New roles in psychology

Contributions to a vision of psychology applied to healthA written monologue 16th July 2006

Derek Mowbray

DRAFTIn confidence but for discussion (in other words keep it close

to your chest but chat about it to people you can trust)

This is a personal reflection of the workshop held on 13th July in Birmingham as part of the work of the new roles working group which is part of New Ways of Working for Applied Psychologists

WHERE TO START?

We started with Thomas McKeown and his description of influences on health and wellbeing in his book The Role of Medicine (1976).1 In this he identifies genetics, nutrition and behaviour as having significant influences on health and wellbeing. This had a profound influence on my own thinking about the role of psychology in our lives and how aspects of psychological science could be applied to the issues of health. The complexity surrounding defining health is made more difficult by the dominance of the medical interpretation of illness, and the resulting definitions which have been consistently ascribed to classifications. In the end, health is about feeling well or wellbeing. Our own personal levels of tolerance of illness will manifest themselves in ways we describe how we feel. An objective measure may reveal we are, de facto, suffering an illness, but we feel OK about that. Psychological wellbeing may be more difficult to define as it is about the ability the respond positively to events; in effect, to survive.

So far, then, we have come up with some influencing features – the idea of survival, and acting positively. It is an essential aspect of living that there is a drive to survive. Only when all options for survival have been exhausted do we tend to accept the inevitable and not survive. Up to that point there is a strong driver to survive. BUT is there a strong driver to prosper? In today’s society in western Europe it is a question of surviving and prospering. Unlike other societies where the imperative is to survive, we tend to accept that survival is a given, but prospering is something that requires energy. So, our society accepts the basic levels of survival, but we want more. We want people to feel positive, live in harmony, embrace different experiences and cultures, contribute to society at large and specific communities. We expect people to be understanding of different points of view, to become engaged in the growth of communities, to contribute to….anything. The giving of ourselves for no personal gain is altruism. Altruism is rare – what we seem to be doing is giving of ourselves for personal gain – contributing because something positive will happen to us; this reciprocity of giving and receiving may be a key to unlock the door to prosperity.

1 McKeown, Thomas. The Role of Medicine – Dream, Mirage or Nemesis. The Rock Carling Fellowship 1976. NPHT. 1976.

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Our interpretation of wellbeing is influenced by these matters. Psychological wellbeing will have as the baseline the psychological strength to survive AND prosper. Where prosperity is in doubt we will intervene. Our social interventions start at birth and continue for life. Our health interventions start with birth and continue for life. Our psychological interventions start when someone suggests it may be a good idea to chat to a psychologist. Yet where does all the science about attachment theory, about gender influence in upbringing, about the fascinating issue of available time to learn (instead of listening to family rows and the TV) come from? It comes from psychologists.

Another feature is the criterion against which wellbeing is judged. As survival is finite, prosperity is ambiguous. The criterion for judging prosperity comes down to a criterion based on personal expectation. I expect a happy family life…is ambiguous, but could be made more finite by establishing the expectations of those involved in a systematic manner which reveal their genuine expectations. If their expectations are hovering around the survival level, then we can suggest expectations which imply prosperity.

Psychological wellbeing, then, has something to do with moving forward towards something, not simply surviving. On this basis, encouraging people to move forward will provide psychological wellbeing and, by implication, positive health.

PSYCHOLOGICAL CULTURE

Culture is represented by clustered values, rules, symbols, myths, history, stories and anything else which people find influential in their lives and working lives. Research in this field discovers interesting items such as common language, folk culture represented by songs, dress, behaviour. Some personality assessments, such as the California Personality Inventory (CPI), are based on the idea of folk personalities.

A psychological culture might be one which focuses on the individual ability to move forward. The USA culture is psychological – the land of the free where you can achieve anything you want. Not bad for a country where all kinds of intolerance is accepted as the norm.

A psychological culture might be one which honours and respects the individual. In this context the Chinese culture respects the old, accords them with a special place in the family, and, to a certain extent, revolves their family lives around them. Recent headlines in UK press would suggest that there is little respect for the vulnerable elderly here.

