discussing clinical psychology

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Issue 6 May 2014

Perspectives

Free to circulate. Please pass on to friends and colleagues

Welcome from the Editor

Aspire
Welcome to the new issue of
Aspire.
As ever, life has pressed a
million other demands on me
and the rest of the team, so
this comes to you after our
customary long incubation
period (though we still hope
to increase the frequency of
future issues). I know that
many of you will be feeling
stressed due to organisational changes, service pressures
and the fact that this years
selection for the clinical training courses is well underway.
I hope that this magazine will
provide a replenishing interlude, and plenty of material to

Contents
A Week in the Life of

My career to date

Psy Vs Psy

Time to ditch delusions?

16

Why do we need Clinical Psychology?

18

Psychologists and Prescription

Rights

20

The Great Debate

23

Who do they think they are?

29

Rumour Mill

32

The Communications Papers:

Noise! 33
Book Review

35

Review: WASI 2nd Edition

37

Clinical Vignettes

38

Gillystrations 40
Caption Competition

get you thinking. Meanwhile,

the forum continues to grow
and be a source of support,
information and interesting
conversations, and our twitter
feed has a large number of
followers and is another way
to interact with us. (BTW, If you
are comfortable with social
media and wanting to get
more involved with the forum
we are currently looking for
people to contribute to our
twitter content as it has been a
bit quiet recently, so drop me
a PM).
This issue has the theme of
perspectives, and that has
resonance for me in terms of
the changes in perspective I
have had at various points in
my life. Both personally (and
professionally) my perspective
has changed over various life
stages, for example through
becoming a parent and experiencing being an attachment
figure after learning about
and working with these issues
for so long, and also since I
left the NHS and got more
involved in the national picture for the profession. Most
recently I have had the change
of perspective of visiting a less
developed area of the world
on holiday and realising how
much we are able to take for
granted in the UK in terms of
health and social care, diet,
housing, justice, infrastructure,
communication tools (like uncensored information access
via the internet), education
and the ability to influence
government. It reminds me of
Maslows hierarchy of needs
and the fact that increasing
psychological wellbeing (happiness) is actually the icing on
a cake that for many people
is missing much more basic
ingredients.

40 Hopefully the forum and

Aspire are both sources of a

Psychkus 41 range of perspectives, both

in terms of the diverse range

of individuals who contribute

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(in terms of gender, ethnicity,

sexuality, religion, age, socio-economic status, life stage,
disability, physical and mental
health, relationship status, political persuasion, background,
experiences and personalities)
and in terms of the way we apply our skills professionally to
different population groups,
within different service structures, and encompassing
various academic, counselling,
IAPT and educational roles
as well as students, graduate
roles and qualified CPs. I know
that I find it a good sounding
board for ideas, and a way to
see issues from a variety of different angles. I have yet to see
a thread in which someone
says yes, you seem to have it
covered there and every other
posts reads agreed. Often
threads take an unexpected
detour, such as our recent foray into gender expectations.
At a personal level I entered
2014 facing the new and
unpleasant challenge of having to downsize my business,
after we were unsuccessful
in securing research grants
and service contracts we had
bid for. This was a salutary
reminder of the flip side of the
high level of autonomy and
agileness of the company that
I had been enjoying, as the
buck stopped with me and
responding to market conditions meant making decisions
that were personally stressful.
Although it was amazing to
successfully deliver a one-year
pilot of enhancing physical
care for diabetes with brief
psychological interventions
where there were co-morbid
mental health problems, and
we evidenced not just a high
level of satisfaction and efficacy in improving mental health,
but also cost-effectiveness
through savings in physical
treatment costs, it has been
disappointing that the service
has not (yet) been picked up
by local commissioners or
NHS trusts. Im hoping that

Aspire
at least we will have gained
useful knowledge we can
publish and share with other
providers. I can see colleagues
within the NHS having to
cope with cuts in the context
of increased demand also,
so I know that this feeling is
not unique to the private and
non-profit sectors.
I am also struggling with the
immense cuts that have been
swept through with regard
to Legal Aid. For those of you
who havent been impacted personally, the cuts have
meant a reduction of cases
in which experts are used (so
many decisions about parenting capacity, including many
parents with mental health
difficulties or Learning Disability, are being made by judges
with only the insight of social
workers who dont have specific training in these areas)
with a complete absence of
experts and legal representation in most of private law
(including contested custody cases with allegations of
abuse, domestic violence or
parental substance misuse).
Those cases that do involve
an expert have to use much
reduced numbers of hours at
significantly lower rates of pay
(below the rates paid by insurance companies or many private clients for therapy, and far
below the rates paid to NHS
trusts per session for mental
health services, even if they
are above the hourly rates
paid to salaried clinicians).
And to rub salt in the wound,
the contract used to instruct
all experts allows Legal Aid
to retrospectively judge how
many hours were necessary
and claw back any overpayment, without any insight into
what it is the expert actually
does or seemingly any reference to their own terms and
conditions. For example, refusing to pay extra for a capacity
assessment because they
didnt know what that was, or
refusing to pay for non-attend-

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ed appointments even though

their own documents state
that charges can be applied
to any appointments which
are not given 72 hours notice
of cancellation. It might seem
trivial, but this unpleasantness
and having to battle over the
amount of hours required and
why they deserve payment
is not comfortable for clinicians who are there to serve
justice and the best interests
of the child, and is the reason
that a significant proportion
of highly experienced expert
witnesses have ceased to do
this work. It would seem to me
that this risks miscarriages of
justice, and these are harmful
from the perspective of the
client and of justice and of the
public purse!
On the other hand I remain
passionate about the value
Clinical Psychology can offer
to a multitude of issues and
settings, including a wide
range of services in the NHS.
My book Attachment in Common Sense and Doodles has
allowed me to connect with
new audiences, and opened
up speaking and training
opportunities, and I am also
exploring new technologies
- developing web tools and
apps for clinicians. However
I am still hoping to secure
time/funding to complete
the research I am passionate
about, with regard to making
effective adoptive matches,
and outcome measurement
and placement planning with
regard to Looked After Children. I think the new language
of health economics joins up
well with the research and
outcome evaluation that we
are taught as clinical psychologists, so I am very glad to have
a profession in which we are
taught more than just therapy
skills. I hope that we can protect the career pathway and
the access to our services for
clients, through these austere
times. And I very much hope
that after the next election the

pendulum will begin to swing

in the direction of investing in
the wellbeing of the population and particularly the preventative and early intervention work that saves social and
economic costs later down the
line.
We have started some nascent
discussions about whether it
would be helpful to develop
some kind of associated network or use the forum as a
think tank or lobbying body
with regard to mental health
and wellbeing. This seems to
be something we are missing,
given that the BPS feels unable to be political because of
their charitable charter and
their process is inherently slow
and conservative, so I would
be interested to hear whether
this has any appeal.
As always, feel free to comment about Aspire or give us
any feedback about how our
whole array of services can
be more useful to you on the
forum. We are open to offers
if anyone wants to pick up a
more active role on the forum
(doing research, social media,
promotion or securing advertising), or to contribute to
future issues of Aspire.
I leave you hoping I will be
writing the editorial for the
next issue before the end of
the year, and wishing you
every joy in your personal and
professional lives in the interim.

Aspire

A Week in the Life of

A Forensic Psychologist in Private Practice

Brendan OMahony

Monday
Today I attended a Parole Board Oral hearing to give evidence. I had been instructed by HM Prison Service in April this year to complete a full psychological
risk assessment of an offender who is serving an Indeterminate Sentence for Public
Protection. I prepared for the Parole Board hearing which was held in a Cat C
prison by re-familiarising myself with my report and the conclusions that I had
drawn based on a risk of violence assessment, personality disorder assessment and
an assessment of anger and provocation. I re-examined all protective factors as
this was the first question that I had been asked at a previous Parole Board hearing. I was also aware that the offender had instructed an Expert Witness Clinical
/ Forensic Psychologist to give evidence. Having given evidence and returned to
the office I spent some time reflecting on the similarities and differences in opinion
between myself and the other psychologist. I discussed my thoughts in peer supervision.

