PSYC766 Becoming a Practitioner

Psychologist

Key concepts, issues and debates in

clinical psychology

Dr Deanna Gallichan PhD, DClinPsy

Consultant Clinical Psychologist
Associate Professor in Clinical Psychology
Learning Objectives

 To define clinical psychology as a discipline and a profession

 To broadly map the roles of clinical psychologists and the services in
which they work
 To describe key principles and values of clinical psychology (inc. the
scientist-practitioner model and concepts such as formulation)
 To be familiar with professional standards and regulatory bodies that
govern professional clinical psychology practice
 To gain a critical understanding of the impact of wider socio-cultural
and socio-political contexts on clinical psychology
 To discuss some specific areas currently debated in clinical
psychology including access to funded training
Menti quiz
How many of you are keen on the idea of clinical psychology as a
career?
Practitioner Psychologists Mentimeter
 Practitioner psychology careers

Clinical Psychology & Counselling Psychology Neuropsychology

Forensic Psychology
Occupational Psychology

Health Psychology

Educational & Child Psychology

Sport Psychology
 Bachelors Degree in Psychology
(Or conversion course)

= Graduate Basis for Chartered Membership

Masters degree
(Stage 1) Research Doctorate
1 yr Full Time Practitioner Doctorate (PhD)
DPsych, DClinPsych
DCounsPsych, D.EdPsych,
DHealthPsych
3-4 Years Full Time
BPS
Qualification 3 Years Full Time
(Stage 2)
2 Years Full Time Research & Teaching
Clinical Psychology
Educational Psychology (Scotland)
Counselling Psychology
Forensic Psychology
Educational Psychology (England)
Health Psychology
Forensic Psychology
Occupational Psychology
Health Psychology
Sports & Exercise Psychology
Sports & Exercise Psychology https://careers.bps.or
 E-books & Hard copies are available via the Library

How to How to
become a become a
Forensic Health
Psychologist Psychologist

Coming soon Coming soon

Link Link Link Link Link

 Wider psychological workforce roles

Psychological Well-being Practitioner Education Mental Health Practitioner

(PWP) (EHMP)

Child Psychological Wellbeing Practitioner Clinical Associate Psychologist

(CWP) (CAP)

https://www.healthcareers.nhs.uk/explore-roles/psychological-therapies/roles-psychological-therapies
https://ppn.nhs.uk/resources/careers-map/
https://www.healthcareers.nhs.uk/explore-roles/compare-roles/compare-roles-health
https://www.healthcareers.nhs.uk/explore-
roles/psychological-professions
  What do they look like?
 What are they doing?
 Where are they?
Imagine a  Who is ‘the client’?
Clinical
Psychologist  (in groups – one artist per group with pen and paper)
 “Clinical psychology aims to reduce
psychological distress and to enhance and
promote psychological well being by the
systematic application of knowledge
derived from psychological theory and
What are the data”
aims of
Toogood, R. (2010) The core purpose and
clinical
philosophy of the profession
psychology?
  British Psychological Society founded in 1901 as a
scientific, learned society
 1914-18 Some psychologists became involved in army
medical services (‘shell shock’, ‘war neurosis’ –
predecessors of PTSD); work was psychoanalytically
orientated
 Post WW1 some psychologists worked (as researchers) in
hospitals such as the Maudsley
 Post WW2 clinical psychologists started to be employed
History of in mental health services at the invitation of psychiatrists;
initially mainly as testers, often in ‘subnormality’ hospitals
the  1950s – tension in the BPS between
psychometric/behaviourist orientations (Eysenck) and
discipline in psycho-analytic medical section (Tavistock)

the UK  1959 English Division of Professional Psychologists

(educational and clinical)
 1966 Division of Clinical Psychologists
 Why ‘clinical’ psychology

 First use of ‘clinical’ in connection with psychology often seen as occurring in 1896
(Lightner Witmer, University of Pennsylvania, USA) referring to a ‘clinic’ for children with
developmental differences.
 But….
 One earlier usage in 1861 in a phamphlet published in Scotland by James Critchton-
Browne, a doctor, writing that medical authorities “will be compelled at length to
incorporate clinical psychology with the other departments of professional education”
 Term ‘medical psychology’ also used in the late 19th-early 20th century.
 Early British and American uses of ‘clinical’, ‘medical’ and ‘abnormal’ psychology
became confounded
“ Clinical psychology involves people as well as
problems, flair as well as training, art as well as
science…above all the clinical psychologist
has to learn to be useful, to doctors, to patients

