50 YEARS OF CLINICAL PSYCHOLOGY TRAINING AT QUEEN’S UNIVERSITY,

BELFAST

THE END OF THE BEGINNINGTHE HISTORY & FUTURE FOR

CLINICAL PSYCHOLOGY

Professor Tony LavenderCanterbury Christ Church University

Friday 20 November 2009

INTRODUCTION

1. Personal - Introduction

2. Birth of Psychology

3. Birth of Welfare State & Clinical Psychology in the UK (1948-1959)

4. NHS & Clinical Psychology Growth (1959-1979)

5. NHS & Clinical Psychology Cost Containments & Consolidation (1979-1999)

6. NHS & Clinical Psychology: ‘You never had it so good’ (1997-2010)

7. The Future: Conclusions

BIRTH OF DISCIPLINE OF PSYCHOLOGY

• Psychology emerged as a discipline from philosophy– Pioneering work – William James

• The Psychological Society founded in 1901– Inaugural meeting of ten– Sully Grote, Professor of Mind and Logic– Four meetings a year on a Saturday – business,

research paper and a meal– Mix of medics, philosophers, mathematicians and

other academics– Ward & Rivers started British Journal of Psychology

1904

British Journal of Psychology, 1904, vol.1, part 1 p.1.

“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.”

• British Psychological Society 1906– 1906 – 13 members– 1908 – 54 members– 1914 – Adopts BJP as official journal– 1918 – 100 members

• Pre World War II – three strands– Educational Section formed 1919– Industrial – 1913/14 – Psychology industrial efficiency

• Mental Health – wars provided impetus– GPs– Hospitals– 1920s establishment of Maudsley and Tavistock

Institute

• Second World War – influence– Selection assessment (personality & intelligence)– Assessment of psychological problems and impact of

brain injury (scientific perspective)– Eysenck At Mill Hill Emergency Hospital– Slater at Sutton Emergency Hospital– Zangwill Edinburgh Brain Injury Unit– Asylum employment of Raven & Penmole at Royal

Eastern Colchester before Raven’s move to Royal Crichton in Scotland

• From these beginnings clinical psychology sprang

A DIVERSION OF SUBSTANCE: THE NHS

• Post War Reconstruction – the Beveridge Report

Beveridge wrote that he used three guiding principles in developing the Report

i) A revolutionary movement in the world’s history is a time for revolutions, not patching.

ii) His plan for social security was mainly an attack on want. But the other ‘Giants’ on the road to reconstruction, that is Disease (Health), Ignorance (Education), Squalor (Housing) and Idleness (Employment), were equally important to tackle and may prove more difficult

iii) Social security must be a result of co-operation between the State and the individual (i.e. “contributions in return for benefits”).

• Disease (Health) – Creation of the NHS

“This is the biggest single experiment in social service that the world has ever seen or undertaken”

Aneurin Bevan, 7 October 1948

“It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation, it was a unique example of the collectivist provision of health care in a market society.” Klein 1986

CREATION OF THE NHS• Nye Bevan

• Medics– Consultants persuaded– GPs came in threatening boycott

• Money– How much when backlog of disease cleared– Few effective treatments– Massive unmet need– Costs rise

CLINICAL PSYCHOLOGY IN USA

• Witmer – Pennsylvania Psychological Clinic – first use of clinical psychology 1896

• Clinical psychology longer history– Journal of Abnormal Psychology (1905)– Journal of Consulting & Clinical Psychology (1937)

• USA post war a focus on how to prevent the inhumanity of Third Reich: psychoanalysis significant influence

• Boulder Conference 1948– Scientist Practitioner

CLINICAL PSYCHOLOGY: UK/US CONTRAST

• Early influence of Eysenck & Maudsley

APA (1948)“The need for clinical psychologists with a combination

of applied and theoretical knowledge in three major areas: diagnosis, therapy and research.”

Eysenck (1949)Clinical psychology should not involve a training in

therapy “therapy is something essentially alien”.

Clinical Psychology demands competence in diagnosis and/or research.

Eysenck (1949) 

“Psychology can not go where social need requires. A science must follow more germane arguments than the

possibly erroneous conception of social need.”

APA (1948)

“Unmet social needs for more and better mental hygiene services, including research. The task before clinical

psychologists lies in adopting such policies in their training institutions that are best calculated to provide

services that can demonstrate social usefulness.”

