A Short Introduction to Clinical Psychology

Katherine Cheshire, David Pilgrim

• Publisher: SAGE Publications Ltd
• Year: 2004
• ISBN:
  9781446234204
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

A Short Introduction to Clinical Psychology gives an accessible overview of the field for psychology students and anyone considering training as a clinical psychologist.

Setting out the theoretical and practical dimensions of clinical psychology, the authors examine its origins, knowledge base and applications with different client groups, in different contexts and through different modalities (individuals, groups, couples, families and organizations). They also highlight issues affecting everyday practice - from professional relationships to government policy.

Drawing on the first-hand experiences of people who have recently qualified, the book describes the process of training and the transition that takes place from trainee to practitioner. Throughout, the book captures a sense of clinical psychology as a dynamic and changing field which has grown up fast alongside other more established professions involved in mental health care and which is continuing to evolve in response to contemporary needs.

As an overview of the field, A Short Introduction to Clinical Psychology is an ideal text for undergraduate and post-graduate students in psychology and as initial reading for clinical psychology courses.

1

THE SOCIAL AND HISTORICAL CONTEXT OF THE PROFESSION

Like all professions, clinical psychology has both features that it shares with other professions and characteristics that are peculiar to itself. In this introductory chapter we will first examine the nature of professions, drawing heavily on their sociology. This summary of sociological approaches to professional life should assist the reader to understand how clinical psychology reflects and reproduces general features of what came to be known during the twentieth century as the ‘new middle class’ (Carchedi, 1977). After this general sociological introduction we will identify one aspect of the particular character of British clinical psychology: its history. This history reflects the contested knowledge base of the profession – a subject we will return to in Chapter 2. In Chapter 6 we revisit this discussion by examining the ways in which this knowledge is expressed in British clinical psychology, both organisationally and rhetorically, as a form of clinical expertise. Our final chapter incorporates further discussion of the profession’s internal dynamics and socio-political context and suggests how these factors are shaping its future.

What are professions?

The reader of this book, and of others in the series, can appraise the socio-political character of particular professions on a continuum from hostile scepticism to naïve trust. The former can be summarised in George Bernard Shaw’s suggestion that ‘the professions are a conspiracy against the laity’. This expression of outright distrust of self-serving professionals is also found in the sociology of the professions, as is its opposite: the view that professions are benign, altruistic and productive contributors to modern societies. In order to make sense of this range of views, and their potential applicability to clinical psychology, we will provide a summary of some sociological work about the mental health professions.

The mental health focus may seem overly restrictive, given that today clinical psychologists work in a variety of settings. However, the roots of the profession lie mainly in mental health work. Furthermore, in other clinical settings such as learning disability, child and adolescent services and physical health care, the profession finds itself, competitively or co-operatively, working alongside psychiatrists and other mental health professionals. Finally, the activities clinical psychologists are involved with in all health service contexts aim to improve well-being and quality of life, ameliorate distress, and reduce or control dysfunction. Taken together, these aims constitute mental health work in a very broad sense.

Clinical psychology is part of what poststructuralist sociologists call ‘the psy complex’ (Rose, 1985). Here the word ‘complex’ refers to a complex of professions (psychiatry, psychiatric social work, mental health nursing, counselling and psychotherapy) in interaction, with a variety of overlapping practices. The boundaries within this complex are murky, as we will show. Consequently, many of the issues considered in this text, although primarily focused on clinical psychology, necessarily address the psy complex in its totality.

Sociological accounts of modern professions

We noted above that views of the general public and of sociologists studying professions form a continuum. Saks (1983) compared sociological accounts of modern professions and identified three main types. The first, derived from the work of Emile Durkheim and Talcott Parsons, emphasised the functions of professions for society and the positive traits expected of, and delivered by, professionals (altruism, integrity, efficiency, unique skills, trustworthiness). This conservative trait and function approach no longer finds much favour within sociology, although professionals themselves may offer such descriptions as part of an exercise in collective self-promotion. Another point about this approach is that the very word ‘professional’ has entered the vernacular. It has come to mean efficient and trustworthy expertise. While sociologists have developed critical perspectives on the professions, our everyday discourse about them may still imply positive personal and social features.