Tuesday
I attended the Crown Court where I was acting in the role of Registered Intermediary (This is not an expert witness role) for a vulnerable witness with intellectual disability. I fulfil this role because
of my professional training as a psychologist and my experience of
working with this client group. I was called into the court to discuss
my recommendations with counsel and the judge and I successfully
argued that the vulnerable witness did not need to view her video-recorded evidence again at the same time as the jury as to do so would
fatigue her and reduce her concentration for the subsequent cross-examination. When the witness did give evidence I intervened as necessary if the questions were too complex. I also ensured that counsel
slowed down the pace of questions to allow the witness adequate time
to process a question and to formulate an answer.

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Wednesday
I spent today preparing for two lectures that
I have been asked to deliver to an MSc university class. The broad topic areas are Investigative Interviewing of Witnesses and Credibility Issues in Allegations of Sexual Assault.
I discussed the learning outcomes with the
university lecturer who instructed me and
I searched the relevant academic databases
to ensure that I was familiar with the latest
research in these areas. I began developing the
PowerPoint presentation and sourcing other
teaching materials this afternoon but I will
need to re-visit this task on another day.

Thursday
I have had the usual administrative tasks
to complete in the office such as preparing
quotes for expert witness reports, chasing
outstanding invoices and signing off the tax
return. Oh, I mustnt forget the time wasted
on the phone to HMRC trying to sort out a
DD for my National Insurance contributions! I found time to update my Continued
Professional Development (CPD) records
with details of a training day that I had
recently attended and devised plans of how to
implement the learning into my daily practice.

Friday
I spent today analysing qualitative data for my doctorate thesis which I have been studying
part-time for 5 years now. I am also writing a careers style book for undergraduates / graduates
interested in pursuing a career in forensic psychology, so I have been chasing up the various contributors this afternoon. Finally I prepared for Mondays Parole Board oral hearing by reading
my report which I completed in August. Mondays Parole Board has a psychologist panel member that I know so there is a little bit of extra pressure! The offender is on a determinate sentence
and due for release but still presents a risk of sexual re-offending. There are resource issues and
responsivity issues (recent diagnosis of Aspergers) when planning the treatment pathway for this
individual and I anticipate a discussion about managing his transition into the community.

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My career to date
William Curvis:
Trainee Psychologist
I was sixteen. I didnt have a clue what I wanted to do when;
or if; I grew up. Going with what I had been good at so far, I
started college doing A-Levels in Maths, Computing, Electronics and German. I had nothing like a firm career path in mind.
I took an almost instant dislike to Maths and German, going
from top of my high school class to struggling to keep up. I
managed to complete the first year of my Maths A-Level (I
scraped a pass by three marks) but I decided after three lessons that German wasnt for me. In desperation, I signed up for
Psychology.
It wasnt a subject I knew much about Id seen Cracker, I
knew Sigmund Freud was some guy who asked questions
about your mother but aside from that, it was a new world to
me. I loved it. I looked forward to lessons, the teachers were interesting and most importantly, I enjoyed the content. When it came to choosing a degree, the choice was obvious
- tinkering with computers or electronics was the last thing I wanted to do. It had to be
Psychology (I think my dad has just about forgiven me for this).
I had an absolute ball at university. I loved the social side of things and made a lot of great
friends. But I also found time to do a bit of work. I was pleasantly surprised to find that
I was developing a real passion for Psychology it was no longer just an alternative to
failing German. I loved the variety in perspectives, I loved the theory... I even loved the
research and statistical stuff. I liked that it brought in things I had enjoyed at school and
college writing academic essays, using principles of maths and science to guide research
and so on. More than anything else, it felt useful, like it might be of value to people. I
breezed through first year fairly painlessly but
then hit a lull in second year. This left me in the
unfortunate position of having to do really well
on my dissertation to secure a 2:1.
I threw myself into it like I never had done with
anything before. I locked myself in the university
library for days at a time scouring through books
and journal articles. I spent a great deal of time
discussing my project with a fantastic supervi-

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sor; and between us we came up with an interesting study looking at ADHD symptomatology and academic performance in young children. It was tough going but I loved every
second of it, I even enjoyed the writing up process. I found that I wasnt just blagging it
anymore I actually cared about what I was doing and I was shocked to receive 80 on my
dissertation, which was enough to push me up to a 2:1. For the first time I was starting to
understand what my high-school teachers had meant when they said I needed to apply
myself more than anything else the dissertation was what kick-started the enthusiasm
and motivation I had previously been lacking.
At this point I began looking into career options. I wanted a role that allowed me to do
something valuable, something I could motivate myself to get out of bed for and Clinical
psychology instantly caught my eye, I liked the sound
of using psychological theories to help people. I even
liked that it involved research it seemed like a good
way to build on everything Id enjoyed during my
studies to date. So; largely in denial about the competition; I read everything I could on the topic and started to look for jobs.
I found my first relevant role fairly quickly, supporting
people with learning disabilities and severe and enduring mental health problems. I really enjoyed this
job and built up good relationships with service users
and co-workers. More than anything, I learned how
stigma and a lack of psychological thinking really limited these peoples ability to reach their potential. After
around 18 months I felt ready for a new challenge and
began looking for other jobs, though I do continue to
do occasional support shifts in my spare time.
My next role was working as a Primary Care Mental
Health Worker; I was employed as part of the Improving Access To Psychological Therapies programme
(this role is now more commonly referred to as Psychological Wellbeing Practitioner).
Working for the NHS was a complete change for me, I was surrounded by a great team
and was fortunate enough to get fantastic supervision from CBT therapists and Clinical
Psychologists.
The training gave me an excellent introduction to the skills involved in developing therapeutic relationships with a range of people and delivering interventions based on cognitive-behavioural therapy. Working as part of a multi-disciplinary team in this role gave

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me skills in assessment, intervention, risk management and outcome measurement all
relevant to the role of a clinical psychologist. It was helpful in developing my confidence,
interpersonal skills and understanding of mental health services.
During this time I topped up my PCMHW postgraduate certificate into a Masters, developing my skills in academic writing and critical appraisal. My dissertation looked at the barriers older adults face for referral, assessment, management and treatment in primary care
mental health settings. Studying alongside my full-time role was tough, but it strengthened my resilience, organisation and time management. I contacted a lot of psychologists
and researchers at local universities offering to help out with some data collection. This
led to working on a paper testing the validity of using the Strengths and Difficulties Questionnaire with young children. Were currently submitting this for publication and its been
a really useful experience.
Feeling ready for something new, I took a role as
Locality Lead for a PCMHW step two service in a
different NHS trust. By managing a PCMHW team
I developed leadership skills, enjoying increased
autonomy and responsibility. Supporting the team
through the move to IAPT was challenging at
times but a valuable learning exercise. Seeing supervision from both sides of the process was useful and I learned the value of a guiding approach,
allowing for reflection and advice seeking whilst
building resilience. Before this I never saw myself
as a manager, however I thoroughly enjoyed the
experience and learned a great deal.
I was offered a place at Lancaster University this
year, my second time applying (after being on the
reserve list last year). I did my research, and Lancaster was where I wanted to train the course
ethos seemed very much in line with my values
and ideology and I tried hard to get this across
in interview. I see myself as someone who didnt
follow the traditional path Ive never had a paid
AP or RA post yet I worked hard to make the most of the experiences I had. I made good
links with the people I worked with, and was confident clinical psychology was the career
path I wanted to pursue.
Hopefully this has been of some use to anyone thinking about applying. Also I have to say
Im writing this from a very reflective position30,000 feet in the air, on my way to Australia for a well-deserved month of sun-shine before the course starts!

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VS

The Vignette
Dear Psychology Colleagues,
RE: Sara Loresti D.O.B 17.04.1995
I was wondering if you could see Sara for me, she lost her parents in a car accident approximately one year ago and for ten months afterward lived with her
older sister and brother-in-law. Although Sara was referred by her sister shortly after the accident for hearing the voices of her parents subsequent to their
deaths, she presented as emotionally stable, was comfortable with
her sense of self and had no problems connecting with others. Sara
seemed comfortable in living with the voices and described them as
both positive and loving.
Approximately eight weeks ago, Sara was moved to a young persons
home due to her sisters inability to cope with her presentation. Since this time
she has refused to connect meaningfully with anyone at the home and she has
come to fear the social workers who she has known and got along with well
since the accident. What little she has communicated since moving to the home
suggests that her parents voices have become negative and derogatory. The
home are so concerned they have taken steps to prevent self-harm although no
previous attempts at self-harm have been made.
Janeece Waltston
Social Worker.

