largely on the ingenuity and idiosyncratic interests and concerns of people working in the field. We need to encourage creativity, not stifle it.
Far too much of the management programme for a profession such as ours constitutes a farrago of nonsense and does not at all reflect the strange and no doubt imperfect way things actually work. We have all, however, been persuaded into passive acquiescence to and complicity with this sort of approach by the not always subtle application of power; but I do think it is one with which we simply cannot comply and survive.
Clinical psychology is and always has been about invention and discovery, critique and empirical investigation. Even if, for example, we consent to calling "research" "audit", we are going to have to insist on the existence of a real world which refuses the rationalizing ideals of Business; the kind of knowledge we are interested in is not simply manufactured by a centralized R&D department and then conveyed to the factory floor by the training department. At the risk of appearing elitist, we have to distinguish ourselves from competing professions by developing the empirical critique of therapy and counselling, to continue to call into question the conceptual (not to mention moral) shortcomings of the illness model, and to preserve for our patients and clients the possibility of an understanding of their predicament which is both accurate and open to investigation. Our function is not just to deliver pre-identified packages of care, but to foster the skills of invention, hypothesis-testing and evaluation which permeate everything we do and which, most importantly, are not possessed by others in the field.
Maybe some would say these are not clinical, but academic functions. I do not think so. Without meaning it at all in a derogatory sense, one of the limitations of most academics in our field is that they do not know what they are talking about. Whatever our rhetoric may have proclaimed in the past, the great value of clinical psychology has been in developing a critical understanding of the phenomena of distress based on real experience. Real knowledge can only be gained and elaborated in this kind of "scientist-practitioner" context, and perhaps we just need to be a bit bolder and more assertive about saying so now.
It could be said, I know, that this is the view of someone on the very edge of retirement and what I am advocating ignores a "real world" in which younger colleagues are going to have to earn their living, and that they have no alternative but to operate the agenda set by power. But how knowledge is actually acquired is the true reality, and at this stage in our development subservience to power in the short term may, 1 fear, be our undoing in the long term.
Smail, D. (1993) Putting our mouths where our money is. Clinical Psychology Forum, 61, 11-14.
Smail, D. (1995) Clinical psychology: liberatory practice or discourse of power? Clinical Psychology Forum, 80, 3-6