”
and to his own discipline

Oliver Zangwill 1965

It is fair to say that Hans Eysenck would have fervently disagreed with this!
What are the differences between clinical
psychologists and psychiatrists?
(Menti)
Reflection
points  Scientific measurement versus idiographic or
phenomenological understanding: can one have ‘expert
judgment’ on someone’s subjective experience?
 Western understandings of mental health can tend to be more
‘individualized & intrapsychic. Does this neglect cultural
contexts and increase socio-political power
differences/inequalities?
 How Western modes of mental health are ‘imported’ may be
viewed as ‘psychological colonization’ (Patel et al., 2000)
 Profession (like many requiring high level of academic
qualifications) remains overwhelmingly white and middle class
whilst serving a diverse population.
Different academic roots in
psychology
Philosophy/Ethics Empirical Sciences
 Phenomenology  Experimental
 Consciousness & Subjectivity  Objectivity
 Introspection  Measurement
 Reflection & Narratives  Testing - Psychometrics
 Hermeneutics/Interpretation  Statistics
 Culture- and context-dependent  Categorisation
 Values-based  Diagnosis
 Critical & reflexive psychology  Positivist-empiricist psychology
Other influences

Therapy & Models Profession

 Psychoanalysis/psychodynamic  Code of conduct
 Learning theory  BPS & HCPC registered
 Humanistic psychology/therapy  Ethical & Values-based
 Systemic approaches  Multi-disciplinary & agency
 Community psychology  Independent profession
 CBT ‘family’  Diversification (Trethowan Report
1977)
 Postmodernist approaches
The Scientist-Practitioner model

 Established at the Boulder conference on Graduate Education in Clinical

Psychology, Colorado in 1949
 Refers to clinicians who conduct research and draw on research in their
practice
 Therapeutic competence AND expertise in applied research
 Adopted in the UK but with fierce debate between key figures and
institutions (e.g. Eysenck at IoP vs Tavistock)
 Clinical psychology training was initially an MSc and became a doctorate
in 1995
 Modal number of publications for clinical psychologists widely quoted as
zero
“ The essential function of the
clinical psychologist …..must
be to make available to the
NHS the contribution of the
science of psychology ”
M.B. Shapiro, 1967
  The intuitive practitioner, who conducts clinical
work on the basis of personal intuition and
knowledge from sources other than research.

Models of  The scientist‐practitioner, who is competent as

both a researcher and a practitioner.
how  The applied scientist, who conducts clinical work as
a form of applied research.
practitioners  The local clinical scientist, who applies a range
of research methods and critical thinking skills to
use of solve local problems in clinical settings.

consume  The evidence‐based practitioner, who

systematically searches the literature to obtain the
best evidence on which to base clinical decisions.
research  The clinical scientist, who draws on general
(Barker et al, psychology to produce research on clinical
problems for the evidence‐based practitioner to

2015) use.
 The practice‐based evidence model, in which
clinicians generate evidence about the
effectiveness of clinical services using their own
routinely collected data.
Characteristics of professional models
(from Barker et al 2015)
Model Orientation to research Research emphasised
Intuitive practitioner Nonconsumer or indirect Narrative case studies
consumer
Scientist practitioner Producer and consumer Basic and applied
Applied scientist Integrated with clinical Applied small N
work
Local clinical scientist Integrated with clinical Evaluation and action
work
Evidence based Consumer Controlled trials
practitioner
Clinical scientist Producer Controlled trials
Practice based Integrated with clinical Case tracking
evidence work
Think, pair, share

 Discuss in pairs or small groups for 3 mins:

 What are the potential benefits to clinical psychology of adopting a
scientist-practitioner model?
 Are there any potential drawbacks?
 Feedback via Menti
What do Clinical Psychologists do? (Menti)
Who uses services offered by clinical
psychologists? (Mentimeter)
ANYONE & EVERYONE
What services do clinical
psychologists work in?
 Different client groups, settings

 Primary, secondary and tertiary care services

 IAPT services
 Community Mental Health Teams (CMHTs)
 Children and Adolescents’ Mental Health Services (CAMHS)
 Learning Disabilities Services
 Forensic services
 In-patient units/psychiatric hospitals
 Specialist services (e.g. Eating Disorders services, Early Intervention in Psychosis
services, dementia services, substance misuse services)
 Physical health settings
 Therapeutic communities
 Private hospitals/services; private practice
BREAK
 Assessment

Formulation
THE CLINICAL
‘LIFE CYCLE’
Intervention
What do clinical
psychologists
do? Evaluation
Assessment
 Psychological assessment

 Aim is to respond to a referral BUT…..there is rarely a neat

association between the referral question and the
assessment you end up doing.
 Key consideration: “Who wants what for whom?”
 Often need to gather information from various sources
 Aim is to enable a formulation to be developed to help the
client or system to understand the issues they face
 Formulation *should* then determine intervention
Assessment question examples:

Does this person have learning disabilities?