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The CAT approach

Dr. Yvonne Waft: Clinical Psychologist.
My name is Yvonne Waft and I am a Clinical Psychologist working in an Adult Psychological Therapies Service in the North of England. I would not usually see someone quite as young as Sara, but I do see people from 18 years old and its not that much of a stretch to think about how I might work with Sara.
My initial thoughts on reading the referral were that Sara probably isnt an ideal candidate for a CAT
approach, mainly because there is not a lot of evidence in the referral of longstanding difficulties in relationships and this being the main strength of CAT. However, it also struck me that the sister and brother
in law had struggled to contain Saras grief and help her manage it, such that what started out as a fairly
normal grief reaction has now spiralled into something far more problematic. I began to wonder about
Saras early relationships and the predominant reciprocal roles within the family.
Reciprocal roles are what we learn in relationship with our primary caregivers. A loving parent enables
a child to feel loved, thus a LOVING <-> LOVED reciprocal role is learnt. We develop procedures related
to these reciprocal roles that reinforce them. So for example a loved child might want to spread the love
(aim), they may believe they are lovable (belief ), so they will approach others in a loving way (action), and
receive love in return (consequence), which neatly loops back to the loving part of the reciprocal role. As
the reciprocal roles are internalised and reinforced over time they are applied intra- and inter-personally.

So the loved child learns to love himself and others and elicits love from others through his actions.
Of course, the people who use our services usually have some less virtuous reciprocal roles in their repertoire. I wondered whether the negative and derogatory aspects to the voices Sara was hearing might
reflect a criticising <-> criticised reciprocal role. Parents are often critical of their children because they
see their own failings reflected in their children and want them to do better. However, that critical parental voice becomes internalised and a belief of not being good enough develops leading to efforts to try
harder and a vicious cycle is born.

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Conditional approval can be just as harmful. A compliant child who gets oodles of praise for being
good, but is completely ignored or shouted at if they get upset, will learn to hide their negative feelings
in order to keep the approval coming. This can create a precarious sense of self as the child cuts off from
difficult emotions and therefore doesnt develop a strong sense of what they want or need. This weak
sense of self tends to lead to a pattern of placating others whilst ones own needs are not met. I wonder

whether there is some sense of this with Sara and her sister. In dealing with the traumatic loss of both
parents at a relatively young age they will both have been overwhelmed with strong emotions. If they
are not used to acknowledging, containing and dealing with strong emotion, then it is likely that their
normal grief reaction will escalate into something uncontained and frightening for them.
Another reciprocal role Id be interested in exploring with Sara would be to do with her sense of abandonment by her parents (ABANDONING <-> ABANDONED/ALONE). Whilst she probably knows as well
as anyone else that her parents could not help being killed, she probably feels terribly angry, alone and
abandoned by them. This will then link in to the other reciprocal roles weve looked at in terms of Sara
criticising herself for having angry feelings and trying to suppress them in order to be a good girl who
copes well with things. This might be very central to the completed diagram. One of the procedures
stemming from the abandoned/alone place might be around wanting to feel cared for and safe, believing that people will abandon you, so acting out in various ways to elicit care (such as threats of self-harm

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and withdrawing from those who do care), with the consequence that people feel rejected by you or feel
they cant cope with you, refer you on and effectively abandon you, leaving you feeling more alone than
ever.

After about four sessions I would have a reasonable idea of what I thought was going on for Sara and
would write a reformulation letter outlining the key difficulties she seems to face, how/why they came
about and how they play out for her day to day. I would suggest a therapy of about 16 sessions, whereby
the first 4-6 are information gathering, writing the letter and working on the diagram, this is the Reformulation stage. The next few sessions are about Sara learning to recognise when she is playing out those
key procedures we have identified, this is the Recognition stage. This is followed by the Revision stage
where we work together on finding exits to the procedures.
I would predict that the hardest part of this therapy for Sara would be the ending, and we would be talking about that right from the start. She has come into therapy predominantly as a result of a traumatic
bereavement and is bound to be very sensitive about endings and loss. If the ending is not addressed
sensitively, she will feel abandoned again and any good work done within the therapy could be sabotaged. However, a good reformulation and diagram will enable these issues to be discussed openly as
they come up.
It is likely that the exits would be around emotional regulation and self-soothing. This might include
mindfulness exercises, as well as more appropriate ways of seeking care from those around her. We
might well look at some compassion focused work to help Sara be less self-critical and more accepting of
herself and her feelings. We would certainly talk a lot about her grief, normalising that and encouraging
her to talk with her family about what has happened. Whilst I would have in the back of my mind the
possibility of psychosis and a referral to the Early Intervention Service, my gut feeling is that this is not
psychosis, but is a rather uncontained, but essentially normal grief response, that needs containing within a structured therapy model.
There isnt the scope within this article to show you the completed reformulation letter and diagram, but
I hope Ive given you a sense of what CAT seeks to do and how it might be helpful to someone like Sara.

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Cognitive interpersonal model

By Ruthie

I have a couple questions Id want to be asking before proceeding with this referral. One, Id like to know
why Saras sister no longer felt able to cope with her presentation and what changed sufficiently for Sara
to need moving into a young persons home. Secondly, Id like to know what steps the staff are taking to
prevent self-harm and why. Based on the referral and Sara not connecting with anyone at present, I am
not sure that proceeding immediately with individual work with Sara would be the best starting point
given she may not be willing to engage with me. In my mind, this looks like a case that is ripe for consultation and work with the team.
I would start by reading Saras background, talking to Janeece and to Saras sister about how things have
changed to get a fuller picture of how things have been. I would then want to meet the staff from the
young persons home and find out more about their concerns and what they are doing to manage their
perceived risk of self-harm. I would ask them to think about what they wanted to get out of the consultation. In this case, a very reasonable goal would be to to develop a psychologically informed (ie formulation based) care plan which will enable Sara to engage meaningfully with the people around her. In
saying this I would also be clear that the staff may have very good reasons to be concerned about Sara.
It seems very likely that Sara is very distressed by the move, may be experiencing low mood and anxiety
and may well be at risk for self-harm. However, the best way to find out about this so we can better support Sara is likely to be by engaging her more meaningfully so as to foster more open and meaningful
relationships between Sara, the staff and her sister.
I often find that in these situations, unless the individual (i.e. Sara) is willing to engage and tell us what
they are experiencing and what it means to them that formulations need to be quite tentative. A gentle,
Socratic approach can open up hypotheses and psychological thinking which can inform a more helpful
team approach. I often find myself drawing on a model introduced to me as a trainee by Anna Vizor (Vizor et al., 2007) which helps to formulate interations between staff and the people they are working with.
It strikes me immediately that Saras beliefs about voices and the staffs beliefs are quite different with
Sara seeing the voices as her parents and perhaps seeing them as helpful guides even if they are derogatory towards her. By contrast, the staff
seem to be seeing the voices as indication of mental illness and risk of self
harm. I would not say that directly but
I would ask the staff about what their
beliefs about voices are and drawn
up a formulation in their own words.I
would be interested in their past experiences of people who hear voices
and self-harm and how this is informing their beliefs about voices and their
approach to Sara. I would also ask
them to consider how Sara might see
her voices, particularly given her previous experiences of the voices being
positive and "loving". Sara may have
started to see her voices as giving her
guidance even if the voices are critical
or derogatory in nature.

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Depending on the direction the conversation goes in, I may then ask staff to consider possible reasons
for Saras withdrawal.