The second approach to the professions suggested by Saks (1983) is derived from the work of Max Weber and remains the one most critical of the professions (more so than a Marxian approach: see p. 3 below). The neo-Weberian analysis of professions suggests that they act to exclude competitors in the market place and subordinate or dominate both their target client group and less-developed professions working in their field. Two notions in particular capture these processes: social closure and professional dominance.

Social closure entails professional groups advancing their interests in society by controlling their recruitment and excluding competitors. By these means they justify the maintenance and extension of both their economic value (fee or salary) and their social status and influence, by successfully convincing their employers and clientele that they possess unique expertise. This activity of closure entails professions regulating their own boundaries. Thus, entrance to a profession requires the acquisition of credentials and successful employment in a particular role. Those without this accredited and employed status are denied access to both privileged knowledge and forms of legitimate action, whether they are other workers or the profession’s clients.

Professional dominance means that professionals try to acquire and maintain a dominant position in relation to others in society. This takes three forms. First, professionals have power over their clients, who are less knowledgeable and therefore may depend on professional expertise. Second, they have power over aspiring colleagues – applicants for training and those recently qualified. Third, they may acquire power over other professionals who have weaker claims to legitimacy because, for example, these latter professionals’ knowledge base is less exclusive, their training is shorter or they lack formal legal powers (such as the power to detain a patient under the Mental Health Act). In particular, dominant professions will resist encroachment from other groups, whilst the latter will endeavour to encroach on work dominated by older professions or make bids for the legitimacy of new work.

A third sociological approach to the professions is that of the Marxian tradition. This approach has generated contradictory interpretations. Marxists can be found arguing that the professions constitute a part of the ruling class (Navarro, 1986); that they are part of the working class (the ‘proletarianization’ thesis: Oppenheimer, 1975); or that they constitute a new class in between the proletariat and the bourgeoisie. This last view of professionals, as a contradictory social group, has been argued by Carchedi (1977) and Johnson (1979). In their view the professions serve the interest of capital by forming a regulatory apparatus to maintain social stability in a capitalist society. However, when they are state employees (for example, in health and education) they are subject to bureaucratic subordination, which erodes their social power, making them wage slaves like any other worker.

Since Saks offered his overview of the sociology of the professions in the early 1980s, sociology has been influenced significantly by poststructuralism – especially the work of Michel Foucault. A fourth sociological position has emerged, arguing that power is dispersed and is not possessed clearly by one social group in relation to another (as suggested in different ways by Marx and Weber). Instead, the poststructuralists argue that power takes the form of discursive practices or discourses, which are precarious and can be challenged. At the same time, in their orthodox dominant forms, professionals and clients alike can share and be trapped in a particular set of practices and ways of framing reality. For example, professionals may have preferred ways of conceptualising and practising their work. Their current and potential clients can accept, ignore or resist this authority. Similarly, some in a profession may conform to an orthodox approach, while others may construct an alternative view.

A fifth current within recent sociological debates has been feminism, which at times has overlapped with Weberian, Marxian and poststructuralist accounts (Crompton, 1987; Pollert, 1996). The central organising concept is that of patriarchy, according to which some or all social divisions are accounted for by the political struggle between men and women, with the former dominating and the latter resisting. When this frame of analysis is applied to professional life a number of topics recur, including barriers to female entrants; obstacles to career advancement for women within professions; gendered divisions of labour within and between professional groups; the lower status and earning power of female-majority professions; and the experience of women as workers and mothers (Davies, 1996). Davies argues that the central issue for women is not their exclusion from the professions but the gendered way in which they are included. Another topic that has emerged within feminist debates about the professions is the gendered nature of professional knowledge, a point we return to in Chapter 6.