A psychological culture might be one which honours and respects differences and absorbs the notion of the whole being greater than the sum of the parts. My own blood family is constituted of English, Scottish, Jamaican and Canadian born. With their interests in world affairs my daughters currently inhabit China and Africa, and their close friends include Chinese, Polish, Indian, French and German born. The mix of experiences and backgrounds contributes immeasurable benefits to their lives and would appear to provide them with a degree of confidence I haven’t yet discovered.

If we are interested in promoting a psychological culture we will need to establish the principles on which a culture will be formed. This will be seen as social control, but it is no more, nor less, than the social control exercised by individuals who invoke the use of national resources through their own actions, thus depriving the rest of society

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the opportunity of using the same resources for other purposes. Smoking springs to mind.

One way into this is to take the determinants of health policy and declare that a psychological culture is being developed around influencing positive outcomes in relation to the critical health issues facing this community today.

LANGUAGE

We were pondering the relative failure of psychology to make a mark on how health can be improved, in particular, a failure to grasp the sheer power of psychology in influencing wellbeing and health.

Two influences were discussed. One was the lack of courage of psychologists to stand out as champions of a science which could make a difference to many. The other was the simple, but complex issues of language. Simple because language is a subject most people understand – it’s what distinguishes us from other species, and helps to create cohesion. It is complicated because psychological discourse can be in simple and complex language. The simple language makes psychology seem like common sense, and can support the idea that everyone is a fully developed psychologist. Semi-complex language (the kind of stuff one of my close friends records and berates me with when we meet – like “direction of travel” or pro-active or psychodynamic). This is seen by my friend, at least, as psychobabble and instantly dismissed as words from a lesser being. He’s a lawyer and has no legs to stand on, but when has that stopped a lawyer? The complex language can exclude others from understanding, and can sometimes (often?) create the hilarious situation where someone is speaking complicated psychology to an audience that hasn’t a clue what she is talking about. And that could be in a court room.

What we need is a psychological language to go along with the psychological culture. To me the language needs to be robust and not fluffy; it should be strongly identified with moving forward, overcoming things, producing personal satisfaction, peace of mind, providing confidence – an assertive type language, but not macho; a language of depth, not superficial; a language of warmth, not distancing; a language of encouragement. Somehow it has to be distinctive from the language of the clergy.

AWARENESS OF PSYCHOLOGY

The idea that everyone is a psychologist is true, but there are limitations placed on the untrained and uneducated psychologist about which the general public is probably unaware. Put bluntly, a medic can chop out something and the patient goes home OK and grateful. A psychologist cannot do this in quite the same way, although there are plenty of illustrations of the public being grateful for the services of psychologists; it doesn’t seem as immediate.

Although CBT is now gaining stardom status, and there are interesting media depictions of psychologists as profilers and being forensic, there is a need to raise the awareness of the public of the benefits and contributions which the science of psychology makes to the wellbeing of society and the understanding of events.

Over the recent past there has been a drive for scientists in general to communicate effectively with the public. This must be equally important for psychologists and social scientists. The public is influenced by the media; the media controls the public’s agenda. This is a specialist area, and could become a new role.

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HOW DOES PSYCHOLOGY INTERVENE?

I developed the model of strategic purpose about 12 years ago in Ireland. I was doing the makeover of Cork Regional Hospital and its services at the time, and trying to engage as many senior staff as possible in deciding what the hospital and its services should do. There were many and varied outcomes from that two year piece of work, but the most obvious was the change of name to reflect the purpose of the hospital as a teaching and research institution. The model has been used regularly since, by many people around the world, and has stood the test of many applications.

There is a huge role in prevention. If Thomas McKeowen is to be believed then behaviour has a significant influence on the wellbeing and health of the population. By intervening early in the processes of personal development, wellbeing and health, there is a prospect that behaviour patterns will follow those which lead to health and wellbeing. As mentioned earlier social care can intervene at birth; the same with medicine, yet psychology isn’t there seeking to ensure the psychological wellbeing of mother, father and child, together with providing the support needed to start a life in a direction leading to health and wellbeing. As school age approaches, the role of psychology in interaction, learning, behaviour, assessment for potential as well as for developmental factors, diagnosis, and general family support is well established but not widely available.