Personal Therapy

Eysenck was at his most strident in his response:

“It is proposed that the young and relatively defenceless student be imbued with the ‘premature crystallizations of spurious orthodoxy’ which

constitute Freudianism through the ‘transferences and counter-transferences’ developing during this training. Here, indeed, we have a fine soil on which to plant the seed of objective, methodologically sound,

impartial, and scientifically acceptable research”

APA, which advocated that:

“some kind of intense self-evaluation and that whenever possible that should be psychoanalysis”

THE ROLE i) It helped establish clinical psychology as a scientifically

based profession

ii) It defined clinical psychologists having reasonably unique areas of expertise, i.e. A psychological approach to diagnosis and research design.

iii) It neatly fitted professionally into a politically acceptable division of labour. To quote Eysenck:

“The team of psychiatrist-psychologist-social worker constitutes a combined attack of the problem. The psychiatrist responsible for therapy, the psychologist for diagnosis help and research design, the social worker for investigation of the social consideration.”

CLINICAL PSYCHOLOGY POST EYSENCK

• Interwoven histories – responsive to health and social needs

• Embraced therapy – for others

• Substituted formulation for diagnosis

• Kept assessment and research

CLINICAL PSYCHOLOGY & NHS• 1957-1979 Training programmes grow by one a year approx

– Dating first courses difficult– 1959 puts Queesn amongst first – IoP started it from 1957

• 1966 Division of Clinical Psychology formed

• Psychology services diversify– By speciality– By setting– By therapy– Through creativity and innovation

• First NHS reorganisation 1974– ‘Tears About Tiers’ (Regions, Areas, Districts, Hospitals/GPs) – Patrick Nairne– Economic downturn – IMF help – Denis Healy 1976

• Health & Social Care Service – Northern Ireland 1973– Integrated NHS & Social Care (Four Area Boards)

TRETHOWAN REPORT 1976

Started in 1973

• Legitimisation to develop freedom from medical control

• Organisation tiers in clinical psychology should parallel NHS tiers – Area, District

• Area Department headed by top grades

• Principal psychologist established in all specialities

• Area Department should have defined base

• GPs should be supported by psychological technicians

THE CONSERVATIVE YEARS 1979-97: TRENDS

• Controlling costs – restoring public finances

• Controlling the professions and Unions

• Introducing general management

• Introducing marketisation – purchaser/provider divide

• In Mental Health Services – closing of hospitals and moving to community, leading to a shift in spending from NHS to Local Authorities

THE CONSERVATIVE YEARS 1979-97• NHS reorganisations gather pace

– 1982 Health Services: Structure and Management• Areas abolished• Districts empowered• RHAs & CHCs maintained• Units established (e.g. Acute Unit, Mental Units) under district control

– 1983 Griffith’s Letter – Introduction of General Management• NHS Management Executive• Regional, District and Unit General Managers

– 1989 NHS reorganisation • Working for patients• NHS & Community Care Act

– 1994 Regions abandoned (8 Regional Offices created)

CONSERVATIVE YEARS 1979-97: CLINICAL PSYCHOLOGY

Clinical Psychology

1978/79 Beck arrives in town – CBT in the UK

1979/85 Struggling to implement Trethowan

1981 British Journal of Clinical Psychology starts

1987 Privy Council grant order for BPS to maintain a ‘Register of Chartered Psychologists’ – voluntary

1979 – 1990 Slow increase in numbers of new training programmes and gradual increase in numbers of places.

THE CONSERVATIVE YEARS 1979-9: CLINICAL PSYCHOLOGY

Clinical Psychology

1989 Manpower Advisory Service Report (Mowbray)

Never fully adopted but• Level 1 Simple rapport and counselling• Level 2 Manualised therapy• Level 3 Use of theory analysis to tackle new problems –

original solutions (characteristic of CPs)• Shared care model• Recommend increase in psychologists including training place

from 173 to 300 by 2000 (actually hit 450)

1990 BPS agreed all CP training should be 3 years by 2000

1995/96 First Doctorates in Clinical Psychology – all Doctorates by 2000

REFORM• Fund holding removed – replaced with Commissioning• Quality Assurance System: First class service (1999)

– Review evidence and produce guidelines (NICE)– Clinical governance ensure best practice locally– Inspection and review (Commission for Health Improvement –

Healthcare Commission – Care Quality Commission)• Primary Care Groups to Primary Care Trusts for commissioning –

reduced in numbers to about 150 in 2006• Trusts: All major providers to become Foundation Trust (started in

2004) overseen by Monitor• Strategic Health Authorities

– Regional Offices – 8 gave way to 28 SHAs 2002 to 10 in 2006– Provide leadership co-ordination, manage performance of PCTs and

Trust, build capital, also commission training

• Increased funding

THE LABOUR YEARS & THE NHS 1997-?