The applicability of sociologies of the
professions to mental health work

We now turn to the relevance or ‘fit’ of different sociological approaches to the professions when mental health work is studied. We will focus on clinical psychology but allude at times to other professions. To focus on clinical psychology alone might mislead the reader by giving the impression that only this profession needs to be analysed critically; and the activity of clinical psychologists, like that of other professionals, occurs in an inter-professional context, especially in health care bureaucracies. Clinical psychology cannot be understood in isolation.

We mentioned that the trait and function approach has fallen from favour within sociology. This approach, elaborated by Parsons, embraced the preferred accounts offered by professionals (especially professional leaders) and contemporary examples can be found in standard introductory texts about clinical psychology. One such ‘public relations’ view is provided in a recent account of the profession by two of its senior members:

In summary, clinical psychologists are psychologist-practitioners applying scientific knowledge and principles in a professional role to the alleviation of human suffering and the improvement of the quality of life.

(Marzillier and Hall, 1999: 9; italics in the original)

This view is the bread and butter of professional leaders’ negotiations with employers and politicians. For example, when the Division of Clinical Psychology or the Professional Affairs Board of the BPS is asked to the negotiating table with civil servants, or its written comments on legislative or organisational change in the NHS are requested, it will take the opportunity to promote the interests of psychologists by stressing their special skills.

This activity is predicted most emphatically by the neo-Weberian approach to the professions, which suggests that they are perennially in the business of boundary maintenance, the making of new bids for legitimacy and the exploitation of opportunities for social advancement. Shaw was probably wrong to suggest that this happens conspiratorially between the professions, because they are frequently in competition with one another. For example, the activities of mental health nurses and of psychiatric social workers overlap. This creates the risk of one group substituting for the other (Rogers and Pilgrim, 2001). Clinical psychologists face a similar risk when they retain a therapist-only role in their work since those trained in psychological therapies from other professions, such as mental health nursing, can also fill that role. In order to counteract this threat, leaders of the profession have argued that psychologists employ unique skills within the therapist role (Parry, 1989; Hallam et al., 1989). In the 1980s, when the role of psychologists in the NHS was examined by government, boundary maintenance was negotiated successfully by leaders arguing that clinical psychologists alone have ‘level 3’ therapy skills (see, p. 18 below).

Clinical psychology is one of the highest-salaried non-medical professions and yet it is predominantly a female profession. Concerns about women undermining the social status and salary levels of clinical psychology have been publicly expressed by some men (Crawford, 1989; Radford and Holdstock, 1995). The point made by Davies about the peculiar ways in which women are included in the profession is relevant here. Although the majority of the profession is female, men are over-represented in senior management roles (Murray and McKenzie, 1998).

As we noted in the introduction to this chapter, generalisations in the sociological literature on the professions beg particular questions about individual professions. In the present discussion this prompts us to acquaint the reader with relevant details from the history of British clinical psychology.

A short history of British clinical psychology

In the early days of British clinical psychology, one of its professional leaders, Hans Eysenck, noted that ‘psychology has a long past, but a short history’ (Eysenck, 1953: 22). In this book we will explore the meaning of this claim. Clinical psychology is one of several specialist applications based upon what is now the single academic discipline of psychology. However, while psychology is typically organised in dedicated university departments, its theoretical and empirical concerns overlap with those of its neighbours, such as philosophy, other human sciences (e.g. anthropology and sociology) and the biological sciences (e.g. physiology and neurology). To understand this connection to other academic disciplines, clinical psychology’s ‘prehistory’, as well as its history, needs to be examined. In this chapter we will first deal with the period just prior to the profession’s formation in the 1950s and then with its development after that time. Finally, some points will be made regarding North American influences on the development of clinical psychology in Britain.

Academic psychology becomes established in Britain

By the end of the nineteenth century it was becoming evident that the discipline of psychology was about to differentiate itself from philosophy. This first took place in Germany, with other countries such as Britain and the USA catching up within a few decades. The earlier developments in Germany meant that the German model of experimental work was influential for a while across both the Atlantic and the English Channel, with pioneers such as Weber, Fechner, Helmholtz, Lotze and Müller first defining the academic field.