On a wider scale, the inter-relationship between systems, organizations and policies have a direct impact on the potential of the individual to survive, thrive and prosper. The link between employment and wellbeing is now established; the link between family integration and wellbeing is, also, reasonably clear; the link between poverty, employment and wellbeing has been established for over twenty years. A role for psychology in this mix of tensions is to provide the coping ability to transform a reaction of helplessness to one of survival and prosperity.

As children move through adolescence we know there are particular risk situations. Apart from the lifestyle issues of sex and booze, there are the complex issues of adolescent boy suicides, and girl anorexia. Logic suggests that some kind of trigger exists for these two painful experiences, for which psychology should have some kind of answer or at least hint from which active intervention at some stage might be possible.

The empty nest syndrome can plummet people into depression. Just as mothers might be considering a return to employment they are plunged into a sense of helplessness, both in terms of being equipped to work once more, and in emotional terms having entered into a bereavement process because of their children leaving home. The impact of this on the economy may be known to others, but with the rise in the numbers attending universities, and the shrinking of the employable population size, with the increasing numbers of dependants on the State, the performance capability of mothers at this stage in their lives becomes an issue for psychologists.

The idea of preventing deterioration comes from the notion that once anyone is in contact with a professional service, that service would have the purpose of preventing any deterioration in the condition or reason for being in contact. The antithesis of this is for people in need to be in contact with a service and then be placed in a queue to be supported at some later stage. There is little point of being in contact with a service only to have to wait a further period for attention. If someone acted in this way in a shop, the customer would probably cry with frustration or leave

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and go elsewhere. In health terms this delay can be fatal. If I hadn’t insisted that my wife go to her GP, and he hadn’t had a dermatological house job in his career, and if the Frenchay team hadn’t operated within a week, that nasty melanoma might have taken its toll. As it was it was five years of absolute misery. But she didn’t deteriorate. She got better and returned to being a mother and eventually work, and her actuarial insurance assessment is now better than mine.

Preventing deterioration should be a significant purpose for psychologists. Does it matter that those in need wait? For some physical conditions it may not. There are some orthopaedic conditions which can wait, but not many and the wait shouldn’t be too long. Those with cataracts used to be asked to wait until the cataract was ripe, but now cataracts can be blasted early with a better outcome. In psychological terms there should be no wait. Anyone in need is in need at the time they identify themselves or are identified to be in need and the sooner they have support the sooner they can get back to their ordinary lives. Crisis intervention is a description of services which are invoked under certain circumstances to ensure early intervention in a situation to prevent further deterioration. The term, however, suggests an exceptional situation requiring an exceptional response, whilst I would argue that many events require a prevent deterioration response, not the few.

For psychological services there may be no such thing as ‘an event’ which triggers a response. The active surveillance of people which is offered to communities of people at risk to medical deterioration may have application to people at risk of psychologically based deterioration. There are many such groups or communities – teenage girls at risk of sexual ill health highly influenced by the levels of respect teenage boys grant to girls; teenage boys at risk of suicide; people from fragmented families; partners of people with illness; people working in poorly designed organizations and jobs; the growing old, and so on.

Restoration has the purpose of restoring people back to their normal level of independent lives. This strategic purpose is the more common of all the purposes, and is the basis for much of the acute healthcare provision. The application of this strategy tends to result in highly resourced services with the expectation that individuals will be diagnosed and treated quickly. The results of the application of this strategy will be obvious – either a successful return to normal independent life even if this means accepting a level of independence which is less than prior to the event, or a failure and the individual succumbs to the event, or a referral into the chronically dependant strategy where the individual is unlikely to return to their normal level of independent life and will deteriorate towards death at some stage in the future.