For example...
* Her voices may be telling her not to trust staff leading her to feel anxious, paranoid and unable to trust
* She may be feeling rejected by her sister and feeling guilty about no longer
being able to live at home, perhaps she has started seeing herself as in some way
bad or unacceptable to others
* Perhaps as her sister was unable to understand her experiences of hearing her
parents voices she assumes that staff will not understand either and is withdrawn
* Id also want to know about what the staff are thinking and feeling in relation to
Sara and how this is impacting on their relationships with her
* Perhaps the staff think the voices are signs of mental illness that could lead Sara
to self-harm and are becoming anxious when they realise she is hearing voices
and are telling her things like, Its not real or adopting a restrictive approach to
looking after her (e.g. taking anything she might use to self-harm away from her)
* Perhaps the staff are so concerned about the voices they keep asking Sara about
them and whether she has any thoughts of self-harming
* As an old supervisor of mine often says, It takes two to tango and with lots of
staff and systems involved, it might be more like a rather chaotic Congo line with
different staff doing different things! I would want to think how Sara's difficulties
and the team's approach are interacting and perhaps perpetuating each other.
This could lead to hypotheses like...
* In telling Sara the voices arent real, Sara might be thinking no-one understands
her and therefore withdrawing from staff
* Sara may be feeling alone and in withdrawing start to think she needs to rely
more on her voices for guidance
* In being so concerned about her voices and risk of self-harm (for which there
appears to be no evidence), they may be overly focused on these and not considering other aspects of Saras life (e.g. her friendships, interests, ambitions etc.) and
could be missing out on valuable opportunities for engagement
* Sara may be interpreting their concerns as disapproval or as a sign that there is
something wrong with her or bad about her, with again would likely lead to
shame and withdrawal. The more Sara withdraws and feels bad or ashamed of
herself, the more she is likely to be caught up in her own internal experiences of
voices and the more derogatory and distressing they are likely to become.
* In becoming more withdrawn, staff may become more anxious about Sara's mental state and the risk of self-harm and become even more focused on them and
further lose sight of Sara as a person thereby perpetuating some of their unhelpful behaviours in relation to this

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I would also ask about exeptions to the rule. Are there times when Sara seems to engage even a little bit
and ask the staff to think about these and what hypotheses these might offer us.
Drawing on those hypotheses, I might offer staff some training about voice hearing and psychoeducation (e.g. about the percentage of people in the population who hear voices and famous people who
hear voices) to offer some alternative perspectives about the meaning of voices.
I would then ask staff to test out different approaches to see what happens. Maybe they can try talking
to Sara about other things or offering her activities she may be interested in. They could ask Saras sister
for suggestions about what may be a useful approach here (e.g. if they found Sara was very into art or
music, they could bring materials for this activity to her and see if she would like to do something with
them). Instead of looking for signs of voices, distress and possible self-harm, they could look for moments
of calm or potential opportunities for low-key engagement on a personal level and try to exploit these to
engage more meaningfully with Sara. They could document these and communicate about them to each
other rather than focusing solely on their concerns.
Then over time and as I often have to remind staff, slowly slowly (few of these approaches will get an immediate breakthrough and they will need to be patient and persistent), hopefully Sara will engage more
with them and they can start to work meaningfully with her to support her move towards her own goals
and values.
I would perhaps want to meet regularly with the staff to review progress, find out what is working and
revisit our hypotheses about what is going on if things are not progressing or are getting worse so as to
fine tune the formulation and develop the care plan further.
In all of this, I am aware of Saras sister and I would hope that she is receiving some support as well. I may
meet with her and again in a similar way help her to reflect on her relationship with Sara. She may be
feeling guilty about Sara no longer living with her or she may be similarly anxious about her voices and
this may be resulting in her behaving in similar ways to the staff. Again, helping Saras sister in a supportive and non-blaming way to consider other ways of communicating and reaching out to her sister may
be helpful as well. Perhaps some psychoeducation about voices and ways of understanding them may be
helpful to Saras sister too.
As Saras engagement with people improves, we could also think about bringing Sara and her sister
together to understand what has happened at home that left Saras sister no longer being able to cope
and how this has impacted on both of them. We could help both Sara and her sister come to some agreements about how to communicate with each other and how to talk about Saras voices. Also, they may
need to explore what living separately means for their relationship and how they would like to relate to
each other in the future.
Likewise, once more able to engage with other people, Sara may benefit from her own individual therapy to help her move forward in her life and to manage the voices in a way that does not interfere with
her ability to engage in every day life and with other people. There are various approaches to this which
may include CBT or ACT with Sara and Family Intervention or Behaviour Family Therapy with Sara and her
sister. However, I have chosen in this article to focus on the initial stage of work with the staff team and
hope it is an interesting example of how a consultation based approach can be helpful.

Reference:
Vizor, A., Balleny, H., & Quakely, S. (2007). Using a cognitive interpersonal model in consultation. Poster Presentation. World
Congress of Behavioural and Cognitive Therapies, Barcelona.

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Time to ditch delusions?

Matt Berlin: Trainee Clinical Psychologist
Unusual beliefs, or delusions in common professional parlance, are frequently regarded by both mental
health professionals and society at large to be symptomatic of a variety of psychiatric disorders, most notably schizophrenia. As mental health professionals we
exercise extreme power in classifying and categorising
others beliefs as unhelpful, abnormal, or even downright pathological. We need not entirely suspend our
disbelief and be prepared to unquestioningly enter our
clients reality (assuming, of course, this would even be
possible). I will argue here, however, that we must be
prepared to openly acknowledge that although we may
not share someones beliefs, this does not equal the superiority of our experiences of reality over their own. In
turn, this can hold important implications both for what
we call these beliefs and how we work with them.
Though not the primary focus of this article, it seems
worthy to first note that the scientific validity both of
schizophrenia and its more slippery relation psychosis
has been thoroughly challenged (e.g. Boyle, 2002). Why
bother to mention this? Because the power to label an
individuals beliefs as deluded in part stems from the
assertion that these beliefs are due to mental illness
in the absence of a psychiatric disorder the person
wouldnt hold such strange beliefs, so the argument
goes. But when we bring into question the validity of
the diagnostic criteria, must we also not re-examine the
assumptions that accompany them? The more squeamish psychologist may employ terms such as psychotic
symptoms to sidestep the reification of psychosis into
something real, but the end-effect is essentially the
same: we continue to define others beliefs as pathological misrepresentations of reality.
We may disagree with biomedical explanations for
these beliefs (though the popularity of stress-vulnerability hypotheses and biopsychosocial models in
psychological formulations perhaps suggests otherwise), and instead postulate that causality lies in some
anodyne myriad of cognitive, behavioural, affective,
psychodynamic, interpersonal and social factors. And
naturally, we would always attempt to understand
these in an individualised and idiosyncratic formulation
tailored to the needs of the client in question. We might
even go as far as arguing that these beliefs cannot
be understood outside of social, cultural and political
contexts.

www.ClinPsy.org.uk

But although psychologists may be likely to pay heed to

the content of delusions -treating these as meaningful
and communicating something of a persons experiences - it is much harder to escape modernist discourses
of objective reality. This is not intended as personal or
professional criticism: discourse shapes and limits our
thinking and we cannot simply will it away because
we find it problematic. Even the most open-minded

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psychologist can encounter someone whose beliefs are
so incompatible with their own that they cannot help
but draw the conclusion that the other person is plain
wrong in their thinking. One approach is to simply ignore this judgement. We know that unusual beliefs a
term sometimes used to avoid some of the assumptions
of delusions are actually not that unusual (e.g. Peters,
Joseph, Day & Garety, 2004). People, us psychologists of
course included, hold all sorts of weird and wonderful
ideas that to others appear bafflingly barmy. We can
argue therefore that it is not objective reality that we
are interested in, but rather whether or not the beliefs
are causing the individual distress. However, once we
deem this distress criterion to be fulfilled, it can be as if
we have been given a green light to help in changing
these beliefs for ones that are supposedly less problematic. We may understand the clients beliefs as an
effect of distress; however, we are also signalling that to
some extent they are the cause. Though we are avoiding making an explicit judgement on the veracity of the
beliefs, this question (along with the potentially unpalatable concept of delusions) is surely still lurking in the
shadows.

