Clinical psychology comment

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We can do a power of good

Many clinical psychologists welcome the draft mental health bill because it would give them more power, enabling them, for example, to prevent the use of ECT or the over-medication of patients, argues Peter Kinderman. Moreover, he says, it's time clinical psychologists stopped clinging to the myth that, presently, they have no power.

April 11, 2005

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Many psychologists now know about the proposed revisions to the Mental Health Act 1983 and the implications for their profession. The situation, of course, changes daily, but the current position is this: the 2004 draft bill was scrutinised by the House of Lords House of Commons Joint Committee on the Draft Mental Health Bill. The committee produced its report on 23 March. The Department of Health now has 60 days (plus the election campaign) to respond. The committee agreed with all the recommendations of the British Psychological Society for amendments to the bill - but we shall have to wait to see how the Department of Health responds.

By a happy coincidence, Health Minister Rosie Winterton addressed last month's BPS Annual Conference. Although she was unable to answer whether the Department of Health would accept the recommendations of the scrutiny committee, some things are clear.

First, assuming we have a Labour government after May 5, it is almost inevitable that the bill (hopefully following revision) will be tabled with a view to it becoming law with a high degree of urgency.

Second, it is clear that psychologists will be given new powers in respect to compulsory treatment. We can be sure of this because (a) we are fully engaged with discussions about the selection, training and accreditation of 'clinical supervisors', and b) the scrutiny committee endorsed the government's plans in this respect: "Psychologists possess the competencies [of a clinical supervisor] and it is true to say that "the clinical actions of psychologists cover the breadth of mental health problems, and certainly all of the so-called categories of people that fall under the Mental Health Act"."

One detail is still unclear. The bill, as drafted, distinguishes between 'examiners' (the people who make the decision to use the law in the first instance) and 'clinical supervisors' (who will receive the patient, draw up a care plan etc, including the decision to continue to use the law). At present, the examiners have to be 'registered medical practitioners', whereas psychologists may be clinical supervisors.

Nevertheless, we can be sure that psychologists will soon have powers under a new mental health act. What will this mean for psychologists and for patients?

Many psychologists welcome the new roles proposed. We have a distinctive view on the nature of and appropriate societal response to 'mental disorder', as the bill terms personal distress. The 1774 Madhouses Act reformed the provision of services for 'lunatics'. Prior to the 1774 Act, people had been 'cared for' by the local civil authorities, with genuinely dreadful consequences. The 1774 Act gave responsibility for care to the Royal College of Physicians, through the licensing of London's madhouses. This resulted in genuinely better care for the individuals, but it instantiated two massive (worldwide) concepts: that 'lunatics' are 'ill' and that doctors should care for them.

And my point is that the law dominates mental health policy. It may be the case that policy - within the Department of Health, the National Institute for Mental Health or the NHS more widely - has shifted towards multidisciplinary care. But I would suggest that legislative framework is a necessary forum for major societal change.

David Smail (1993) argued that: "What makes [psychologists] different from other professions in the field is ... [that we] … can't lock them up; we can't drug them or stun them with electricity; we can't take their children away from them. The only power we have is the power of persuasion and this ... more or less forces us into an attitude of respect towards our clients." (Smail, 1993, pp 12-13).

I disagree. I think that what makes us different from other professions is that we have a different - a strikingly different - framework of knowledge, understanding and skills. Many psychologists are frustrated that a - I'll say it again - strikingly different framework of medicine, diagnosis, treatment, physical treatments, dominates the mental health care agenda. So many psychologists see the proposals for a new Mental Health Act as a major step forward for services as a whole.

In this context, it should be noted that (a little noticed element of the proposals) the new bill would represent a radical shift in this direction. Whereas the Mental Health Act 1983 gives 'registered medical practitioners' the power to 'treat' people under compulsion, the 2004 draft Mental Health Bill would give a clinical supervisor the powers to draw up a care plan which must be multidisciplinary in nature and then to implement that plan. The law, of course, relates to the disagreeable issue of compulsion, but the conceptual framework is, I believe, what we need.

And many psychologists welcome the prospect being able to influence the package of care in individual cases. I think it would be wrong to over-emphasise the level of dispute and contradiction that occurs between psychologists and other professionals in psychiatry. But equally my impression is that many psychologists would relish positions that gave them greater leadership, influence and - yes - power within the system. We have, of course, not been here before. But my speculation about how individuals' packages of care could develop would include a refusal (by a clinical psychologist as clinical supervisor, and therefore with legal authority) to sanction ECT, polypharmacy and prescriptions over BNF - British National Formulary - limits, conversely legally-binding demands for the inclusion of psychological, social and occupational elements into care packages, wider consideration of social and psychological issues in the considerations of the criteria for compulsion, and a different set of assumptions.

This last point refers to the diagnosis / treat model currently sanctioned by the 1983 Act. I suspect that, in a few years time, psychologists acting as clinical supervisors will be questioning (I repeat, with legal authority) why a care team is trying to 'treat' hallucinations in a person who has been considered in need of hospital treatment not because he has started hallucinating, but because his self-care had dropped dramatically. In such a situation, I suggest, patients are more likely to find that care plans will meet their personal needs, and less likely to meet the spurious demands of the medical model, if the clinical supervisor is a psychologist.