There may be a need to examine in greater detail those psychological interventions which fall within the framework of this strategic purpose. Much of psychotherapy is applied to those who have experienced an event of some kind and need interventions to return to a state prior to the event. The push to expand psychotherapy provision may be seen within this strategic purpose, whereas it should, perhaps, be seen within the prevent deterioration strategy, emphasizing the immediate and earlier need for service to prevent decline, as well as being an intervention once decline has occurred.

Palliation is a construction which reflects the purpose of providing services to maintain the highest level of independent life knowing that the individual concerned will deteriorate towards death regardless of the intervention of anyone. Some may argue that a significant amount of psychological service can be found within this strategy. Whilst this is of importance, it does raise a question concerning the utility of psychological interventions if a significant proportion is applied to this strategy in

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favour of other strategies. It may be a matter of perception. Normal independent life for someone with a certain level of learning disability is different to that for someone with no learning disability. Both have a normal level of independent life. Some people’s normal level does change. A catastrophic event such as a stroke can place someone into a different normal group. They may not be deteriorating towards death other than from natural deterioration. They become someone for whom preventing deterioration becomes the strategy of choice, not the strategy of palliation.

The ‘next generation’ has the strategic purpose of preventing carers from requiring any of the services within the previously described strategies. This is a particularly vulnerable group of people, and includes those who care for others throughout their entire life, to those who care for others during an intense and difficult but acute period of life. Interestingly this strategic purpose has been uncovered recently by Government that is now developing policies to assist carers. The psychological challenge for carers is immense. It includes the loss of their own independent life, the development of altruism, the need for skills, knowledge and experience of caring, the development of coping strategies, and, of course, practical help.

THE APPLICATION OF STRATEGIC PURPOSE TO THE DETERMINANTS OF HEALTH POLICY

Demographic changes includes the growing old, and the increasingly rich mix of cultures. The mix of cultures requires consideration in terms of encouraging pluralism, or the notion of multi-culturalism, or silos, or ethnic enclaves, or religious communities. Psychological theory and principles has much to contribute to the understanding of the issues behind a suitable social policy regarding a pluralistic society and the embracing of diversity. Psychological theory and techniques will assist with the implementation of such a policy. This subject area, together with the issues of growing old, is, perhaps, a major challenge for an island, and psychological intervention to prevent conflicts between groups and communities and to enhance diversity in the workplace and communities is a new role.

Globalisation raises anxieties over issues of power of major corporations. Globalisation also brings people together from diverse backgrounds, and maintains communication between people at the level never experienced before. For psychologists this means a global science, as well as the challenge of applying the science globally to the positive and negative aspects of globalization. A global psychological culture might be a place to start, where psychologists let it be known how they see the development of the world, and how their assessment might lead to greater wellbeing for more.

The influence of disease is a health policy determinant perhaps most obviously connected with bird flu which has produced a policy which has enabled huge resource to be pumped into the pharmaceutical industry on the back of a prediction of a pandemic. Medical science has proved immensely powerful. What about psychological power? We have the opportunity of observing and commenting on the implications of patterns of behaviour amongst different communities and how this affects the notion of health; we have the effects of developments in genetic definition of causes of illness and behaviour. Once more it is in the strategy of prevention where psychological interests could develop.

Public expectations seemingly do not include a psychological culture. There are expectations that raise the demand for services, and the increasing use of psychological therapies might be a result of this, suggested by an economist. It is this interest in psychological wellbeing by economists and other financial orientated

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people that may help psychology have a greater impact on society as a whole. It can be predicted that insurance will increase its influence on the provision of services, and that insurance companies will become progressively more robust about the analysis of risk. Public expectation towards psychology might, therefore, move in favour of supporting any initiative which lowers the premium costs of insurance. Insurance companies will, in turn, be keen to ensure that payment to people is limited to those who have followed all the requirements to mitigate risk. A scenario can be health maintenance organizations funded by insurance where the provision of services focus on prevention and preventing deterioration, and payouts made to people who have sought to prevent possible events themselves. Second level national restoration services may be provided by the public purse, whilst top level restoration services may be provided by insurance companies to those members who have done their best to reduce their own risk. Psychological services could have a close link to insurance companies, and this development may suggest a new role.