Our clients may indeed ask for us to help them change

the way they see the world. However, an alternative
approach is to work within the belief system of the
person concerned. Tamasin Knight, for example, has
written on how she simply bought bottled water from
another region as a way to cope with the belief that
her local water supply was contaminated (May, Hartley
& Knight, 2003). Though both approaches have their
individual merits and detractions, it is perhaps helpful
to ask ourselves to what extent we enable our clients
to make informed decisions about how we might best
support them. Our own personal and professional
understandings as well as pressures from service and
policy levels will guide our discussions with clients, the
formulations we construct with them and also the intervention options that get put on the table. The construct
of delusions perhaps leads us towards acting in ways
in which we see change as needing to occur within the
individual, working on their distress. Maybe this also
means we are less able to think of how to effect change
in the social and material contexts in which this distress
occurs and to consider to what extent the distress be-

www.ClinPsy.org.uk

longs solely to the individual and how much it belongs

to and arises from the social systems around them.
I have suggested that it is time we ditch the term delusions. In which case, we might reasonably ask what
alternative words and phrases are available to us, which
do not carry the same assumptions of pathology. This
is not a case of somehow attempting to be politically
correct rather it is about how we use language to
construct reality. Although terms such as unusual beliefs have been suggested as alternatives, this may not
actually be a very accurate reflection of the frequency
of such beliefs. I myself have been drawn into using the
term as a form of critical psychological shorthand perhaps as much a sort of social constructionist badge of
honour for my own benefit as an attempt to influence
how others view clients experiences. However, I have
started to question whether this is simply a cop out that
changes very little in terms of either my thinking or that
of others. Might it be better to more explicitly acknowledge that we are discussing beliefs that are not shared
by others and that some of the distress may come from
this lack of shared understanding?
It may feel like we are treading a terminological tightrope here and in practice we might choose a variety
of different terms depending on context or purpose.
Therapeutically we might wish to abstain from making
pronouncements on whether we personally share a
clients belief or not. However, there is perhaps some
promise in taking a position that acknowledges that
some, or indeed many, people do not share a clients
understanding without suggesting it is within our power to determine true from false. Part of our professional
task as psychologists can be to embrace complexity and
I believe that sometimes it is better to use ten words
than one. Snappy it may not be, granted, but surely it is
better that than telling our clients they are wrong.
References
Boyle, M. (2002). Schizophrenia: A scientific delusion?
(2nd ed.). London: Routledge.
May, R., Hartley, J. & Knight, T. (2003). Making the personal political. The Psychologist, 16(4), 182-183. http://
www.thepsychologist.org.uk/archive/archive_home.
cfm/volumeID_16-editionID_93-ArticleID_537-getfile_
getPDF/thepsychologist/apr03knight.pdf
Peters, E., Joseph, S., Day, S. & Garety, P. (2004). Measuring delusional ideation: The 21-item Peters et al.
Delusions Inventory (PDI). Schizophrenia Bulletin, 30(4),
1005-1022.

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Why do we need Clinical Psychology?

A few of my favourite things (a service user point of view)
Jo Hemmingfield

My favourite thing about

clinical psychologists is
that they are the experts
in the person-centred
approach. It is a great skill
to be able to climb into
someone elses shoes,
look at the world through
their eyes, meet them
where they are and seek a
complete as possible understanding of what it is
like to be them right now.
Clinical psychologists can
take a non-judgemental
approach to people who
are going through a time
of distress and are able
to connect with those
who have lost all trust in
other human beings. It
is a lonely place having
lost all trust in others
and it is a wonderful gift
for someone to help you
start to trust again. It
might seem all in a days
work but it is a vital key
to recovery.
Health services are not
perfect. Mental health
services are far from perfect. There are pockets
of good practice and of
course excellent dedicated staff. One benchmark

www.ClinPsy.org.uk

of true excellence
is a reflective
service, where
staff are prepared
to take a long
hard look in the
mirror and say
to themselves
what have we
learned? Services
which really want
to know how
they are doing,
what difference
they are making
to peoples lives, are the
best services around.
Measuring the difference
that working with someone has had is an essential part of the science of
psychology. Clinical psychologists are in an ideal
position to blaze a trail of
evaluating all of services
by finding out how people feel about the services they receive.
On a personal level, after
being sectioned three
times, my most helpful
encounter with health
services was when I
agreed to see a trainee
clinical psychologist. I
had come to the point

where I did not trust the

mental health services.
My hospital admissions
had been characterised
by me being unable to
get straight answers to
reasonable questions like
why am I in hospital. I
did not feel ill - yes, I had
been angry and communicated that anger in
stupid ways, I had been
in need but it was unclear
how being put in a hospital would solve my practical problems. In theory
it could have been somewhere for me to calm
down and think through
why I was angry and how
I could solve my practical problems. In fact the

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belief seemed to be that
the medication would fix
everything. It did not.
I discovered at my first
admission that treatment did not mean being treated really well
but taking pills. When I
saw a trainee I was given the space to tell all of
what had happened to
me for the first time, I was
helped to trust my own
thoughts and rediscover
my sense of self. It is my
belief that the psychiatric diagnosis of
Bipolar Disorder
actually undermined my sense
of self and gave
me a negative
self identity that I
have since battled
against.
Psychology gives us
an alternative to psychiatric diagnosis that for
me is a more helpful way
of understanding things.
A person is not born with
a broken brain ready to
flip out into psychosis
at any point but none of
us are bomb proof and
we are all vulnerable to
psychological distress
when put under certain
pressures all of us, including clinical psychologists and other mental
health professionals. The
landscape of health is
changing and it is more

www.ClinPsy.org.uk

important than ever that

health colleagues care
for themselves and each
other, that the healthcare
community is one that is
open and supportive.
My experience is that my
diagnosis does not seem
valid. No matter how
many times I have tried
on the label of bipolar
disorder, like a pair of
size 10
jeans,

it does not fit and does

not suit me. My times of
vulnerability are far better explained in terms of
relationships than biochemicals, not in terms
of a broken brain but
in terms of trust, anger,
forgiveness and love. I
cant do anything about
my brain other than let
someone take a knife to
it and I cant do anything
about my biochemicals
other than take pills but

I can choose to dare to

trust, understand why
I am angry, choose to
forgive and to love. As I
understand my world in
new ways and bathe my
synapses in endorphins
my dynamic, living brain
will adapt its structure to
the new healthier me.
I enjoy my life it is not
perfect, I have the privilege of parenting two
wonderful and extraordinary children and engaging in meaningful
work. I know who
I am, I like myself
and I believe my
life, like everyones is precious.
I have a purpose
and hope for the
future. It was a
trainee clinical
psychologist who
helped me along
the way within a system that had hurt me.
Sometimes it is just one
idea that you can plant
in someone that much
later will grow into an
area of encouragement
in their life. As a clinical
psychologist there are
many opportunities to
plant seeds of possibility and hope in peoples
lives. I encourage and
applaud you in your desire to become a clinical
psychologist. It is an ethical, life-giving profession.
I wish you all the best.

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Psychologists and Prescription Rights

The US as a Case Study and Directions in Europe

Silvia Marin

In 2002, New Mexico was the first U.S. state to pass legislation that would allow clinical
psychologists prescription privileges. The American Psychological Association lobbied for
over 20 years for such rights, after the first military psychologists gained similar training
and privileges for their work with armed troops.
In 2004, Louisiana was the second state to give prescribing privileges to psychologists,
and since then, there has been an ongoing debate in the community whether this option
should be available to all psychologists, and how can this legislation affect service users.
(Lavoie & Barone, 2006)
Usually, psychologists have to refer their patients to physicians for medical evaluations
to obtain prescriptions for them. The American Psychological Association has stated that
around 70% of psychiatric medications are prescribed by general practitioners, who although may have extensive medical training, they lack the mental health experience that
psychiatrists and psychologists have acquired. This issue is often compounded by the fact
that patients in rural or disadvantaged inner city areas are even less likely to get quality
mental health care, due to a shortage of psychiatrists.
The APA hopes that although clinical psychologists will further their understanding of
pharmacology and the medicines that their patients take, they will not consider medication as the only treatment, and continue to offer quality talk therapy. Psychologists view
their right to prescribe as important as the role of helping patients wean themselves off
of psychotropic medications
that are not helping them, as
is the case with many children.
The training received as a clinical psychologist empowers a
provider to consider all of the
biopsychosocial factors before
offering a prescription, and
taking the time to conduct
thorough clinical interviews,
observations and assessments
which can only provide benefits
for the patients (APA Monitor,
2006).