In Britain, the work of Francis Galton (Darwin’s cousin) and the social movement of eugenics ensured that an evolutionary perspective would become important in both British psychology and psychiatry. Its specific impact on later clinical work derived from the notion that innate individual differences between people could be measured – the beginnings of the psychometric measurement of intelligence and personality that became known as differential psychology. This hereditarian focus was at odds with the older empiricist tradition in Britain, and subsequent developments (for example in Eysenck’s methodological behaviourism) reflected a principled acceptance of the variable interaction between genes and learning. Methodological considerations in this nascent period emphasised experimentalism, psychometrics, the hypothetico-deductive method and the use of statistical methods to map populations and define experimental and control groups.

In the academy, the differentiation from philosophy was slow, with leaders of the parent discipline retarding the independence of psychology. By the outbreak of the Second World War, there were still only six chairs in psychology in the British academic system (Hearnshaw, 1964), despite the emergence of a dedicated professional organisation at the turn of the century. The Psychological Society was inaugurated at University College, London, in 1901, taking the term ‘British’ in 1906 to become what is still called the British Psychological Society (BPS). In 1902 its membership was a mere 13 and the BPS remained a tiny club of philosophers and psychologically minded medical practitioners until the First World War (Edgell, 1961).

Soon after the BPS was founded, the British Journal of Psychology was also set up (although this was, to begin with, separate from the Society). In the very first statement from the founding editors, James Ward and W.H.R. Rivers, the remit of the new discipline was announced:

Psychology, which till recently was known among us chiefly as mental philosophy and was widely concerned with problems of a more or less speculative and transcendental character, has now at length achieved the position of a positive science; one of special interest to the philosopher no doubt, but still independent of his control, possessing its own methods, its own specific problems and a distinct standpoint altogether its own. ‘Ideas’ in the philosophical sense do not fall within its scope; its inquiries are restricted entirely to facts. (Editorial, British Journal of Psychology, 1904, 1 (1): 1)

Given the slow organisational separation of psychology from philosophy in the academy during the first quarter of the twentieth century, Ward and Rivers were being rhetorical rather than accurately descriptive. Indeed, they were setting out the stall for the new academic discipline and their emphasis upon the pursuit of ‘facts’, together with their insistence on psychology being a ‘positive science’, is therefore important. The central orthodoxy in British psychology was and still is positivistic, although philosophical idealism has been a constant thorn in its flesh (most recently this has been evident in the emergence of postmodernism within academic psychology). Psychology made its initial claim for separate legitimacy by emphasising objectivity and empiricism as the features that distinguished it from philosophy, which was preoccupied with metaphysics and logic. While philosophy was a cerebral activity, relying on speculation, introspection and reflection, psychologists had begun to test experimental hypotheses and devise practical interventions based on emerging theories.

Developments in the USA followed a similar pattern although the differentiation of psychology from philosophy occurred slightly earlier and was driven by members of both disciplines. For example, in their textbooks at the end of the nineteenth century both William James and John Dewey explored the need to shift from philosophy to psychology, while recognising the debt owed to the former by the latter (James, 1890; Dewey, 1886). It is significant that although Dewey was a philosopher, he championed pragmatism in his discipline. The special relationship between Britain and its ex-colony has led to an identifiable form of Anglo-American psychology over the past century, but British developments have generally tended to foll...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Preface
• Acknowledgements
• 1 The Social and Historical Context of the Profession
• 2 The Knowledge Base of Clinical Psychology
• 3 Clinical Psychology Training
• 4 Careers in Clinical Psychology
• 5 Changing Practice and Changing Roles
• 6 Experts and Expertise
• 7 Internal and External Relationships
• Glossary of Therapeutic Approaches
• Further Reading
• Appendix
• References
• Index