Technology has a significant impact on health policy. Not long ago I took the chief executive and his deputy from North Western Health Board in Ireland to the Mayo Clinic and Abbott Northwestern Hospital, both in Minnesota, as part of my mentoring scheme for chief executives. At Abbot Northwestern my mentee subjected himself to a prophylactic MRI which showed his heart and vascular system to be in perfect shape. When he returned home he published the scan in their newsletter stating that this chief executive was in excellent health and unlikely to resign due to stress or anything else over the coming few years. Armed with this knowledge he played a central role in the recent Irish Health Services changes, retired at 50 and is now a property developer. It was an amazing use of technology. It is paid for by insurance companies. The use of screening techniques is set to expand, and the subject of screening for psychologically based conditions is a development waiting to explode. Even I am in on this. I am developing an organizational health screening tool measuring degrees of commitment, trust and strength of psychological contracts, in order to provide insurance companies with an idea of the likely risk of levels of stress within companies. This will have a direct impact on the level of premiums paid for Employee Assistance Programmes and the expected costs of providing such services. The development of screening, the use of technology in screening, on line assessments and protocol driven therapy is where a new role might be considered.

Scientific advance and new knowledge from a psychological perspective requires attention. In his article Peter Watson2 exposes the relatively poor development in the science of psychology when compared to some physical sciences. Even worse his use of language makes fun of the attempts of psychology to try and be a science. I love the article, and keep it in the back of my mind constantly. However, it raises issues which need addressing. At the moment the only big hitting scientific advance in psychology that the public can see is CBT because an economist says so. The fact that I cannot explain to my younger daughter why she is severely dyslexic, with all the trappings which go with that, as assessed by one psychologist, and yet told by another psychologist that the condition doesn’t exist when letters fly about in front of her, is a sever embarrassment, and hasn’t helped me in my cause of being an ambassador for psychology. I worry endlessly about the growth in counseling as a strong psychologically based delivery process when there seems to be little evidence of effect to support this particular delivery process compared with normal interaction. I scream at commercial sessions where new leadership assessment instruments are presented that claim everything with no evidence that even the basic question has been addressed – what is leadership? (In this particular session I asked the guy who developed the instrument (LDQ) whether the application of the instrument would

2 Watson, Peter. Living in a dream world: analysis The Times 15th May 2003. Page 8 Times 2.

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draw out the leadership characteristics of the players in a court of law – my thinking being that leadership characteristics reside with the barristers who have to have all the transformational skills available to them to encourage the jury to go along with him/her whilst the judge has no need for any leadership skills as he is merely administering regulations and the law. The guy didn’t think the instrument could draw out that distinction, and, hell, he hadn’t thought about that!). There are moments when I resort to the fabulous Taylor and Novaco3 book on anger treatment, not only because it’s a good read, but because it is what psychology is all about for me.

I am surprised about the relatively slow progress in R&D. The whole shift towards creating doctors of clinical psychology and now doctors of other kinds of psychology was partly to encourage and develop the science. The scientific practitioner idea is one which has enormous strength if it were true. Yet, the impact of psychological science on the public is not obvious. OK, we see the results in the marketing strategies of companies, and we know of the results in many walks of life, but the fact they come from psychological science is not obvious – whereas taking a pill is clearly chemistry and pharmacology, and a building is architecture and engineering and so on. We need to have a look at R&D psychology roles.

The same is said about the environment. The link of the environment to health and wellbeing is becoming clearer as the planet comes under threat. Yet we are not good at being compliant with the ideas needed to conserve our planet and survive and prosper into the future. There is a role for psychology here, which is linked to the psychological culture, and the psychological language that are needed. We may need to travel to Scandinavia to find out the triggers which enable their societies to take societal issues seriously, and how measures are implemented, and why everyone seems to comply.