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The Pros

The Cons

One of the main arguments that advocates put

forth is the fact that there is a shortage of psychiatrists in rural and disadvantaged inner city areas
and there is a mental health need not being met.
Moreover, it appears that considering the extensive training clinical psychologists receive, it would
be a logical extension to offer them the option of
pursuing pharmacological post-doctoral studies.
Patients would receive a more comprehensive
evaluation through extended clinical interviews,
at-home or in the classroom observations, and
psychological tests, and there would be a natural
continuation in care.

Lavoie & Barone (2006) point out an interesting historical phenomenon in the mental health field. Up
until the Second World War, psychiatrists were opposed to psychologists providing psychotherapy
in the U.S., claiming that they lacked proper training. In spite of this, clinical psychologists moved
onto the territory of talk therapy quite fast, and
within only a couple of decades they have made
psychotherapy one of their central activities. And
While training standards for prescription rights can
be analyzed, it is difficult to overlook the progression psychiatry took since that time. In the same
amount of time that clinical psychologists moved
on to psychotherapy, psychiatry slowly became a
Another important argument that is often brought mostly prescribing profession. Could this also hapup in these debates is the fact that other providers pen when clinical psychologists gain prescribing
have had prescription privileges internationally,
privileges?
and that the APA only advocates for privileges limited to prescribing psychoactive medications. Ac- It is easy to observe that many patients would precording to Lavoie & Barone (2006), both physicians fer the easier route when it comes to treatment.
and dentists have unlimited privileges in Canada
Psychotherapy, even short-term types, still requires
and the UK, and several other providers have inde- regular appointments over a certain period of
pendent privileges in the US, such as optometrists, time, it is a commitment from the patient, and it
podiatrists and nurse practitioners. (For a complete cannot give them instant gratification. Medication
comparison between providers by country, please also does not give instant satisfaction, however,
see Table I.).
the patient is only seen rarely for medical checks,
and they can leave after their first session with a
Often times, for diagnoses of ADHD, anxiety or
prescription in their hand, which might appear the
mood disorders, it seems more comprehensive
easy way out for the patient. Similarly, it might
to have the same provider do both the pharmaappear preferable to overbooked psychologists
ceutical treatment, and the psychotherapy. The
who work in areas where there are shortages, and
therapy would give the provider plenty of oppor- medical insurers might see it as a way to lower
tunity to thoroughly assess the patients reaction
costs for the treatment of each individual. These
to the medicine, and adjust accordingly, while
are traps that have slowly moved psychiatry into
the patient would benefit from the safe and open the predominance of medication treatments
environment. The patient might see a noticeable
where it is today, and clinical psychology might
change when starting the medication, and they
follow. Moreover, more focus on a medical model
would be more willing to continue to attend their might dilute the biopsychosocial approach that
psychotherapy sessions. Moreover, many studies
psychology is trying to integrate into its practice,
have shown how the combination of medication
and into the practice of health care in general.
and therapy provides better and longer lasting
results for various conditions, and being offered
The issue of training is also seen as debatable.
by the same provider enables a more natural and Although military psychologists appeared to be
integrative progression of treatment. (APA Practice successful with the two year training they received
to prescribe, physicians often argue that it might
Guidelines, 2011)
not be sufficient. Clinical psychologists would need
to gain an in-depth understanding of the patients
metabolism, and interactions with other disorders
and medications. A thyroid condition can affect
how a medication is metabolized, and it can also
interact with other supplements a patient might
be taking. It appears that there are many factors
that need to be considered and not all of them can
be covered in such a short training.

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A Moderate Approach and European Directions
After considering both sides, it
seems that there is a need for a
moderate approach that would
address properly most concerns
and that would prove beneficial
to service users. Differences between the way clinical psychology is practiced in Europe, and the
way it is in the U.S. might provide
a starting point.
For example, graduate programmes in the U.S. (equivalent to DClinPsy) last around 7
years, and many states require
post-doctoral training before
offering licensure. It seems reasonable to assume that changing
the way clinical psychology is
taught at the doctoral level is
not feasible, but that the pharmacological training should be a
post-doctoral addition, and optional. Other European countries
are observing closely the debate
that is happening in the U.S., and
are considering implementing
similar movements. The New
Mexico State University program
that offers training to psychologists who want to prescribe has
enrolled in 2008 their first cohort
of twenty-two Dutch psychologists. (APA Psychology International, 2012). While this in itself

can raise many issues regarding

the portability of the program to
other countries, it highlights the
interest of European psychologists in prescription rights.

a very different approach from

the US, where private health
insurance agencies pressure
physicians to keep appointments
short, to offer mainly medication,
and reduce as much as possible
Research and evaluation are two the cost per patient. Clinical psymain aspects that need to be
chologists practice in the US is
considered in order to underin mainly private environments;
stand the effects of prescription
and often due to the size of the
rights offered to the psycholocountry; they practice alone or
gist. The evaluations that have
only with other psychologists.
been done were based on a care- Psychologists in the UK have the
fully controlled and monitored
benefit of a nationalized health
sample of psychologists trained
care system, and they can be
by the Department of Defense.
found as part of mental health
While their training proved to
teams that consists of diversified
be successful, there is a need for
practitioners. This team setup is
further research on the effects
preferable from many points of
of offering such programs to
view: it can provide the necesmany more psychologists from
sary space for supervision if they
different environments, and the
decide to prescribe; and it can
potential benefits and dangers
also provide an argument that
posed to the service users.
there is no need for prescription
rights in such settings, encouragThe UK already appears to have
ing collaboration with practitionthe upper hand when it comes to ers from allied fields. Irrespective
general practitioners and family
of ones preference for one side
physicians the MHRA offers
of the debate or the other, there
guidelines on proper administra- is no doubt that this new chaltion of psychoactive medication
lenge can bring to light many
and encourages the considissues that the mental health
eration of psychotherapy as a pri- field needs to address in order to
mary treatment for patients with better serve its users.
mental health conditions. This is

References
American Psychological Association. (July 2006).APA Monitor: Psychologys prescribing pioneers Retrieved
November 17, 2012 from http://www.apa.org/monitor/julaug06/pioneers.aspx
American Psychological Association. (March 2012).APA Psychology International: Psychologist prescriptive authority movement in Europe, Retrieved November 17, 2012 from http://www.apa.org/international/
pi/2012/03/prescriptive-authority.aspx
Lavoie, K. L., & Barone, S. (2006). Prescription privileges for psychologists: A comprehensive review and critical
analysis of current issues and controversies. CNS Drugs, 20(1), 51-66.
Practice guidelines regarding psychologists involvement in pharmacological issues. (2011). American Psychologist, 66(9), 835-849.

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The Great Debate

Should Religion Have
A Place In Therapy?

NO! says FuzzyDuck (assisted by Schizometric).

Should religion have a place in therapy? I dont think so, both in terms of the relationship between therapist and patient, and the value it has to offer as a systematic practice. I believe that making room for
religion in therapy could have serious implications, both for the therapist and for the field itself.
I believe that the best way to demonstrate these implications is to ask more questions.

Does supporting religion add significant value?

This cant be answered without firstly determining the ways in which religion could or would be supported; how much it would cost to introduce that support; the cost, in terms of time and money, of the extensive training in all known religions; and ensuring maximum awareness; the cost of losing clients because
religion was handled inappropriately; and so on.
Business aside, how much would this improve the service a therapist offers to their client? From my
own perspective, the risk of the relationship with a client deteriorating because of a misunderstanding
or assumption about their beliefs would far outweigh any possible benefit that discussing them would
provide in the first place.
This brings me on to my second question:

Does it run the risk of crossing professional boundaries?