Or dementia?
Or autism?
What is the impact of this person’s brain injury?
How has this person’s physical illness impacted on
their psychological health?
Why is this person experiencing distress and what
is the best way to help at the moment?
Assessment sources
Questionnaires and
Referral letters and assessment forms
previous reports completed by the
client

Information provided
Assessment interviews
by others (carers,
(verbal and
family members, other
observational data)
professionals involved)

Standardised and non-

Observations
standardised measures
 Assessment

Formulation Intervention
“
Formulation is the summation and integration
of the knowledge that is acquired by the
assessment process (which may involve a
number of different procedures). This will draw
on psychological theory and data to provide a
framework for describing a problem, how it
developed and is being maintained
”
Division of Clinical Psychology, 2001
Psychological formulation
 Synthesizes and integrates information obtained via
assessment with psychological theory
 Provides a framework, a working hypothesis to enable the
person to understand their situation
 Seen as an alternative to psychiatric diagnosis but does not
have to ‘compete’ – can be complementary
 Can be compared with data analysis, as making sense of
information from a specific perspective, i.e. context-specific
and theoretically informed or theoretically-driven
 Ability to ‘access, review, critically evaluate, analyse and
synthesise data and knowledge from a psychological
perspective is one that is distinct to psychologists’ Clinical
Psychology Benchmark statements (QAA, 2004)
 Open to ‘re’-formulation as new information emerges
 Biological

Psychological Social
 Describing: Summarising the client’s main presenting
issues

Finding patterns/links: Identifying connections between

the client’s difficulties by drawing on relevant theories

Commonalities Explaining: Making a suggestion as to why the client has

developed these current difficulties
in formulation

Planning: May lead to a plan of intervention that is

grounded in the theories that are drawn on

Being tentative: Remaining open to change and can be

revised as more information emerges
 Which factors are regarded as most relevant (i.e.
Points of thoughts, feelings, behaviours, social context etc.)
difference in
formulation Explanatory concepts used (e.g. the unconscious, core
beliefs and schemas, discourses, conditions of worth)

Epistemological perspective

Power issues: Expert position versus collaboration

Criticality: Stance towards psychiatric diagnosis

Purpose: Truth versus usefulness of formulation

Practical aspects: How it is developed, shared and used

What is the purpose of a formulation?
Collaboration & communication: Working alongside the client to help them make sense of their situation

Decision-making: To identify the best way forward

Finding a focus: To help prioritise issues and problems

Planning: To help with intervention planning

Informing assessment: To notice gaps in the information gathered so far

Evaluating progress: To aid thinking about lack of progress

Therapeutic benefit: To help the client feel understood and contained

Supportive for therapist: To help the therapist feel contained

Normalising and understanding: To normalise problems by making them intelligible

https://www.bps.org.uk/psychologist/we-
are-engaged-something-much-more-
complex-debate-about-evidence

From ‘What is wrong with you?’ to ‘What

happened to you?’
  Formulation as a process – a recursive
process of assessment,
discussion/interpretation, intervention,
Formulation as a feedback and re-assessment, revision
process or an event  Formulation as an ongoing sense-making
activity in case discussions, supervision and
consultancy
 Formulation as an event
 Letters to referrers
 Formulation letters in certain approaches, e.g.
CAT, Schema Therapy; ‘therapeutic’ letters
 Written formulations can be diagrammatic or in
narrative form
Example: Gemma

Dear Team
At her recent annual health check, Gemma’s staff team raised concerns that
she was often refusing care and also hitting out at them when they tried to
support her. We have done all the basic health checks and she appears
otherwise well. Please can you see her?

