On clinical psychology as part of the problem

It feels a bit trite writing this now.

Last week, (and believe me, I have never said these words before) I wanted to go to Birmingham. There was a conference I fancied going to, on the topic of ‘Power, Interest and Psychology’. The conference sprang from the ideas of David Smail, a deeply influential psychologist who died last year. I never met him but he wrote prolifically on ideas related to the causes of distress – not faulty genes or a lack of moral fibre, but a society in which power is distributed unfairly and in which humans suffer as a consequence. I love that stuff – the chance to think about the unequal structures we have created and the ways in which they can be dismantled; the chance to be (legitimately) angry; the chance to thrash the ideas out with friends and colleagues who are sympathetic to them. I didn’t make it because it was priced well out of my reach which, if anything, shows at least that the organisers, my professional body, retain some sense of irony. But I was going to write a blog, regardless. Then Paris happened and my thoughts were consumed with that. I have toyed with writing something on that – on being Muslim in Europe; on having spent my entire adult life being part of a group widely feared as potential terrorists; on the fact I am now more acutely aware of my Muslimness than ever before – but I don’t know what the point is. I wrote things after the London bombings and after Lee Rigby and after Charlie Hebdo and I don’t know what more there is to say aside from the fact that I am weary of it and I am increasingly feeling less safe as a Muslim woman and that I see no sign of any improvement.

So, in that context, you will see why it feels trite to write this now. But life does not stop because of atrocities and I am still a psychologist and I still think there is much to be done in the world of psychology. Those who know something of me will know that I struggle enormously with my profession. I think it is worthwhile, which is why I do it, and  I often enjoy it, but it is far from perfect and  I would be lying if I said we always got things right. I suppose my attempts to do things slightly differently – to organise conferences looking at social context and to be part of a group which contributed evidence for a DWP report on Workplace Capability Assessments – stem from this; from some sense that there is so much more to be done than spending the next forty years tackling only the resulting distress, rather than the root causes. I don’t believe in cure without some attention to the causes and I certainly don’t see myself as some kind of healer. I think there is value in the work I do with people but to be perfectly frank by the time I see them there is often so much damage that has been done that it cannot be undone. I may be many things but I am not a magician. I can do nothing about the fact some of my patients were brutalised by their parents; about the fact many were raped; about the children they have had removed; about the violence they have endured; about the bullying they have experienced. I can do nothing about the fact that they have grown up in a deeply unequal society in which being gay or black or poor or an immigrant is often stigmatised. I know that experiences such as these lead to distress – I mean, I have data to back it up, because apparently we can’t just think in terms of common sense anymore – but I see virtually no efforts to do anything about it. Instead, we only see people when their own resources have been entirely used up and they are in desperate pain and we might try to help but the blunt truth is that our systems can brutalize and damage people further. It’s an unpleasant thing to think and to write but it is sometimes true.

A simple example is children who are sexually abused. We know that these children are much more likely to: develop an eating disorder, self-harm, drop out of school, use alcohol and drugs, have violent relationships, end up in the psychiatric system and get a diagnosis of borderline personality disorder, which, until fairly recently, was seen as ‘untreatable’. Now, if you get a BPD diagnosis, you might get some form of help, though the cuts are wreaking havoc, frankly. But the thing is, for some people BPD is a really bloody awful diagnosis to have – think of it, a label slapped on you which tells you your very personality is deficient. I can’t say I’d be thrilled. But if you are a person who has been sexually abused and who has had lots of bad things happen to them as a result because your attachments are ruptured and you find relationships hard and you feel ashamed and guilty and worthless and you take drugs to numb those very painful feelings, you may well not get the help you need, no matter how much you ask for it, because, unless you have a BPD label, you might not be seen as ‘ill’ enough. So what’s the message mental health professionals give people? ‘Get worse, if you want any help. Show us how desperate you are for help.’

Our system, dear reader, is flawed.

But of course it’s more fundamental than that. As psychologists, my colleagues and I are highly trained. Many of us have three degrees; some four or five. We are trained researchers and clinicians. We understand health but we could probably hold our own in some areas of sociology as well. I lecture trainee clinical psychologists on the topics of social context and race and class and sexuality. We are highly skilled people, often with vast amounts of knowledge at our fingertips. We know the causes of inequality and emotional distress; we know that intervening early is more useful than doing so later on and we tend to have the networks and the credibility to use that knowledge for social good.

Unfortunately, for most of the past 100 years, we haven’t. It wasn’t psychology which campaigned for the civil rights movement; it wasn’t psychology which rioted at Stonewall. On the contrary; we were too busy being involved in the eugenics movement and ‘treating’ people for being gay, which was classified as a mental disorder. More recently, we have had the dishonour of being complicit in torture. My profession does not have a good record when it comes to fighting for the rights of the oppressed, the marginalised and the dispossessed. And even now, knowing the crimes that were committed by our predecessors, many of us are content to sit in our consulting rooms and our ivory towers, working with the tiny proportion of people who come through our doors. I don’t know if you have ever tried to access NHS psychology but it is not easy. There are too many people in pain and too few of us to be able to provide them with what they need. I have the luxury of being able to see people for six months at a time if they need it; maybe more. Many people I know have nothing like that flexibility because their resources are so stretched but ultimately it’s our patients who draw the short straw.

