Grasp The Future


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A presentation to the Division of Clinical Psychology 2009

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Grasp The Future

  1. 1. 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 My relationship with Clinical Psychology director of the Management Advisory Service to the NHS, I won the contract to review Review of Clinical Psychology 1989 Clinical Psychology, a study sponsored jointly by the BPS and A College of Healthcare Psychology 1990 the Department of Health. As I had a very strong applied The Development of a Role of research background I was MAS Associate Clinical Psychologist 2003 particularly concerned about the New Ways of Working for Applied Psychologists 2007 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. 1|Page
  2. 2. 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 Observations and conclusions from 2009 worse state than in 1989, principally by being over and inappropriately qualified for the work that clients expect from them. This has been •Professional in a non-professional world •Lost level 3 skills, knowledge and experience made worse recently by the failure •Out of step with key issues •Missed opportunities to persuade the Health Professions •Lost identity •Not pack animals – more like cats that want to follow Council that eclectic psychological •Depressed 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. 2|Page
  3. 3. 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 The psychological challenges today – part 1 psychologists. The first is the challenge of becoming engaged •Groupthink in the complex issues affecting •Communication •Interaction health and wellbeing, and •Social networking •Poverty and deprivation addressing these from the •Compliance with change •Demographics •Wellbeing perspective of promoting •Lifestyle •Environment •Performance wellbeing and performance. •Scientific knowledge and advances •Technology •Expectations Health policy determinants are •Disease •People 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 The psychological challenges today – part 2 psychological culture which focuses on wellbeing and performance that influences the ways in which leaders Psychological culture- focused on wellbeing and performance in society deliver their own agendas. Psychological language – neither too–simple nor too complicated The psychological challenges today part 1 Currently the UK daily cultural signals are coloured by extensive negative Delivery – ensuring appropriateness, efficacy, effectiveness, and efficiency 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 3|Page
  4. 4. 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 The psychological challenges today – part 3 major client for clinical psychology. It is an organisation The clients (commissioners): that is characterised by the need those wanting a ‘quick fix’ – executives and patients those wanting to change the world - champions for rapid solutions to complex The culture: problems, is target driven, target driven quick fixers culture – transactional paranoid in places responsive to a controlled market, and has a management culture of The organisation: bullying and harassment. The ambiguous stress inducing 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. 4|Page
  5. 5. 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. A Positive Work Culture Applied Psychology strategic framework based on wellbeing and performance Strategic framework Focus Purpose Prevention Culture To promote a Positive Work Culture based Prevention on wellbeing and performance To manage threats to wellbeing and performance Next Prevent Generation deterioration Prevent deterioration Self To prevent personal deterioration in wellbeing and performance Restoration Support services To restore people back to their normal level of independent life and beyond Palliation To support people with chronic Palliation Restoration psychological distress Next generation To prevent psychological distress in support workers/carers © Derek Mowbray 2009 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 A framework for the future of Applied Psychology of primary clients. Secondary clients are agents who commission services on behalf Clients Communities Organisations (controlled communities) of the primary clients. With respect to the Challenges Individuals •Groupthink •Communication NHS the secondary clients are •Interaction •Social networking Wellbeing •Poverty and deprivation commissioners. •Compliance with change and •Demographics •Lifestyle Strategies •Environment •Scientific knowledge Performance Prevention The overall purpose of applied psychology Prevent deterioration and advances •Technology Restoration •Expectations Palliation •Disease within this framework is to facilitate one of The ‘next generation’. •People 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. 5|Page
  6. 6. 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. Some ingredients of the applied psychological cake More ingredients of the applied psychological cake Quality assurance Psychology Organisation and Psychological scientific Money rock’n’roll psychology Management development Strategic direction sleep psychology pop psychology Marketing Cultural development ? Regulation Applied psychology obese psychology Wellbeing and Performance psychology service community psychology vacation psychology demographic psychology ego therapy Training and baby psychology Academic psychology Development travel Psychological therapies Media communications psychology 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. 6|Page
  7. 7. 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 Architecture – national level aspects of the agenda that will inform practitioners of effective psychological Challenges Money approaches and interventions. Clients Management Culture Media Strategies Marketing There is, also, a requirement to raise the Institute of Psychology Applied to profile of psychology applied to Wellbeing and Performance wellbeing and performance, and to Support to Prevention Prevent deterioration create and sustain a ‘power house’ of Quality assurance Centres for Psychological Health and Restoration Regulation Wellbeing Palliation influence on health policy development Next generation 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 7|Page
  8. 8. wide mix of skills would practice from these centres, including psychological Architecture – local level Social enterprise franchise therapists, alternative therapists with a psychological focus, and nutritionalists Positive Work Cultures People in work whose practice impacts of psychological Research and development Positive community cultures Centres for wellbeing and performance. Community economic Psychological Health and People at home development and growth Wellbeing Personal development These Centres need to be established in as Prevent, prevent deterioration, Community wellbeing Restoration, palliation many communities as possible, being a and ‘next generation People in education parallel chain of Centres to general medical money management media marketing 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. 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 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. 8|Page
  9. 9. In the red box in the following slide are the topics that influence commitment, Other rules trust and engagement, and which form the criteria against which any rules need Portfolio careers ‘rules’ that build commitment: to be assessed to achieve a cohesive and Flexibility The job Recruitment committed workforce. Independent Professional Practitioners Pay Challenges Security Career opportunity Citizenship Marketing expertise Training Development Team working Psychological businesses Life balance Step 6 – how to play the game Networking facility Work experience CPD and supervision specialists allowances The final aspect of building a new organisation is ‘how to play the game’ or Support services Mothership 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 How to play the game will migrate from the security of a single employer to being independent practitioners wishing to engage with Join a Mothership – a Centre for Psychological Health and Wellbeing others in the delivery of the strategy Join an independent family of psychologists - PsychologistsDirect outlined earlier. Join a Network – Strictly Psychology Establish an Institute of Psychology Applied to Wellbeing and Performance Don’t rely on the taxpayer for income 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. 9|Page
  10. 10. 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 from Centres of Psychological Health and Wellbeing Psychologists will be getting their needs met from PsychologistsDirect and Strictly Psychology Derek Mowbray is visiting Professor of Psychology at Northumbria University and Director, OrganisationHealth, the Stress Clinic and PsychologistsDirect. email: 10 | P a g e