Religion can be a highly personal, or private, aspect of an individuals life. The therapist couldnt reasonably know enough about the impact of religion on a clients life so as to be able to engage in any meaningful discussion about it. This isnt the problem, per se. The problem is in having to dive into that aspect
of the clients life and ask questions about it that are both sensitive, and relevant.
If I was asked about my religion by my therapist, I wouldnt feel comfortable talking about it, nor would I
feel that it would be a relevant line of inquiry. If they didnt believe in the same thing as me, I would find
it difficult to trust what they had to say, because they lack expertise in what I believe.
Of course, some people think otherwise: The New York Times reported in 2011 that 83% of Americans believed their faith and mental state were closely linked, and 75% believed their counsellor should take this

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into account and try and integrate it into their therapy. While 75% believed religion defined their entire
approach to life, this sentiment was not shared by as many clinical psychologists, 67% of which did not
feel the same about religion as many of their potential clients. [1]
This arguably presents a new problem. The entire point of using a therapist is to receive help and advice
from someone who either objectively knows more about something youre unlikely to fully understand,
or is able to empathise on a level that feels genuine. There is no such authority or authenticity when it
comes to my personal beliefs, and to this extent I believe a boundary would be crossed if a therapist
attempted to exert it.

Does an incompatibility of beliefs raise a barrier to therapy?

People want their therapist to validate, not confront, their religious values. (therapydoc, 2008)
As a clinical psychologist, you may or may not have religious beliefs of your own. As a client or patient,
they may have entirely different beliefs. You both may have similar beliefs, but different perspectives. This
presents an immediate disadvantage to clients who dont share the same, or similar-enough beliefs, and
at worst presents a niche whereby therapists market themselves as sympathetic to certain religions.
As a clinical psychologist it would certainly have to be taken into consideration that a client may hold
views -- homosexuality, gay marriage, arranged marriage, misogyny and the role of women in some
religions, and so on -- that are clearly in conflict with what they believe themselves. And Querying religion as part of the process will surely bring these issues to the fore-front, presenting the psychologist the
challenge of separating these beliefs from what they perceive to be the causes of the issues the client is
having.

What happens when beliefs are conflated with symptoms (and vice versa)?
Consider religion: its not uncommon to hear a Christian might say theyre the recipient of Gods messages, or the reason they do something is because its Gods will to do so, or theyve seen a sign.
Now consider therapy: its not uncommon to hear a client might say they can hear voices in their head,
or the reason they do something is because that same voice told them to, or maybe they can see things
other people cant.
How much would either of these two scenarios, treated independently, be influenced by either the clients or the patients religious tendencies and the strength of their beliefs? What would happen if certain
religious beliefs were mistaken for the symptoms of a mental condition -- such as hearing voices and
believing in hearing Gods voice -- and vice versa?

Does it present a conflict of interest?

In plenty of circles, science and religion are completely at odds. For a science to embrace religion as an
alternative methodology is not, to me, a big deal. However, the broader implication of this is dependent
upon what the client thinks, not the professional.

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After a course of therapy that actively involved their religion, there is nothing stopping the client from
concluding that it wasnt the therapy that was effective; it was their faith. If it didnt work, then presumably the therapy was ineffective and faith is kept out of the picture.
This sounds like a nightmare scenario more than anything, but given battles such as that between Creationism and evolution - to name just one - its really not worth the risk to encourage more of it.
References:
[[1] Parker-Pope, T. 2011. When God Is Part of Therapy *New York
Times* March 22. Retrieved October 16, 2012
(http://well.blogs.nytimes.com/2011/03/22/when-god-is-part-of-therapy)](http://well.blogs.nytimes.
com/2011/03/22/when-god-is-part-of-therapy)
[[2] therapydoc. 2008. Leave your religion at the door?. *Everyone
Needs Therapy* January 22. Retrieved October 16, 2012 (http://everyoneneedstherapy.blogspot.
co.uk/2008/01/leave-your-religion-at-door.html)](http://everyoneneedstherapy.blogspot.co.uk/2008/01/
leave-your-religion-at-door.html)
[](http://www.apa.org/monitor/dec03/religion.aspx)

YES! says Ruth Ann

Where therapists fear to tread
Im writing this from the perspective of a clinical psychologist who specialises in working with people
with complex and often enduring mental health difficulties in a CBT framework. Although I do not hold
traditional Christian beliefs, attend church or adopt Christian practices, my cultural and family background sit within this tradition, I recognise that it has led me to develop a set of beliefs and values about
compassion, hard work, effort and humanity that has doubtless directed my career path and informed
my work.
So first off does it matter?
Well, does race matter? Does gender matter? Does sexual orientation matter? I am sure that most therapists working with any client group will say that these are factors that do need to be considered sensitively in the therapy. People with a strong faith or spiritual practice often say that they are vital components in their lives. Not just that, people involved in a faith community are often highly influenced by the
relationships and support that they experience within that group. One would be hard pressed to argue
that such a vital aspect of someones life can be ignored in therapy. Indeed, the Department of Health
(2007) requires health professionals to demonstrate that they have considered spiritual issues, just as
they would other issues of diversity such as race and age. 86% people say that they have a faith (Office of
National Statistics, 2001) so this would appear to be an issue affecting many of the people we see.

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So my purpose in this article is to argue that religious and spiritual beliefs are relevant to therapy, to
discuss how they can help therapy and how they may interfere with it and to consider common therapist
dilemmas based on my own practice.
So how can religion and spirituality be useful?
The good news is that the majority of research has found that religion and spirituality is good for mental
health (Koenig, 2009). It can provide a social support network, an array of meaningful activities and a
sense of self-worth and purpose in life. In my experience, religious groups are not infrequently a relatively
safe haven for people whose mental health or other difficulties often results in social stigma and isolation. One client I worked with who had social anxiety, found her church group to be a place where she
could test out her beliefs about other peoples reactions and set herself the meaningful goal of serving
drinks and snacks after the Sunday morning service strengthening her belief that she was a person of
value with something to offer others. Another struggling following a series of challenging life events
found both emotional support in his Sikh community and practical advice and help to sort out his affairs.
Indeed, much of my work with the client was to address his beliefs and consequent reluctance about
relying on others for help.
Another issue to consider is models of mind.
All cultures, including religious cultures have a model of mind. For example, Sufi Muslims have a tradition of the self as made up of four elements: heart, spirit, soul and intellect. Haque (2004) suggests that
these can be linked to the CBT domains of emotions, behaviours, thoughts and reflection which can
help to explain the CBT model in a way that is acceptable and relevant to people from a different cultural
background. Of course, this sounds relatively easy in practice, but what of the average clinical psychologist or CBT therapist whose client base is as diverse as their knowledge of different religious and spiritual
traditions is scant. My experience of working in inner London with a multi-cultural client group is that a
thorough knowledge is often unnecessary. Often, I can ask a client to explain their beliefs to me if they
are important and we can collaborate together to come to a shared understanding of their difficulties
and potential ways forward, which is entirely commensurate with the collaborative stance that is the
bedrock of cognitive therapy (Padesky, 1993). Other times, I can draw on team members from different
cultural backgrounds to explain how things may be understood in the clients culture (although one
must not make the mistake of assuming that all people from the same culture thing the same way as this
is obviously not the case). If there is a large community from a particular cultural background within a
service then forging links with local faith leaders can be a helpful way of making our services more culturally acceptable and sensitive. An example I can think of is seeking the advice of local Muslim leaders
during Ramadan to communicate to people who rely on anti-psychotic medication that there was not an
expectation for them to fast (which would be medically inadvisable) and to suggest other ways that they
can observe Ramadan (e.g. partial fasting such as by giving up treats or following a more basic diet or
even more importantly, to practice charitable giving). An awareness of cultural and religious practices in
particular cultures may be vital to engagement. Examples might be taking off ones shoes on entering a
Chinese Buddhist home or not shaking hands with someone from an orthodox Jewish community. However, they might become even more vital in treating particular mental health problems and advice from
a clients family and/or spiritual community (with their consent) may be vital in distinguishing what is
usual practice from what would be considered excessive washing or neutralising in the case of Obsessive
Compulsive Disorder. Both Huppert et al. (2007) and Paradis et al. (1996) present fascinating discussions
on this issue in relation to people with OCD in Orthodox Jewish communities where ritual washing is part
of a rich cultural tradition.
Working in a CBT framework