My job is full of ethical dilemmas. Do I see the lonely old person because seeing me is the only social contact they have and because it lifts their mood slightly? Or do I discharge them because I am not ‘doing psychology’ with them? I’m not sure what ‘doing psychology’ is, really – as far as I’m concerned, most of my job is simply talking to people and trying to understand their situation and how they came to be in it and trying to fathom a way we can help them change it. Sometimes we can’t change it but that doesn’t mean there is no value to my input. I can’t just discharge someone sad and lonely without any follow-up but other agencies are drowning in referrals and their waiting lists would make your toes curl. But I can’t see people unless I can justify my involvement and sometimes it is hard to do that when you are the only psychologist covering a massive borough and sometimes I have to, with regret, discharge them and hope I have done enough.

But there are the bigger dilemmas. Make no mistake – I earn my living because other people are in emotional distress; because life has battered them and they cannot cope. You may say that I am doing a ‘good thing’ by doing what I do and that I must be a ‘good person’ but, believe me, there is very little about me that is noble. I care about my work and about my patients but the fact is that the day we manage to eradicate inequality, oppression and societal violence is that day many of us will be out of a job. Of course, given our current policies, that day isn’t coming anytime soon, but that in itself is a concern.

I see my job in the way I see a charity. It exists to fill a gap. If a charity is effective, at some point it should cease to be necessary because the gap has been filled by advances in policy and practice and it should close down. If I and my fellow psychologists were doing what we should be doing – focusing on preventing sexual violence, war, substance use problems, torture, racial and gender inequality, homophobia – we would, hopefully, run ourselves out of jobs at some point. That would be a good outcome, societally. A world in which you don’t need mental health professionals is a world I would like to live in. But we don’t do it. We don’t fight the causes; we firefight the dreadful consequences. And the effects on us are terrible. Health professionals are prone to all sorts of mental health problems. And why wouldn’t we be? Imagine spending forty hours a week hearing of others’ pain and distress. Imagine doing that for forty years. Imagine what that does to your view of humanity. Imagine what that does to your relationships. Make no mistake: our jobs can destroy us.

So, in fact, our lack of action when it comes to dealing with the root causes of emotional distress serves no one. It doesn’t serve those who continue to be marginalised, oppressed and victimized. It doesn’t serve the people around them. It doesn’t serve us as professionals. It doesn’t serve society. It simply perpetuates the damage and the despair; it keeps rotten systems alive and it maintains a steady flow of people through our doors for decades to come.

It is an outrage and we should be ashamed.

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7 comments

  1. Thanks for writing this, it’s an interesting article. However, I have a couple of questions that I wondered whether you could answer:

    1) What specific recommendations/suggestions would you have for clinical psychologists to help “eradicate inequality, oppression and societal violence”?

    2) Why do you feel that clinical psychologists should be “ashamed” for not doing more? Surely lives are frequently improved due to the input of clinical psychologists. Of course more can be done, but that would be the case whatever somebody chooses to do and we are all constrained by time and resources. Is there any reason to believe that psychologists are “perpetuating the damage and dispair”?

    Thanks,
    Connor

    1. Thanks Connor

      I think those are important questions. I can’t pretend I have all the answers but, in brief, these are my thoughts:

      1) Some psychologists are involved in policy. That is good. But generally they are very senior and don’t necessarily do huge amounts of clinical work. I don’t know that top-down policy-making is the best way. I see it much more as psychologists making concerted efforts in local areas to challenge the issues relevant to that area. For example, to my knowledge, there is a particular part of the NW of England which has the country’s highest rates of child sexual abuse and heroin addiction. Those are issues specific to that area. Surely it would make sense, then, for clinicians to focus on the problems in that area? But we know that lots of people who need help don’t get it or get it too late. That’s why I think it needs to be clinicians finding new ways of accessing those people. Maybe that means hanging out in pubs or betting shops or parks or at nurseries. Maybe that means training nursery workers to look out for signs that all may not be well. Maybe we need to go to communities, rather than waiting for individuals to come to us. But I certainly think that local policy, informed by local knowledge, is the way to go.

      2) In short: I don’t see who else is better-placed to do it. That isn’t meant to sound arrogant; I simply mean we have the clinical and research skills; we are well-educated; we can write and we have credibility. We also have the numbers: there are at least 12 000 of us in the UK. We have a responsibility, as far as I’m concerned. That doesn’t mean we exclude interested others who want to be involved – I am not tribal about these things – but, to be honest, a bit of me wonders ‘if not psychology – then who?’

      Time and resources are a factor, of course. But as I say, there are thousands of us. If we mobilise efficiently we can do an awful lot. And as I always say, if it’s important enough, you’ll do it.

