1 | P a g e

My relationship with Clinical Psychology

Review of Clinical Psychology 1989

MASThe Development of a Role of Associate Clinical Psychologist 2003

A College of Healthcare Psychology 1990

New Ways of Working for Applied Psychologists 2007

Grasp the future – it’s bright out there

A 15 minute update on the future for clinical psychology as seen through the eyes of Derek

Mowbray presented to the Division of Clinical Psychology December 11th 2009 Annual Conference.

Background My love affair with Clinical Psychology started at University where during my final year I

frequently supported patients at our local Psychiatric Institution – Winterton Hospital, and later I

joined Bill Revesley as his assistant in the psychology department at that hospital. I gave this up

after almost a year in favour of

NHS management, but in 1989, as

director of the Management

Advisory Service to the NHS, I

won the contract to review

Clinical Psychology, a study

sponsored jointly by the BPS and

the Department of Health. As I

had a very strong applied

research background I was

particularly concerned about the

evidence of effectiveness of

psychological interventions; a

concern that translated into the

first review of effectiveness of psychological interventions conducted for me by Fraser Watts,

and included as an appendix to the MAS Report. The MAS review conclusions were predicated

on behaviour as one of three principal influences on health and wellbeing – the others being

genetics and nutrition. It was, therefore, important to me to elevate the significance of

psychological theories and principles in relation to issues of health and healthcare. I devised the

different levels of psychological skill, knowledge and experience, concluding that level 3 skills

were those that are unique to psychologists and draw on all the available theories and principles

and apply these to the complex issues of health and healthcare. Effectively this amounted to

eclectic skills, knowledge and experience to be acquired over a period of time and not easily

taught. Level 2 skills were those needed to apply psychological interventions that could be

described by protocol. You didn’t need to be a psychologist to do this. Level 1 skills are those that

we all possess in some form and are based on common sense.

In 1990 at a joint conference of the BPS and Royal College of Psychiatrists I proposed the

formation of a College of Healthcare Psychology. The aim was to draw together psychologists

with eclectic skills, knowledge and experience to focus on the issues of health and healthcare.

Another aim was to raise the profile of psychology and for the College to be a focus for research

and its application to practice – the exemplar of the scientific-practitioner idea.

2 | P a g e

Observations and conclusions from 2009

•Professional in a non-professional world•Lost level 3 skills, knowledge and experience•Out of step with key issues•Missed opportunities•Lost identity•Not pack animals – more like cats that want to follow•Depressed

Realising that my definition of level 3 practitioner wasn’t working in practice (the idea of level 3

practitioner was virtually universally accepted, but decisions to introduce a doctorate level entry,

and a failure to market psychological practice at this level meant most continued to practice at

level 2) something needed to be done to a) capitalise on the 12,000 psychology graduates from

universities each year, most of whom were not going into clinical psychology and b) to shift the

expensive doctorate level psychologists from working at level 2 to work at level 3. With the

support both intellectually and financially from Northgate and Prudhoe Trust I undertook a study

to establish if it was going to be feasible to create an associate role in clinical psychology focused

on providing service at level 2 thus freeing existing doctorate level psychologists to fulfil their

potential of working at level 3. The result was interesting. About half of the trainees waiting to

enter training didn’t want to be a level 3 psychologist preferring instead to be a therapist

practising at level 2. The result of the study eventually translated into pilot training programmes. I

was struck, once again, at the difficulty of gaining BPS support for this initiative, even after the

DoH was lending its support. Soon after the start of the pilots the IAPT initiative emerged and

was implemented at a pace that was breathtaking to watch from the sidelines – a demonstration

of project management at its best, and interestingly, hardly involving the BPS in its progress and

implementation.

In 2006/7 I was invited to help with the New Ways of Working initiative and was asked to prepare

a vision for the future of applied psychology to health. Some of this work is featured in the final

report.

My message has been consistent – the application of the unique level 3 skills to the complex

issues of health and healthcare.

My impact has also been consistent – I have failed to persuade sufficient numbers of the

appropriate people that my ideas have legs.

Observations and conclusions from 2009. I have been profoundly disappointed that clinical psychologists haven’t realised the potential

presented to them in 1989 and subsequently. I believe the path that has been followed has

resulted in the profession being in a

worse state than in 1989, principally

by being over and inappropriately

qualified for the work that clients

expect from them. This has been

made worse recently by the failure

to persuade the Health Professions

Council that eclectic psychological

skills, knowledge and experience is

what is required to meet the

complex challenges of health and

healthcare. This failure has

consequences for psychology as a

science and for applied psychology.