Part of the social environment is the lifestyle we adopt. A long time ago (20 years) Charles Handy (the whizzo from London Business School), in a lecture, predicted a society where we worked half the time, had portfolio careers, increased our leisure time by a half and had greater disposable income. Everyone would be gainfully employed and life would be good. If any of this has come about we seem to be suffering as a result. The current trend of reporting high levels of binge drinking, substance misuse (or avoidance therapy) combined with the increasing incident of STDs in the young, combined with a relatively high unemployment level amongst the employable age, with a higher than ever level of debt, including the atrocious phenomenon of creating debt for students without providing a real choice in the matter (OK, OK buying higher education is the norm in some other countries, but also in other countries the level of fund raising is way beyond anything we experience and not every country has a policy that 50% of school leavers should proceed to higher education and consequently get into debt) and the equally atrocious policy of PFI initiatives which place our children’s adult society in debt without their consent, are all contributing to a bleak context for creating motivation to tackle big issues. One of those big issues is the balance between revenue creating and revenue spending people, and the inbalance which is in favour of the revenue spending people in the future, resulting in a pensions problem, and many others besides. How can anyone have a sense of wellbeing under these circumstances?

It is possible to think of a psychological culture where those who dream up ideas for our society dream them up in a context which asks questions about the impact of ideas on wellbeing and health; where the discussion is around what is good for the

3 Taylor, John L. and Novaco, Raymond W. Anger treatment for people with developmental difficulties – a theory, evidence and manual based approach. Wiley & Sons Ltd. 2005

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health of people and what could prevent people from suffering unacceptable levels of gloom, uncertainty, and consider ideas which enhance our mood, and general sense of purpose.

We have a divide between poverty and relative prosperity in economic terms. There is a link between poverty and health, and there is a link between poverty and low birth rate, lower life expectancy, lower employment levels, higher levels of infection, higher levels of fractured families with the perverse consequence of larger extended but fractured families without the binding culture, although these cultures are present around the country but are not dominant. We have a general state of poor commitment and trust in societies institutions and services, maybe partly created by the press, but potentially destabilizing amongst the poorer people whose motivation and aspirations are currently limited and where individuals have to possess enormous energy and determination to break out. There is a role for psychology in all of this. I am reminded of the times I have traveled in Malaysia where each morning the national newspapers carry a positive message to the people of Malaysia from the Prime Minister. In a potentially volatile pluralistic society there is now a calmness. What strikes me most is the positiveness of the ordinarily people – and no, I have not only been a simple tourist.

MY ROLE

My task is to identify a vision for the development of new roles. I have agreed to try and place the vision into an OD model, and I will use my own which addresses purpose, architecture, rules, and how to play the game.

I need more time to consider the vision ideas and to get some response to these ramblings, but there are ideas around purpose, psychological culture, language, raising awareness and consciousness, creating a strong and relevant R&D function which expands the science, generating confidence amongst psychologists leading to courage, generating strong psychological contracts between people, focusing on prevention and preventing deterioration and carers, encouraging the use of proven techniques but being responsible for their safety, integrating psychological theories, principles and practitioners, and integrating training and development rather than fragmenting these. The development of the eclectic genuine consultant level practitioner whose skills, knowledge and experience is recognized as essential in discussions affecting people; the creation of a career pathway which produces the genuine consultant; the creation of a career pathway that produces the practitioner of techniques who can also choose to become the genuine consultant.

For a number of years I have been keen to see a College of Psychology applied to health established, in recognition of the many and varied psychological interests in health. These days, the divisions in the BPS, their lack of logic (to me), and the blatant self interest of different factions within psychology together with the need to focus on huge and significant issues for psychology and psychologists suggest that the only place where the serious business of development and change can take place is inside a College, or as I now think, an Institute for Psychology Applied to Health, linked academically and funded by government, business and subscription.

CONCLUSION

This is a reflection of the workshop held on 13th July in Birmingham as part of the new roles project group.

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The next step is for me to distill from this and other comments a paper within an OD framework which could be used as a basis for further development within the working group.

Derek Mowbrayderek.moqbray@mas.org.uk

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