      1. Thanks for your reply, Masuma. You make some interesting points.

        I’m not a clinical psychologist so can’t pretend to understand exactly what the role involves, or how many CPs actually get involved in their communities in the ways that you suggest. I agree that it is hugely important for the root cause of mental distress to be tackled wherever possible. However, I feel that you are maybe being a bit harsh on those in your profession (including yourself). Maybe this is a bad analogy but it almost feels the same as criticising an army medic for helping wounded soldiers, rather than making efforts to end the war. Surely it’s not just clinical psychologists who understand that sexual abuse, inequality, violence etc all have a negative impact on people’s mental health and I think that society as a whole has a responsibility to challenge these issues and help where they can. Although I agree that CPs may be in the best position to take the lead in such circumstances.

        In terms of your suggestions of what exactly could be done differently – I would assume that all nursery workers are already well-trained in safeguarding. Of course it would be useful to go directly into communities and find those in need of help and support, but I would imagine that you already have high case-loads and doing this would mean longer delays for individuals who are already on the waiting list and who, arguably, are in greater need of your help and support. If this is the case then your suggestions are going to be very difficult to implement without either a) increasing funding b) CPs working extra hours without pay c) making the role of CPs more efficient in some way. I wonder whether there are some CPs who are already doing the kinds of things that you suggest? If so, these people would surely be invaluable in advising others and helping to change the CP role around the country.

        I’m limited in what other suggestions I can think of myself due to my lack of knowledge around what CPs actually do. Although, I’m aware of groups such as Psychologists Against Austerity who appear to be having a positive impact. Groups like this seem like a good way of bringing CPs together and having their shared message put into the public domain. It also seems a shame that clinical psychology doesn’t really have a media-face. Television/radio/newspapers offer an excellent platform from which to communicate with the public.

  2. Masuma this is such an excellent and powerful blog. I too am sometimes ashamed of my profession , and often exasperated by our apparent neglect or ignoring of our knowledge about the social determinants of distress. Of course there is lots of good ameliorative work going on, but therapy is seductive, and transformational change is so much less immediately rewarding. And sometimes our avoidance of direct political action seems wilfully self serving ( as well as unconsciously defensive – social systems as a defence against anxiety – anxiety of powerlessness? ) Yet we have some really strong and splendid folk within our profession, working for prevention and policy change and justice and humanity. Of course we need more voices and strong messages like yours, and shared action , so that we, together with others outside our profession ( such as social workers and critical psychiatrists and medics and artists and social activists) wake one another up up to speak and act differently. Critical psychologists need to seek out, and speak at, the places where our voices and ideas can be influential. I do have a hope that times are changing and that maybe, just maybe, at last our professional body is starting to be more vocal about injustice and trauma and the social determinants of distress. Community psychology has been a minority voice in our profession for far too long. Psychologists against austerity are doing good things, and it was great to see Jamie Hacker Hughes speaking up about right action for refugees this week. And maybe more to come again on the benefit system. And the new inclusivity policy is a major step in the right direction. But so so much more to be done. Of course it,s all far bigger than our profession. But psychology as a discipline generates huge public interest, is influential, and unfortunately is in league at lots of levels with selfish greedy capitalism. The political systems we operate in are regrettably riddled with the noxious operations of self serving power. And, while that is the human condition, we as psychologists should be busy, as you are here with your blog, pointing this out and trying to shift the balance of power, to make the world a better place, rather than colluding to protect our own interests. Good on you.

    Annie Mitchell, Chair, DCP SW

  3. Hello Masuma! I am a psychology grad student in Chicago with a background in radical organizing. I wonder whether your views about the eradication of social ills, homophobia, racism, misogyny, transphobic, et cetera, aren’t quite realistic? I think these problems never really go away and, especially with the great rise in transgender visibility and conversely discrimination lately, new problems that we’ve never considered come to the surface all the time. What if psychologists, as a profession, could adapt to treat the growing pains of a species that is constantly growing, rather than reach a nonexistent ontological end point free of oppression or trauma? I think there is no world where trauma does not occur: natural disasters, accidents, human death ensures some trauma built into the human experience. I wonder what psychologists could pivot into doing for their communities that cannot be done on an individual scale: how just as we will always need medical doctors for what ails bodies (kids will always break their arms on the swing set, haha) we will always need psychologists for what ails minds. I feel your frustration at times with the profession, and diagnoses, but I think we as psychologists have a responsibility to imagine beautiful futures, for our clients, for our communities, and for ourselves.

  4. Thanks for your very interesting and thought-provoking article. I have just started training, and the course here takes a somewhat critical stance in relation to these issues. We recently had a session inviting us to keep this topic in our minds while we go through training (and afterwards, of course). I think you’re right, there are so many of us and if we were to organise ourselves properly, we could overcome a lot of potential barriers and improve things. Psychologists Against Austerity are doing amazing work, and I’m glad that you’ve mentioned the group. I think we’re raising awareness on a wider level and hopefully with time we will be able to affect the system more and more.

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