3 | P a g e

The psychological challenges today – part 1

•Groupthink•Communication•Interaction •Social networking•Poverty and deprivation•Compliance with change•Demographics•Lifestyle•Environment•Scientific knowledge and advances•Technology•Expectations•Disease •People

•Wellbeing•Performance

The psychological challenges today – part 2

The psychological challenges today – part 1

Psychological culture- focused on wellbeing and performance

Psychological language – neither too simple nor too complicated

Delivery – ensuring appropriateness, efficacy, effectiveness, and efficiency

The training for clinical psychology does not equate to the role I set out for level 3 psychologists

in 1989. The move to pigeon hole clinical psychology removes the prospect of these

psychologists acquiring the skills, knowledge and experience to tackle the complex issues of

health and healthcare, which depends on the integration of theories and principles from across

the spectrum of psychological science. Level 3 practice is about the ability for consultant

psychologists to draw on their broad but detailed skills, knowledge and experience to address

complex issues. This is about applying discretion in what are, essentially, chaotic situations. This is

the core of professional practice, and if it was ever established it is now being lost.

The psychological challenges There are three types of

challenge facing clinical

psychologists. The first is the

challenge of becoming engaged

in the complex issues affecting

health and wellbeing, and

addressing these from the

perspective of promoting

wellbeing and performance.

Health policy determinants are

listed in the slide. Psychologists

have a role to play in researching

and applying research in each of

these areas, by identifying the triggers that influence wellbeing and performance. Clearly there is

need to work closely with others in the top level activities, as well as at the community level to

mitigate the impact of some of the issues on general and individual wellbeing and performance.

There is huge scope for psychologists to contribute positively in this arena, and to advise on

policy content as well as being engaged in delivering appropriate interventions on the ground.

The second challenge is to create a

psychological culture which focuses

on wellbeing and performance that

influences the ways in which leaders

in society deliver their own agendas.

Currently the UK daily cultural signals

are coloured by extensive negative

language displayed in behaviours of

threat and intimidation. The cultural

language of support, encouragement

and engagement for a virtuous

purpose appears lost.

There is the problem of psychological language – either it is psychobabble that anyone speaks

and is too simple or it’s the use of complicated words that convey meaning only to those with a

4 | P a g e

The psychological challenges today – part 3

The clients (commissioners):

those wanting a ‘quick fix’ – executives and patientsthose wanting to change the world - champions

The culture:

target driven quick fixers culture – transactionalparanoid in places

The organisation:

ambiguousstress inducing

psychology dictionary. There is a need for a new language that helps people communicate

positive messages and display behaviours related to cultural foundations of virtuous intent.

Marketing specialists seem to be brilliant at creating new language, and ensuring it is spoken.

There is the challenge of delivering psychology in a way that demonstrates impact. The closeness

of clinical psychology to the medical model and its paraphernalia such as NICE means being

sucked into adopting the same type of effectiveness rigour that medicine requires. This is a

mistake. Psychologists deal with chaos of a different kind to medicine. The infinite variation of

individual and collective response to context and their own physiology is such that a different

kind of effectiveness criterion is required that reflects individual differences rather than

similarities.

The third set of challenges relates

to the National Health Service

(NHS). Currently the NHS is the

major client for clinical

psychology. It is an organisation

that is characterised by the need

for rapid solutions to complex

problems, is target driven,

responsive to a controlled market,

and has a management culture of

bullying and harassment. The

trend of using only evidence based

interventions may be appropriate,

but not necessarily suitable to the

interventions that psychologists provide for the more complex cases. Therefore the focus on

using CBT and variants is in line with the quick fix approach, but has limitations when matched

with the huge range of complex issues that require psychological attention.

Strategic framework for applied psychology With a rather dismal assessment of the state of clinical psychology and the context in which it is

applied, I now turn to the positive and the actions that I think are needed to enable applied

psychology to thrive in the future.

Step 1 – establish the purpose of psychology applied to health

I present a strategic framework for applied psychology. This has five purposes:

To prevent psychological distress, and to facilitate psychological wellbeing and

performance.

To prevent anyone from deteriorating from the point they require psychological

interventions.

To restore people back to, and beyond, their normal level of independent life, wellbeing

and performance.

5 | P a g e

A framework for the future of Applied Psychology

Organisations (controlled communities)

Communities

Prevention

Prevent deterioration

Restoration

Palliation The ‘next generation’.