Yours sincerely

Dr Brown GP
Presenting issue •Gemma (woman with learning disabilities) has been refusing care
and then hitting out at her care staff

Predisposing •Gemma went into care at a young age and has been in several
abusive institutions
factors •Gemma can often struggle to articulate her thoughts and feelings

Precipitating •Recent changes in care staff

factors •Death of father

Perpetuating •Care staff struggling to recruit permanent staff – lots of agency staff,

Factors high turnover

Protective • Gemma has a bond with team leader and is more

able to talk about feelings with her.
factors
 Example of a
Gemma
withdraws to systemic circular
her room formulation

Staff withdraw, New staff offer

do not return to Gemma
the home personal care

Gemma shouts
“go away” or Gemma refuses
hits out at staff

Staff continue
to offer (place
demand)
What intervention would you suggest
for Gemma?
 Think, pair, share
 Early experiences
Example of
formulation based
Core beliefs on Cognitive
Behavioural
Therapy
Rules for living

Critical event

Thoughts

Behaviour Feelings

Bodily
sensations
Early experiences: parents divorced aged 10 – arguments about who he
would like with, had to ‘keep them happy’

Case example:
Core beliefs: “I must be perfect”
Trevor, 24, has been
“I can’t make good decisions” experiencing panic
attacks and has
begun to drink
Rules for living: “I need to be in complete control, or I am out of control” heavily. He recently
started a new job as a
paralegal in a busy
Critical event: First piece of work in new job was criticised by boss firm and is worried
that he will not be
able to function in his
“I can’t do this”
role.

Drinks to calm
Anxious
self

Heart beating
quickly, short of
breath
 Direct Interventions
 Individual therapy
 Cognitive behavioural therapy & third wave approaches
 Cognitive Analytic therapy
 Dialetical Behaviour therapy
 Psychodynamic therapy
 Eye Movement Desensitization and Reprocessing
 Therapy for group or family
 Systemic Family therapy
 Video Interaction Guidance
 Indirect (clinical) work

 Supervision
 Trainees
 Other members of the MDT
 Outside agencies
 Leadership
 Professionally leading teams of psychologists
 Senior clinicians within MDTs
 Management responsibilities
Indirect (clinical) work cont
 Consultation
 Behaviour support planning
 Reflective practice
 Within and outside services
 Teaching, training, mentoring
 Withing organisations
 At Local university
 Service design and development
 Organisational change
 Evaluation/audit
 Research
  Way of making sense of science/practice interface
(Stedmon et al., 2003)
 Attention to different sources of knowledge
 Critical, evaluative stance
 Self-aware (history, personal experience)
 Understanding diversity, social and cultural context
Reflective
Practice  Core competence of personal and professional
development within clinical psychology training

 British Psychological Society (2006) Core Competencies

– Clinical Psychology – A Guide
Intervention is not always therapy

 Wider social and cultural context must be considered

 What is going to be most useful to the person right now?
 Are they ready?
 What do they want?
 It may be writing a letter to another agency (support with housing, PIP)
 Engaging with other services/disciplines
 Signposting to community resources
 Waiting
 Key: being person centred so that intervention is based on what the person
wants for themselves, not on what the clinician wants for them.
Evaluation

CLIENT OUTCOME AUDIT SERVICE

FEEDBACK MEASURES EVALUATION
BREAK
The wider
context
Debate

 To what extent should clinical psychologists seek to intervene in wider

societal issues where they see that this is impacting on their clients in
practice?
 https://www.psychchange.org/ Psychologists for Social Change
 https://xrpsychologists.co.uk/ XR Psychologists and the Climate crisis
  All practising psychologists
need to be registered with the
Regulatory context: HCPC

The HCPC  ‘Clinical psychologist’ is a

protected title
 Health and Care Professions
• Sets standards for professionals’ Council’s Standards of
education and training and Proficiency (SOPs) (2015)
practice https://www.hcpc-
• Keeps a register of professionals uk.org/globalassets/resources/st
who meet HCPC standards andards/standards-of-
• Takes action if professionals on the proficiency---practitioner-
register do not meet the standards
psychologists.pdf
 Health and Care Professions
Council’s Standards of
Conduct, Performance and
Ethics (2016) https://www.hcpc-
uk.org/globalassets/resources/st
andards/standards-of-conduct-
performance-and-ethics.pdf
 Protected titles for practitioner psychologists
• Practitioner psychologist
If you see someone
describe themselves as a
• Registered psychologist flavour of ‘psychologist’ not
• Clinical psychologist on this list then:
• Forensic psychologist a) This is not technically
illegal BUT
• Counselling psychologist b) They are not registered
• Health psychologist and will not have
• Educational psychologist completed an
accredited training
• Occupational psychologist
• Sport and exercise psychologist Is the public aware of this?
BPS guidance for professionals

 https://www.bps.org.uk/news-and-policy/bps-code-ethics-and-conduct
 BPS Practice Guidelines

https://www.bps.org.uk/guideline/bps-practice-guidelines-
2017-0
 BPS Division of Clinical Psychology

- Informing policy, standards and workforce issues

- Supporting members in accessing CPD and developing
psychological research
- Consolidated high-profile UK-wide professional body with
significant user and carer engagement
 Association of Clinical
Psychologists UK
 https://acpuk.org.uk/
 Developed to provide alternative to BPS membership for clinical psychologists
 Representative body that aims to provide:
 A national voice
 Strategic Leadership
 Informing others
 Support for professionals
 Support for services
Remember:

ONLY the HCPC provides regulation for

practitioner psychologists
BPS and DCP membership are voluntary
ACP-UK represents but does not regulate
 Growth of clinical psychology

How many clinical psychologists do you think there are now?

