Continuing the Conversation: a Response to Anne and Friends

Continuing the Conversation: a response to Anne and friends

Dave Harper

At Anne’s invitation and as part of what I hope will be an on-going conversation within the profession, I would like to offer some thoughts on her response to the manifesto. A response to a response, if you like.

On ‘camps’

I fully support the need for a dialogue about the Midland Psychology Group’s manifesto as I feel it has huge implications for what we see as our goals as a profession and how we achieve them. I understand Anne et al.’s concern about the danger of setting up new ‘camps’ but I don’t think the setting out of a new theoretically coherent approach is inherently problematic. It only becomes a problem if there is no dialogue between people working within different traditions. One of the contributions of the manifesto is that, in making clear its assumptions, it brings the implicit assumptions of our own worldview more sharply into focus.

One of the difficulties in these kinds of debates is that we may think we all implicitly share the same assumptions and goals when we do not. For example, is our implicit goal as a profession simply for it to grow, to compete with other professions, to increase the provision of individual therapy and so on? A related problem is that there may be a mismatch between what we would like to think are our goals and what the actual consequences are of what we do. Thus, we might broadly agree with a public health approach which focuses on the reduction of social inequality but then, in practice, support policies which are more in our ‘guild interests’ as a profession – for example a largely exclusive focus on the provision of individual therapy (about which I’ll say more below).

If we wish to increase wellbeing then the evidence seems to suggest that we need to reduce inequality. I would argue that our ultimate goal as a profession should be to contribute to interventions that would create the conditions whereby we no longer need to exist. As there is so little debate about this within the profession I don’t know whether this is a goal shared by others but I suspect it may not be. Similarly, inherent in the manifesto is a critique of neoliberalism, consumerism and Capitalism but, again, I suspect this is not necessarily something everyone will share.

Members of the MPG have discussed the problem of the interests of powerful social groups. The problem is that clinical psychologists are a group which has its own interests but this is a topic which is difficult to discuss – we’re more comfortable as a profession talking about intentions, values and beliefs and less comfortable with talking about consequences and interests.

On agency

I suppose it’s not surprising, given our disciplinary interest in individuals that we focus on the issue of agency. I don’t see anything in the manifesto as denying human agency and I would interpret the use of the term ‘resources’ quite broadly. Along with the MPG I would argue that psychologists risk over-valuing the individualistic andintra-psychic aspects of agency and the manifesto is similarly offering a corrective to this disciplinary bias. The narrative therapist Michael White (2004) put this well in critiquing what he saw as simplistic essentialist and naturalistic notions that people make changes in their lives because of some inner ‘insight’ or ‘resilience’. He argued that this was a ratherthin reading and that, on further exploration with individuals, there were often significant events, relationships with others, discoveries of new skills and knowledges and so on that had led up to them making significant changes in their lives. He suggested that when people used terms like ‘inner strength’ or ‘resilience’ they were using this asshorthand to refer to these more implicit resources. Moreover, he noted that if we think that people make changes because of resilience and inner strength are we then saying that those who don’t make such changes lack these qualities?

I think there is an opportunity here to advocate a more collective view of agency and a discussion about the contexts that lead to agency. Although the late Nelson Mandela was an inspiring leader he didn’t singlehandedly end apartheid. He was an individual engaged in a collective struggle with large numbers of other groups of people taking co-ordinated action, for example international boycotts and sanctions (see also the work of the political theorist Gene Sharp, e.g. Sharp, 2005). If we thought about agency more socially what might this lead to? I’m reminded of Vygotsky’s (1978) Zone of Proximal Development – the way in which the social context can support developmental change. Drawing on this metaphor what environmental changes might lead to community-level change? How might we use our expertise as psychologists to ally with others to facilitate broad social change to reduce inequality and injustice?

On therapy

Like Anne and friends, I’m sympathetic to individual therapy and have seen how it has led to changes for many people. However, it is only ever going to be available to a minority of people for a short period of time. The economics are against provision of individual therapy for all those who experience distress for as long as they need it. The prescription of psychiatric medication (especially anti-depressants but also anti-psychotics) has been increasing year on year for the last twenty years (Ilyas & Moncrieff, 2013; Social Exclusion Unit, 2004). Simply replacing medication with individual therapy, though undoubtedly more benign, may mean that we replace one reactive short-term technical fix with another rather than implementing proactive longer-term interventions to address the root causes of psychological distress (Albee, 1986; Humphreys, 1996). Reading the manifesto prompts one to ask what it means, as a society, that we are increasingly looking for individualistic technical fixes be they chemical or psychological (Rose, 2006)?

On language

As psychologists, we forget how much jargon we all talk. It’s just that, over recent decades, as therapy culture has seeped into popular culture, everyone else is talking our jargon too. I agree that these ideas need to be debated in a range of accessible formats but we need to be careful that the essentials of a social approach are not lost in translation as assumptive worldviews have a habit of assimilating alternatives. For example, although the ‘biopsychosocial’ model appears to include the ‘social’ the danger is that, as John Read (2005) has put it, it operates in effect as a ‘bio-bio-bio’ model. Similarly, if we try to translate these ideas into a language of individualistic psychology then we can confuse real empowerment (where people take power for themselves) with psychologised intra-psychic versions of empowerment. Thus we need to remain vigilant that we don’t just put new wine into old bottles and continue to think about things in individualistic and intra-psychic ways. The key issue here is, I think, developing and maintaining genuinely new ways of thinking and practising.