Clients

Strategies

•Groupthink•Communication

•Interaction •Social networking

•Poverty and deprivation•Compliance with change

•Demographics•Lifestyle

•Environment•Scientific knowledge

and advances•Technology

•Expectations•Disease •People

Wellbeing and

Performance

Individuals Challenges

To maintain the highest quality of life, wellbeing and performance, for those with chronic

conditions who naturally deteriorate towards death.

To prevent carers and supporters from impaired wellbeing, performance and

psychological distress

Applying this framework to my own area of interest, wellbeing and performance in controlled

communities, such as organisations, it can be seen that there is a need for a broad application of

psychological theories and principles, from those required to build positive work cultures,

building resilience and tolerance within people, to the provision of individual focused support

services for those who do suffer psychological distress.

Step 2 – establish a framework for building and sustaining psychology applied to health.

This step brings together the purpose of psychology applied to health, determinants of health

and healthcare, the culture, language and

delivery processes with the identification

of primary clients. Secondary clients are

agents who commission services on behalf

of the primary clients. With respect to the

NHS the secondary clients are

commissioners.

The overall purpose of applied psychology

within this framework is to facilitate one of

the five strategic purposes regarding

wellbeing and performance in

communities and individuals, in relation to each of the health determinants.

This is clearly a massive agenda for psychology applied to health and necessitates the

incorporation of psychologists with specialist expertise in a broad range of psychological theories

and principles. It does, however, provide a basis for a detailed strategic development for applied

psychology that addresses the key issues that affect wellbeing and performance of the

population.

Applied Psychology strategic framework

Prevention

Prevent

deterioration

RestorationPalliation

Next

Generation

A Positive Work Culturebased on wellbeing and performance

Culture

Self

Support services

To promote a Positive Work Culture based on wellbeing and performance

To manage threats to wellbeing and performance

To prevent personal deterioration in wellbeing and performance

To restore people back to their normal level of independent life and beyond

To support people with chronic psychological distress

To prevent psychological distressin support workers/carers

Prevention

Prevent deterioration

Restoration

Palliation

Next generation

Strategic framework Focus Purpose

© Derek Mowbray 2009

6 | P a g e

Step 3 – identifying the ingredients required to populate the strategic framework

The strategic framework should appeal to a broad range of psychological interests. In addition,

there will be a requirement to blend together the ingredients that make a complete service.

These include:

Research

Regulation

Quality assurance processes

Marketing

Organisation, leadership and management

Training and development

There is a requirement to include other functions, such as financial procurement, media

communications and consideration of further psychological specialisation to address specific and

growing areas of concern and interest.

Step 4 – Building sustainable organisations to deliver psychology applied to health

The British Psychological Society is a member organisation established to serve the interests of

its members.

What is required is an organisational arrangement or arrangements that marry the requirements

of clients to those of the science and delivery of psychology applied to health.

The approach is to work through the organisation development model from the perspective of

creating a new organisation. This model requires clarity of purpose, an architecture that

promotes commitment, trust and engagement; rules of how the organisation should work in

practice that also promotes commitment, trust and engagement in the workforce, and training

and development of those working in the organisation so that they may effectively achieve its

purpose.

Some ingredients of the applied psychological cake

Psychology

Psychological scientificdevelopment

Applied psychology

Academic psychology

Marketing

Training andDevelopment

Psychological therapies

?

Organisation andManagement

Regulation

Quality assurance

Cultural development

Strategic direction

More ingredients of the applied psychological cake

sleep psychology

obese psychology

travelpsychology

vacation psychology

pop psychology

ego therapy

community psychology

demographic psychology

rock’n’roll psychology

Wellbeing and Performance

psychologyservice

baby psychology

Media communications

Money

7 | P a g e

Architecture – national level

Institute ofPsychology Applied to

Wellbeing and Performance

Support toCentres for Psychological

Health andWellbeing

ChallengesClients Culture Strategies

PreventionPrevent deteriorationRestorationPalliationNext generation

MoneyManagementMedia Marketing

Quality assuranceRegulation

An Institute of Psychology Applied to Wellbeing and Performance There is a requirement to bring together the psychological theories and principles relevant to the

issues of health and healthcare with a focus on wellbeing and performance. This means drawing

together the existing results from research as well as experiences from practitioners from across

the spectrum of psychology. There is a

requirement to undertake research into

aspects of the agenda that will inform

practitioners of effective psychological

approaches and interventions.

There is, also, a requirement to raise the

profile of psychology applied to

wellbeing and performance, and to

create and sustain a ‘power house’ of

influence on health policy development

and application, focusing on the

performance of organisations,

communities and their constituent

individuals.

