From the individual to the social:The need for a new heading in clinical psychology Dave Harper
The rise and rise of individual therapy • Clinical psychology is increasingly synonymous with individual therapy (esp CBT) • There is an increasing reliance on a range of individual interventions: medication and therapy
The effectiveness of psychotherapy for most of those who receive it is no longer in doubt but neither is the fact that psychotherapy can only reach a small portion of society. Humphreys (1996, p.193) Psychotherapy lured the field into an overemphasis on individual psychology and individual-level treatment as the best approach to society’s ills and an underemphasis on preventive interventions and sociocommunity-level conceptualizations of human behaviour. Humphreys (1996, p.193)
The growth in the membership of the British Psychological Society’s Division of Clinical Psychology (DCP) from its inception in 1966
There are dangers in defining ourselves only in this way • For the profession: increased competition from other single model therapists; promotion prospects etc
Increasing medicalisation • The DSM • NICE guidelines predicated on ‘conditions’ which mirror diagnostic categories (even though their introductory sections routinely critique them) • Rise of ‘disorder-specific’ rather than ‘person-specific’ formulations • Increasing rates of prescription
The increasing expenditure on two classes of psychiatric drugs: anti-depressants and anti-psychotics (from Social Exclusion Unit, 2004).
www.equalitytrust.org.uk The links between distress and social inequality Wilkinson & Pickett, The Spirit Level
What can we do? • Although individual therapy is an important part of the tradition of clinical psychology we are trained in a range of other skills and have a wealth of experience from clinical work • Psychologists are worth the money as long as we exploit all our skills, not just the therapeutic ones. White (2008, p.847).
We need to: • Engage in more public debate about mental health (rather than just advocacy for more individual therapy and more psychologists) • Promote psychosocial explanations (rather than medical and diagnostic understandings) • Promote this approach to epidemiologists, public health, commissioners, the media etc
1. Public health approach • Pro-active research into epidemiology, not reactive and referral-led (would require more problem-specific and less categorical diagnostic research) • Examples: water sanitation in 19th century; smoking • Influencing commissioners • Influencing policy-makers • Documenting the effects of economic downturn • Speaking truth to power about the sources of distress • Helping epidemiologists develop better models • Think tanks • Setting the agenda in the media • Informal contacts
2. Preventative community-level orientation • Go to where people are (schools, employers etc) • Work with groups and communities more (esp supporting self help and peer support groups) • Working much more with NGOs and the ‘third sector’ • Helping communities reduce inequalities (example of homicide) • Need to draw together research evidence and develop further
Opportunities • 2012 Health & Social Care Act moved responsibility for public health to local authorities with a budget • From April 2013, local authorities and clinical commissioning groups (CCGs) will prepare the Joint Strategic Needs Assessment, working through the health and wellbeing board
References • 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. • Social Exclusion Unit (2004). Mental Health and Social Exclusion. London: Office of the Deputy Prime Minister. • White, J. (2008). Stepping up primary care. The Psychologist, 21, 844-847.