THE LABOUR YEARS & THE NHS 1997-?

ADDRESSING FUNDING

1991-1997 6.8% - 7% GDP

2002/03 7.7% GDP

2007/08 9.2% GDP

Wanless said should rise to 11.3% by 2020

1999/2000 £40.2billion £40.2billion

2007/2008 £92.6billion £92.6billion

Appleby (2009) in Northern Ireland says some increase in resource need but should be more effectively used. (£3.87billion in 2008/09, rising to £4.19billion in 2009/10).Probably ‘golden age’ in growth in public sector.

THE LABOUR YEARS & THE NHS 1997-?Northern Ireland

1999 Department of Health, Social Services & Public Safety (DHSSPS) created

• 4 Health & Social Service Boards

2009 Major Restructure of DHSSPS• 4 Boards become one Health & Social Care Board accountable to

the Minister• 5 Local commissioning groups• New Public Health Agency• New Patient Client Council• Regulation & Quality Improvement Agency incorporates work of

Mental Health Commission

Time of major organisational change which as a profession will need to keep alive to

CLINICAL PSYCHOLOGY: THE FUTURE

2005/07 New Ways of Working for Applied Psychologists

PURPOSE OF THE APPLIED PSYCHOLOGIES

“to improve the psychological well being of the population through working with individuals, teams,

organisations and communities.”

CHALLENGES & WAY FORWARD

LEADERSHIP & MANAGEMENT

• Values: ensure psychological perspective. ‘Ways of thinking’ to services

• Encourage psychologist’s into commissioning role

• Take up leadership positions in organisations– General– Leading psychological services

• Organisational lead for psychological services at most senior levels

• Develop psychologists to be politically aware, align with organisational strategic objectives. Business minded and clear on value

• Develop leadership competencies in NHS Leadership Qualities Framework

CHALLENGES & WAY FORWARD

TEAM WORKING – THE FUTURE OF HEALTHCARE DELIVERY

• Psychologists should be actively involved in the design, operation and evaluation of teams making use of appropriate research evidence – ‘help in creating effective teams’

• Psychologists should seek to integrate their work within teams in a way that continues to promote their unique contribution to the care and treatment of service users – ‘don’t stand back, integrate’

• Psychologists should seek to develop their role and improve the effectiveness of services through process consultancy at systems level, peer consultation and supervision and leadership – ‘show your value’

• Psychologists should promote effective roles for users and carers – ‘enhance services’ competence of working with users’

CHALLENGES & WAY FORWARD

IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES

• Get involved and contribute at leadership, delivery, training and clinical governance

• Contribute to service redesign and a stepped care model and look out for interest of clients at secondary/tertiary levels

• Contribute to design and analysis of outcome evaluation

• Contribute to assessment of population needs

CHALLENGES & WAY FORWARD

NEW ROLES

• Develop prequalification career framework– Expand base of career pyramid– Psychology Assistant/Senior Assistant/Associate– Could work with variety of client groups and types of therapeutic

input (may have different names)– Education framework (Postgraduate Certificate, Diploma &

Masters)

• Don’t react to developments as threats but opportunities

• Keep in mind the aim of making services more psychologically informed and increasing access to psychological services and therapy

CHALLENGES & WAY FORWARD

TRAINING MODELS

• The established three-year doctoral training model is robust and has a proven track record: alternatives should not be a substitute for doctoral training. ‘Support other divisions to Doctorates’.

• Existing applied psychology training courses should develop training of assistant and associate psychologists, relevant to their roles, but which provide a coherent training progression from undergraduate to doctoral level. ‘Embrace training implications of service change’.

• Existing applied psychology training courses should explore shared, common modules with other applied psychology training courses within their host institution. ‘Face modularisation’.

• ‘Make undergraduate programmes more relevant to applied psychology’ – be proud of the success of A’Level psychology

CHALLENGES & WAY FORWARD

APPLIED PSYCHOLOGY

• Economic downturn – ‘cold wind of debt’ – staying still will feel like cuts

• Improving psychological services to children and quality/support for parenting

• Mental health and learning disability in criminal justice system – Bradley Report

• Get more engaged at Governmental Departmental level including workforce planning

• Get on and influence Health Professions Council

• Create College of Applied Psychology – virtual organisation inside BPS

CONCLUSION

• All applied psychologists to recognise their ambassadorial role and need to be constructive and innovative on behalf of clients and services

• That’s what has worked till now