Still further, there is a requirement for an arrangement that co-ordinates the results of research

conducted throughout the world, so that psychologists have access to and can apply the cutting

edge science that is relevant to issues of health and healthcare with a focus on wellbeing and

performance.

There is, also, a role to be played in training and development of psychologists with an interest in

the wider issues of health and healthcare, and a need to dovetail training with existing and

planned programmes in clinical and health psychology, together with the relevant training

programmes from other psychological disciplines, particularly social and occupational

psychology.

One element of the proposed Institute is the formation of a National Institute of Psychological

Excellence, based on the idea of NICE but applied to psychology.

Centres for Psychological Health and Wellbeing At the local level there is a requirement to draw together psychologists with different special

interests to focus on wellbeing and performance within local communities, organisations and

individuals.

There is a massive agenda to address in relation to local communities, and the role of psychology

in helping other agencies address societal issues, such as obesity, teenage pregnancy, crime,

unemployment, isolation, corporate and community depression and many other topics of

concern.

Centres for Psychological Health and Wellbeing should be established as social enterprise

franchise organisations, owned by the psychologists themselves. It would be expected that a

8 | P a g e

Architecture – local levelSocial enterprise franchise

Centres for Psychological

Health and Wellbeing

Positive Work CulturesPeople in work

Community wellbeing

Community economic development and

growth

Research and development

Prevent, prevent deterioration,Restoration, palliationand ‘next generation

Personal development

People in education

money management media marketing

People at home

Positive community cultures

wide mix of skills would practice from

these centres, including psychological

therapists, alternative therapists with a

psychological focus, and nutritionalists

whose practice impacts of psychological

wellbeing and performance.

These Centres need to be established in as

many communities as possible, being a

parallel chain of Centres to general medical

practice.

Step 5 – establishing rules

The following slide shows the rules that I suggest be established to help psychology to be

appropriately applied and delivered.

In addition, there are other rules that might be necessary, those that enable commitment, trust

and engagement of psychologists with the profession of psychology. The possible subject areas

are listed in the slide, and the rules will need to be formulated with a view to developing and

sustaining a cohesive workforce situations where individuals may become isolated as a result of

changes in working practices.

Rules

Custodian and leader of psychological science, its development and its application

Incorporation of all psychological theories and principles to health

Focus on wellbeing and performance, including the prevention of ill health

Complementary to medicine where applicable

Graded levels of expertise

Educate, train and supervise psychological applications

9 | P a g e

How to play the game

Join a Mothership – a Centre for Psychological Health and Wellbeing

Join an independent family of psychologists - PsychologistsDirect

Join a Network – Strictly Psychology

Establish an Institute of Psychology Applied to Wellbeing and Performance

Don’t rely on the taxpayer for income

Other rules

Portfolio careers

Independent Professional Practitioners

Psychological businesses

CPD and supervision specialistsNetworking facility

Support services

Marketing expertise

Flexibility

Mothership

Work experienceallowances

‘rules’ that build commitment:The job

RecruitmentPay

ChallengesSecurity

Career opportunityCitizenship

TrainingDevelopmentTeam workingLife balance

In the red box in the following slide are

the topics that influence commitment,

trust and engagement, and which form

the criteria against which any rules need

to be assessed to achieve a cohesive and

committed workforce.

Step 6 – how to play the game

The final aspect of building a new

organisation is ‘how to play the game’ or

the training, development and personal

focused activities that need to be in place to enable the new organisation to work in practice.

The assumption here is that psychologists

will migrate from the security of a single

employer to being independent

practitioners wishing to engage with

others in the delivery of the strategy

outlined earlier.

There are four elements of this game –

working from a Centre for Psychological Health and Wellbeing as the basic Mothership

for psychologists

working with the Institute of Psychology Applied to Wellbeing and Performance

joining together with other independent practitioners and offering independent services

through PsychologistsDirect

joining a network of psychological support called Strictly Psychology – a place where all

professional and many social needs of psychologists will be met.

10 | P a g e

Derek Mowbray is visiting Professor of Psychology at Northumbria University and Director,

OrganisationHealth, the Stress Clinic and PsychologistsDirect.

www.orghealth.co.uk www.the-stress-clinic.net www.derekmowbray.co.uk email: derek.mowbray@psychologistsdirect.org

In 2012.................................

Psychologists will have a development strategy based on wellbeing and performance needs of the UK

Psychologists will have an Institute of Psychology Applied to Wellbeing and Performance

Families of Psychologists will be practising fromCentres of Psychological Health and Wellbeing

Psychologists will be getting their needs metfrom PsychologistsDirect and Strictly Psychology