So I believe that patients will see better care under this proposed bill, with this proposed care plan, with these roles for clinical supervisors and with psychologists in that role. One, cynical, response is to see patients as pawns in a game of power and pay between psychiatrists and psychologists. By that analysis, psychologists either want powers under the Mental Health Act because they are prepared to sacrifice others for their own advancement, or are naive as to the consequences. I prefer to believe that the public, patients and my employers desire my skills and my conceptual model because they are right - just fundamentally correct, effective and moral. By my analysis, the competencies of psychologists benefit patients and will benefit patients held under compulsion. I believe that psychologists will ask questions and make conclusions based upon a fundamentally more appropriate and humane system.

So are there any costs? Definitely. I remember visiting a young person's inpatient mental health unit, on which most of the patients were children treated under compulsion. There was a display board containing photographs of all the staff members - social workers, teachers, occupational therapists, psychologists and psychiatrists. In each case a happy, smiling face … except for the psychiatrists, whose faces had been obliterated by being scratched out with some sharp implement. I strongly suspect that this is because those individuals are seen as the 'enemy', and that psychologists who end up becoming clinical supervisors will attract some hostility.

But I do not believe that psychiatrists 'section' people because they (the psychiatrists) are power-crazed oligarchs. I think they do their jobs because no-one else will, and because they genuinely believe medical care can help. Well, I believe psychological care can help.

And, finally, there is the issue of power. It is, I believe, an error to believe that we as psychologists have no power. We clearly - for all sorts of socio-economic reasons - have much more power than our patients. I think it is a fantasy to relish our powerlessness - because that would be to luxuriate in a myth. Rather, I believe I should use what power I have, as well as whatever skills and education I have, to help people. And, in this case, that means wielding the powers of the Mental Health Act humanely, wisely, cautiously, but also assertively.

References:
Smail, D. (1993). Putting our mouths where our money is. Clinical Psychology Forum, 61: 11-14.
Mental Health Act 1983
Government's draft mental health bill
Joint Committee On The Draft Mental Health Bill Report, 2005
1774 Mad Houses Act

* Peter Kinderman is honourary consultant clinical psychologist for Merseycare NHS Trust, professor in clinical psychology at the University of Liverpool and chair of the British Psychological Society's division of clinical psychology

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Is clinical psychology to be caring, empowering or autocratic?

Comment from: Phil Barker, professor of health science, Trinity College, Dublin, Ireland.
Date: April 13, 2005

I was delighted to read this consideration of the possibilities for using legislation as a lever for constructive, potentially (if long-sighted) empowerment of people with the kind of serious problems of living that bring them under the lamp of the 'mental health act'.

As a longstanding opponent of coercion (in all its guises) and the medicalisation of 'problems of living' as 'mental illness', I congratulate Peter on a fine piece of pragmatic rhetoric. I hope that his burgeoning clinical psychology workforce are worthy of his valuable leadership.

My only reservation relates to the assumption (presumption?) that clinical psychology is anywhere near a unanimous profession.

Having spent much of my career in close proximity to clinical psychologists I guess I have had a better opportunity than most to appreciate the family dynamics of the psychology household; especially how envious many psychologists have been of the power base of their (often less able) psychiatrist colleagues. This has been evident in the US with the widespread scramble for prescribing privileges. In that context, I guess that I remain suspicious that some clinical psychologists will crave 'power' for the same (unfortunate) reasons that mental health nurses crave this ersatz (but well-accepted) form of psychiatric authority.

I hope that at some point in the near future, Peter might discuss how broad is the church of clinical psychology.
Currently, I suspect it is probably a close reflection of the Church of England. Whereas gay marriage and women priests might endanger the artificial 'unanimity' of the Church of England, perhaps the deconstruction of David Smail's (rose-tinted) perspective on clinical psychology practice, through legislative means, might lead to a clarification of what it actually 'means' to be a clinical psychologist; what is/are the ideological affiliations of the individual psychologist practitioner; and where (exactly) psychology stands on the continuum of the helping professions - from empowering/caring/ helper through to controlling/autocratic advisor.

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It's best that doctors have responsibility for care

Comment from: David Bowker, retired psychiatrist
Date: May 10, 2007

I find the comments of Peter Kinderman worrying. Just taking the point about a patient suffering "hallucinations" and demonstrating "poor self care". Neither of these are diagnoses and therefore no doctor would try and treat them. They can be the symptoms of various medical or other conditions, and an accurate diagnosis will enable that condition to be treated.

Even with considerable more training in this field than non-medical professionals such as psychologists or nurses, doctors still make mistakes. I would wish my care to be in the hands of someone best able to make an accurate diagnosis or formulation of my predicament,and who has a wide knowledge and experience of the possible options for treatment.

One further point, ECT and medication are normally treatments accepted voluntarily by patients, and therefore a clincal supervisor is not in a position to refuse a patient their wishes for treatment if this is medically advised, and in any case the tone of the remarks made by Peter Kinderman do not seem to reflect the sort of multidisciplinary working I have ever experienced, or would to hope to encounter.

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