THE FUTURE FOR CLINICAL PSYCHOLOGY
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342 that even in the modern antibiotic era these apparently trivial wounds demand careful management. How com- mon they are is indicated by the fact that they comprised almost a quarter of all hand infections seen at the Sacra- mento Medical Center (59 out of 205 cases). In all but 9 instances, a blow against the mouth had lacerated the knuckle of either the index or the middle finger. Fresh cases (less than eight hours old) were explored under regional anaesthesia, and a tourniquet. The wounds were extended for debridement, irrigated, and, if the joint had been pierced, were drained with a gauze wick. A pad of povidone-iodine was then applied under a bulky com- pression dressing. An initial intramuscular dose of cephalothin was followed by oral cephalexin for two weeks. Neglected cases, and those in which a joint had been pierced, were admitted after the same initiaT explo- ration, treated with warm moist packs changed four- hourly, and given intravenous cephalothin every twenty- four hours whilst in hospital. On or about the fifth day a secondary debridement was undertaken and joint cap- sule or tendon repair effected with ’Dexon’ sutures. Skin wounds were left open and the patient was discharged, on oral cephalexin, next day. Of 20 patients who required this intensive treatment, half nevertheless suf- fered some permanent loss of joint movement. The Sacramento workers see cephalosporins as the antibiotics of choice- because the staphylococci which were most often isolated were penicillin resistant and, though sensitive to penicillin derivatives, were usually associated with other organisms which were not. This monograph is a salutary reminder of a potentially crip- pling condition which is susceptible of control by ade- quate measures. The current British trend is away from indwelling wicks and repeated moist dressings. For early cases at least, a more conservative approach entailing, after exploration, frequent inspection during immobili- sation on a plaster slab, may be sufficient. It should be added that bites in the true sense, involving soft tissues only and not on the hand, are less common, and run a course not very different from that of soiled puncture wounds inflicted by other sharp instruments. THE FUTURE FOR CLINICAL PSYCHOLOGY LAST month the Trethowan Report,l on the role of psychologists in the health services,2 was published. It has had a long gestation, nearly five years, during which the topics of its deliberations have been keenly debated, and some of its recommendations have already been tried out; meanwhile the money to implement them fully has become increasingly scarce. The committee’s report is paved with good intentions, but not, alas, with any gold. The numbers of clinical psychologists working in the N.H.S. have increased considerably over the past fif- teen years, from 198 to 585 in England and Wales, but that number is still a small one. Clinical psychology is still in its early days, and the comments of the Treth- owan Committee smack somewhat of an early school report. Psychology tries hard, shows promise, and 1. The Role of Psychologists in the Health Services: Report of the Sub-Com- mittee. H.M. Stationery Office. 70p. 2. Psychol. Med. 1977, 7, 179. should do even better work in the future. At any prize- giving there may be a few boos from the back row, While, in general, it is claimed that clinical psychologists have made great advances in treatment, and have pro- duced various plausible theories on which these treat- ments are based, others have commented that these claims are anecdotal, that the theories are specious ad- hoc explanations, and that "while the behaviour thera- pists may have stolen the analysts’ bathing suits, they are no better able to swim." 2 The Trethowan Committee comes down firmly for believing that clinical psychology is a Good Thing and should be encouraged, on the basis of its past perform- ance and present status, to make more contributions to health care in assessment, diagnosis, treatment, and research. They endorse the view that these should be extended well beyond the traditional fields of psychiatry, mental handicap, and children’s clinics. They recom- mend that psychology services should be based on an area department, headed by a fairly senior person. This department would cover a wide variety of different ser- vices, including general practice. Eventually, it is hoped that such departments may exist in every district, but at present there are not enough psychologists to form even area departments. A well-organised regional department will also be required, to provide some coordination, par- ticularly in training programmes. The committee recom- mends an expansion of training facilities--essential if their other recommendations are implemented-utilis- ing, where possible, present university-based courses. This will demand another look at the way the students on these courses are funded. The present system is unsat- isfactory. The committee also looked at the vexed question of "clinical responsibility". Much of the conflict of opinion is due, they feel, to the different meanings attached to this phrase by different people. Avoiding the risk of grasping a dead nettle, they first spray the hostile vegetation with that well-known all-purpose weed-killer, the multidisciplinary team, and then proceed to make a distinction between "independent professional status" and "full clinical responsibility". The former is accorded to everyone in the team; the latter only to the doctor in charge. The professional responsibility of the clinical psychologist is recognised, and the committee expects to see many more referrals coming, in the future, directly to clinical psychologists from general practitioners. Another tricky topic, the relationship between clinical and educational psychologists, also comes in for com- ment. Instead of invoking any artificial solutions, in this case they are content for nature to take its course. The two disciplines should be encouraged to grow closely together, and maybe the ecological climax will be the emergence of a new dominant species, child psychology. But maybe not; the pace should not be forced. The report marks a stage in the development, both in terms of scientific and clinical achievement, of the disci- pline of clinical psychology, and should be welcomed by all members of the greater medical profession. The pres- ent financial climate will inevitably give it a cold recep- tion and one of the first rewards of its coming of age will be to find itself competing, with longer-established con- testants, for limited funds. Sometimes it is better to travel hopefully than to arrive.