 Cultural Drivers

Dominant discourses Alternative discourses

 Western medical model  Holistic
 Assess, diagnose, treat  Assess, formulate, intervene
 Expert model / dependence  Collaborative/internal locus of
control/empowering
 Problem located in the individual
 Systemic & social inequalities
 Cure
 Coping
 Medicalisation of difference
 Diversity embraced

Dudley, J. (2017). Clinical Psychology Training in Neoliberal Times.

Clinical Psychology Forum, 298, 30-33.
NICE Guidelines

 Evidence-based practice (EBP)

 Practice-based evidence (PBE)

 Training in clinical psychology

 https://www.plymouth.ac.uk/courses/postgraduate/dclinpsy-clinical-psychology

 3 years, full-time
Entry criteria

 Degree in Psychology - Graduate Basis for Chartered Membership (GBC)

 At least 1 year full-time clinical experience, preferably at least 7 months in
one setting and supervised by a clinical psychologist
 Understanding of the profession of clinical psychology
Selection

 A formal interview is designed to explore candidates' strengths. Panels will

include members of the course team, representatives from our Plymouth
Consultative Group and practising clinical psychologists drawn from
services across Devon and Cornwall. As part of the range of six interview
questions, candidates will be invited to read and be prepared to discuss
material sent prior to interview: these may include a clinical or research
paper, a journal article, a research and/or clinical scenario. There will be a
focus on reflectivity, reflexivity, formulation, values and commitment to
service user involvement. A second interview or a task will comprise the
second part of the process for each candidate depending on restrictions
that may be in place.
Funding/salary

 On entry to the programme all trainees commence on the first spine point
of Band 6 of the Agenda for Change pay scales. Travelling expenses are
currently paid for travel to placement and University fees are currently paid
directly by the NHS. Candidates for 2021 entry should check for funding
updates on the Clearing House funding page
National numbers for NHS places
There has been an increase in places for the last two years of approximately
25% each year. Numbers of places may change again for the next intake.
Equal opportunities? Example: ethnicity
(2020)
Whiteness in Clinical Psychology

 1 in 5 chance of being shortlisted for interview if white

 1 in 13 chance for people of global majority
 88% of UK clinical psychologists are white
 Wood and Patel (2017) Addressing whiteness in clinical psychology training,
South African Journal of Psychology, 47 (3)
 Holding-Up-The-Mirror-Deconstructing-Whiteness-In-Clinical-Psychology-
Ahsan-2020.pdf Journal of Critical Psychology, Counselling and
Psychotherapy, Vol. 20, No. 3, 45-55
Equal opportunities: Socio-economic
diversity (2020)
Diversity? Example: Gender (2020)
Training: Competence development
across 3 domains

Clinical
practice

Academic Research
ability skills
 Following training
 Clinical psychologists usually start in NHS jobs at band 7
 Many will look for a band 8a job after 2 or so years
 Likely to have responsibility for specific areas within a service
 Those keen to take a more leading role in services may progress to band 8b
 Likely to be leading small service areas or teams
 Consultant Clinical Psychologists are band 8c
 The most senior psychologists in an organisation
 Lead, supervise, manage
 Provide senior clinical input to MDTs and wider organisations
 There are some band 9s but these are rare!
Think, pair, share

 What brought you to the MSc Clinical Psychology?

 What are your personal motivations for pursuing the course?
 How do you think these could impact on you as a practitioner?
 What could you become drawn to?
 What do you think your blindspots will be?
Menti quiz
Presentations
Thurs 19th October 2-6pm
 Form groups of 5-6
 Look at the DLE for options on presentation title and marking criteria
 Note that both options mention NHS contexts. International students can
opt to discuss health services in their home country if this is preferred.
 Each group will have 20 mins for their presentation.
 All groups stay to watch all presentations for their session
 Email me by end of next week (Thurs 5th Oct) to inform me:
 Who is in your group (nominate one member to email me and list all members)
 Your chosen presentation title
 Please email me by this date if you don’t have a group and I will join you with an
existing group.