On what to do

I agree with the need for a public health approach and also agree with Anne and her collaborators’suggestions. We need to make our voice heard but, again, I think we need more agreement as a profession on these issues so that we can speak with one voice. For example, one of the dangers here is that we simply re-package individual solutions and give them out to the public. Again, this may be relatively benign but in addition to this, what different kinds of solutions might there be if we took a more social materialist view of distress? How might we need to do research differently? How might we influence policymakers and commissioners who tend to think quite individualistically? Moreover, how might we persuade our own profession given that many may have joined it because they wanted to be individual therapists?

Membership of the DCP has grown from 2,317 members in 1990 to 10,640 in January 2014. Although this has no doubt increased the provision of individual therapy has this led to longer-term changes in the societal conditions which produce psychological distress? I suspect that, despite the best intentions of many clinical psychologists, it has not. There are many reasons for this: the increasing focus in mental health policy on psychologists largely as providers of individual therapy; commissioning priorities focusing on treatment rather than prevention; the expectation that practitioners should do more with fewer resources; the ever-increasing bureaucratisation of services where practitioners seem chained to their computers when not seeing clients; the expectation that services will simply meet an ever-increasing number of referrals (though senior NHS managers and commissioners seem strangely publicly silent about why referrals might be increasing during an economic recession). All of this can lead to a sense of collective paralysis; that change is impossible and that we simply need to meet the demand of increasing numbers of referrals. But, as the celebrations of the life of Nelson Mandela have reminded us, social change is possible. If our goal is to increase psychological wellbeing and one of the ways of achieving this is to reduce social inequality then how might our profession use its skills and knowledge to help reduce inequality? How might our training programmes need to adapt to equip trainees with skills in addition to those of therapy? How might we influence policymakers and commissioners to adopt more sustainable and effective interventions instead of or, at least, in addition to, individual therapy? Debating these questions might provide a way out of paralysis.

Of course, for many psychologists struggling in hard-pressed services, these questions might seem impractical, utopian or even anxiety-provoking if people lack confidence, expertise and experience in alternative approaches. One issue here is that we hear so little about the many attempts by clinical psychologists at community-level public health approaches that we lack role models and practical examples. I’m reminded of Sue Holland’s (1992) attempt to combine the best of individual and collective approaches where a short period of individual therapy and understanding is followed by collective work in groups where common themes are noted and where there is also an opportunity to take collective action. Another example is Guy Holmes’ (2010) adaptation of Holland’s approach (see also the section on community psychology authored by some of the members of the MPG in Cromby, Harper & Reavey, 2013). One way to approach this might be to give much more visibility to psychologists’ attempts to adopt the kind of alternative approaches discussed in this issue. How about a regular ‘Clinical Psychology in Society’ column in Clinical Psychology Forum with an inspiring example every month?

References

Albee, G.W. (1986). Toward a just society: Lessons from observations on the primary prevention of psychopathology. American Psychologist, 41, 891-898.

Cromby, J., Harper, D. & Reavey, P. (2013). Psychology, Mental Health & Distress. Basingstoke: Palgrave Macmillan.

Holland, S. (1992) .From social abuse to social action: A neighbourhood psychotherapy and social action project for women. In J. Ussher & P. Nicolson (Eds.) Gender issues in clinical psychology. London: Routledge.

Holmes, G. (2010) Psychology in the real world: Community-based groupwork. Ross-on-Wye: PCCS Books.

Humphreys, K. (1996). Clinical psychologists as psychotherapists: History, future, and alternatives. American Psychologist, 51, 190-197.

Ilyas, S. & Moncrieff, J. (2012). Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. British Journal of Psychiatry, 200, 393-398.

Read, J. (2005) The bio-bio-bio model of madness. The Psychologist, 18, 596–597.

Rose, N. (2006). Disorders without borders? The expanding scope of psychiatric practice. BioSocieties, 1, 465-484.

Sharp, G. (2005) Waging Nonviolent Struggle: 20th Century Practice And 21st Century Potential. New Hampshire: Extending Horizons Books.

Social Exclusion Unit (2004). Mental health and social exclusion. London: Office of the Deputy Prime Minister

Vygotsky, L. S. (1978). Interaction between learning and development (M. Lopez- Morillas, Trans.). In M. Cole, V. John-Steiner, S. Scribner, & E. Souberman (Eds.), Mind in society: The development of higher psychological processes. Cambridge, MA: HarvardUniversity Press.

White, M. (2004). Narrative practice and the unpacking of identity conclusions. In M. White, Narrative practice and exotic lives: Resurrecting diversity in everyday life. Adelaide: Dulwich Centre Publications.

Affiliation

Dave Harper, Reader in Clinical Psychology, University of East London.