Transcript of THE FUTURE FOR CLINICAL PSYCHOLOGY
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that even in the modern antibiotic era these apparentlytrivial wounds demand careful management. How com-mon they are is indicated by the fact that they comprisedalmost a quarter of all hand infections seen at the Sacra-mento Medical Center (59 out of 205 cases). In all but9 instances, a blow against the mouth had lacerated theknuckle of either the index or the middle finger. Freshcases (less than eight hours old) were explored underregional anaesthesia, and a tourniquet. The wounds wereextended for debridement, irrigated, and, if the joint hadbeen pierced, were drained with a gauze wick. A pad ofpovidone-iodine was then applied under a bulky com-pression dressing. An initial intramuscular dose of
cephalothin was followed by oral cephalexin for twoweeks. Neglected cases, and those in which a joint hadbeen pierced, were admitted after the same initiaT explo-ration, treated with warm moist packs changed four-hourly, and given intravenous cephalothin every twenty-four hours whilst in hospital. On or about the fifth daya secondary debridement was undertaken and joint cap-sule or tendon repair effected with ’Dexon’ sutures. Skinwounds were left open and the patient was discharged,on oral cephalexin, next day. Of 20 patients whorequired this intensive treatment, half nevertheless suf-fered some permanent loss of joint movement.The Sacramento workers see cephalosporins as the
antibiotics of choice- because the staphylococci whichwere most often isolated were penicillin resistant and,though sensitive to penicillin derivatives, were usuallyassociated with other organisms which were not. Thismonograph is a salutary reminder of a potentially crip-pling condition which is susceptible of control by ade-quate measures. The current British trend is away fromindwelling wicks and repeated moist dressings. For earlycases at least, a more conservative approach entailing,after exploration, frequent inspection during immobili-sation on a plaster slab, may be sufficient. It should beadded that bites in the true sense, involving soft tissuesonly and not on the hand, are less common, and run acourse not very different from that of soiled puncturewounds inflicted by other sharp instruments.
THE FUTURE FOR CLINICAL PSYCHOLOGY
LAST month the Trethowan Report,l on the role ofpsychologists in the health services,2 was published. Ithas had a long gestation, nearly five years, during whichthe topics of its deliberations have been keenly debated,and some of its recommendations have already beentried out; meanwhile the money to implement them fullyhas become increasingly scarce. The committee’s reportis paved with good intentions, but not, alas, with anygold. The numbers of clinical psychologists working inthe N.H.S. have increased considerably over the past fif-teen years, from 198 to 585 in England and Wales, butthat number is still a small one. Clinical psychology isstill in its early days, and the comments of the Treth-owan Committee smack somewhat of an early schoolreport. Psychology tries hard, shows promise, and
1. The Role of Psychologists in the Health Services: Report of the Sub-Com-mittee. H.M. Stationery Office. 70p.
2. Psychol. Med. 1977, 7, 179.
should do even better work in the future. At any prize-giving there may be a few boos from the back row,While, in general, it is claimed that clinical psychologistshave made great advances in treatment, and have pro-duced various plausible theories on which these treat-ments are based, others have commented that theseclaims are anecdotal, that the theories are specious ad-hoc explanations, and that "while the behaviour thera-pists may have stolen the analysts’ bathing suits, theyare no better able to swim." 2
The Trethowan Committee comes down firmly forbelieving that clinical psychology is a Good Thing andshould be encouraged, on the basis of its past perform-ance and present status, to make more contributions tohealth care in assessment, diagnosis, treatment, andresearch. They endorse the view that these should beextended well beyond the traditional fields of psychiatry,mental handicap, and children’s clinics. They recom-mend that psychology services should be based on anarea department, headed by a fairly senior person. Thisdepartment would cover a wide variety of different ser-vices, including general practice. Eventually, it is hopedthat such departments may exist in every district, but atpresent there are not enough psychologists to form evenarea departments. A well-organised regional departmentwill also be required, to provide some coordination, par-ticularly in training programmes. The committee recom-mends an expansion of training facilities--essential iftheir other recommendations are implemented-utilis-ing, where possible, present university-based courses.
This will demand another look at the way the studentson these courses are funded. The present system is unsat-
isfactory.The committee also looked at the vexed question of
"clinical responsibility". Much of the conflict of
opinion is due, they feel, to the different meaningsattached to this phrase by different people. Avoiding therisk of grasping a dead nettle, they first spray the hostilevegetation with that well-known all-purpose weed-killer,the multidisciplinary team, and then proceed to make adistinction between "independent professional status"and "full clinical responsibility". The former is accordedto everyone in the team; the latter only to the doctor incharge. The professional responsibility of the clinicalpsychologist is recognised, and the committee expects tosee many more referrals coming, in the future, directlyto clinical psychologists from general practitioners.Another tricky topic, the relationship between clinicaland educational psychologists, also comes in for com-ment. Instead of invoking any artificial solutions, in thiscase they are content for nature to take its course. Thetwo disciplines should be encouraged to grow closelytogether, and maybe the ecological climax will be theemergence of a new dominant species, child psychology.But maybe not; the pace should not be forced.The report marks a stage in the development, both in
terms of scientific and clinical achievement, of the disci-pline of clinical psychology, and should be welcomed byall members of the greater medical profession. The pres-ent financial climate will inevitably give it a cold recep-tion and one of the first rewards of its coming of age willbe to find itself competing, with longer-established con-testants, for limited funds. Sometimes it is better totravel hopefully than to arrive.