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I am particularly keen to help clients discover new and more helpful meanings and ways of thinking
about things. Religious and spiritual traditions can offer an array of culturally salient metaphors and
stories that can form the basis of new belief and behaviour patterns. (For a fuller discussion of the value
of metaphors and stories in CBT see Stott et al., 2010.) Examples of this include a Roman Catholic client
who was plagued by self-criticism who found the image of the Virgin Mary to be a compassionate figure
in which she could find reassurance that she was acceptable and loved, warts and all as a mother loves a
child. Another client was anxious about putting himself forward found a challenge in the parable of the
talents where a master gives his servants talents (financial currency) and rewards the servants who invest
it but takes away the talents of the servant who buried his for fear of losing it. This and the instruction do
not hide your light under a bushel challenged the client to put himself forward and contribute to other
people in his Christian community in a way that he had not had the courage to before. Indeed, he also
found that when he invested himself like this, he was indeed rewarded with renewed confidence and
further opportunities.
We must not ignore the darker side of religious faith.
Examples might include an anorexic client who partakes of a religious fast at a dangerously low bodyweight or a gay person riddled with guilt and self-reproach because their religious background deems
homosexuality to be an abomination. Here, the therapist might have a dilemma. I would argue that religious beliefs are utterly relevant in such examples and must be explored. If religion is important to that
client, I think the therapist who chooses to ignore that clients religion is not likely to get far. The therapist
who attempts to challenge them out of it may be more likely to find the client disengaging altogether.
So what can we do? We might invite the client to seek out and explore alternative interpretations of
their religious tradition or enlist the assistance of a religious leader in the therapy where the client wants
this to happen. Hospital based chaplaincy services can be a very helpful port of call here. One example
I can think of is a client with psychosis who believed he are hearing the voice of the devil attacking him.
The hospital chaplain sat with the client and explored Bible passages where the devil did speak and
discovered that actually when the devil speaks in the Bible, his tone is gentle, tempting and alluring.
This opened up the possibility of other ways of understanding the voices he was hearing and enabled a
psychological model of voices stemming from childhood trauma (the client had experienced particularly
vicious bulling) to be introduced.
This is not to say that using religious ideas, images and stories is right for all clients.
Marlene Winnell writes poignantly of the impact of fundamentalist and controlling religious groups on
members and the challenges people face if they decide to leave such groups. Some of her thoughts are
available on the British Association of Cognitive and Behavioural Psychotherapies website: http://www.
babcp.com/Review/RTS.aspx. People in that situation might well benefit from considering non-religious
meanings and certainly accessing support from other sources if they are leaving a religious group and
facing criticism and rejection by family and friends for doing so. Another example I can think of was a
man who had experienced sexual abuse at a religious school. In this case it was vital to understand and
acknowledge the powerful position his abuser was in and how the abuser exploited this to his own ends.
Although the client had no interest in engaging in religious or spiritual groups or activities, he did seek
some comfort in Christs words But whoever shall offend one of these little ones who believe in me, it
were better for him that a millstone were hanged about his neck, and that he were drowned in the depth
of the sea. (Matthew 18:6, King James Version) The focus of this clients therapy was much more on him
building the friendships, social networks and occupational opportunities that he wanted in a way that
was free from what he perceived as the burden of religion.
All this said, I do think some things are off limits in CBT. I do not think it is ever the role of a therapist to
suggest a religious idea to a client or to instruct them as to what they should believe. Whatever our own

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personal convictions, when it comes to religious and spiritual beliefs, my view is that a Socratic stance
where we explore with genuine interest and curiosity with a client is the way to go. This allows clients to
seek out for themselves what they believe and find meaningful.
My experience
Is that incorporating spiritual and religious beliefs into therapy for those clients who find this important
and helpful is almost always an enriching experience for both therapist and client. It can be uncomfortable too, where I am not entirely comfortable with religious or spiritual ideas because they do not fit with
my way of seeing the world. But in these cases I remind myself that it is not for me to tell a client how to
think but to facilitate them exploring and finding things out for themselves. On a purely anecdotal level,
feedback from clients about incorporating religious ideas into therapy is typically positive. One client
who made wonderful progress in therapy and had discussed it with his priest, told me that the priest
suggested that his CBT had been a gift from God (I tried not to let this go to my head!). Another client
told me that she was reluctant to discuss her Buddhist meditation practice with me as she thought I
would say meditation was a bad idea for someone with psychosis. She was surprised when I suggested
we incorporate mindfulness into our work and asked her to explain more of it to me. She later told me
that her spirituality was so important to her that had I not been open to it, she would not have continued with the therapy. I am glad that she did for two reasons. First, she did well in therapy and developed
some excellent coping skills enabling her to attain her initial goals for therapy and then some. Second,
she taught me a lot about mindfulness meditation that has helped me with other people I have worked
with.
Overall
My experience of incorporating religion and spirituality in therapy has been a positive one. I hope that
this article has given some food for thought as to how this might enrich and enliven therapy. As for me,
in writing this, I struggled to think of examples of stories and metaphors from outside the Christian tradition that have helped people I have worked with. I think I may be more tentative about exploring stories
and metaphors from other traditions that I am not familiar with as I am not always sure how they can be
interpreted in helpful terms and worry about how therapy might go if I do. So I am setting myself a therapist challenge to look out for opportunities to learn from my clients about stories and metaphors from
religious and spiritual traditions that I am not familiar with. I look forward to the journey.
References:
Department of Health (2007). Single equality scheme 20072010. London, Crown Copyright.
Haque, A. (2004). Psychology from Islamic perspective: contributions of early Muslim scholars and challenges to contemporary Muslim psychologists. Journal of Religion and Health 43, 357377.
Huppert., J.S., Siev, J., & Kushner, E.S. (2007). When religion and obsessive-compulsive disorder collide: Treating scrupulosity in Ultra-Orthodox Jews. Journal of Clinical Psychology, 63, 925-941.
Office of National Statistics (ONS) (2001). Census 2001: Ethnicity and religion. London: HMSO.
Padesky CA (1993). Socratic questioning: changing minds or guiding discovery? [Keynote Address]. European Congress of Behavioural and
Cognitive Therapies. London, 24 September 1993.
Paradis, C. M., Friedman, S., Hatch, M. L., &Ackerman, R. (1996). Cognitive behavioral treatment of anxiety disorders in Orthodox Jews. Cognitive and Behavioral Practice, 3, 271288.
Stott., R., Mansell., W., Salkovis, P., Lavendar, A., & Cartwright-Hatton, S. (2010). Oxford Guide to Metaphors in CBT. Building Cognitive Bridges.
Oxford: Oxford University Press.

PLEASE NOTE: ALL CLINICAL EXAMPLES ARE ANONYMISED BEYOND RECOGNITION BUT BASED ON COMMON THEMES IN MY WORK AS A CLINICAL PSYCHOLOGIST IN ADULT MENTAL HEALTH SERVICES

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Who do they think we are?

Perceptions of Clinical Psychologists in the NHS

Dr Julia Cook: Clinical Psychologist

I recently met up with a friend who is a mental

health nursing student. I was curious about his
placements, and asked what he made of the clinical psychologists during the two he had completed so far on NHS inpatient units. His reply initially
jolted me slightly. I thought that he would have
a good insight about what we do as a profession,
considering we had talked a lot about my training.
Lets see what you think about his response...
He commented that on his first placement, someone unidentifiable had walked onto the ward in
large heels and that the nursing staff whispered
amongst themselves that must be a Doctor. An
explanation of who she was did not appear to be
forthcoming, or clear, but he eventually discovered
this person was a psychologist. He said that across
the two wards, the psychologists were hardly
ever there, would seemingly come and go as they
pleased, and had not really explained, nor did anyone seem to know, what their roles were.
Conversely, during an experience in a community
team, the psychologist seemed highly approachable, sat with the team despite having their own
office, and mucked in. The nursing staff may not
entirely have understood what this psychologist
was there for we dont know, but this psychologist was certainly perceived as one of the team.
Whilst this is anecdotal and not exactly peer-reviewed research, it got me thinking about what
other professionals think we do. Particularly as this
friend of mine knew of our role from what Id told
him. Many dont have that inside knowledge and
what on earth must they think? Who do they think
we are?

community mental health and medical settings.

What is probably clear to most is that in psychology we assess and intervene. But wait! Dont we
all do that, cry other mental health professionals?
Perhaps what distinguishes us is our strong theoretical grounding at undergraduate level, and
further teaching in order to apply that learning
during training. This acts as an aid to formulation
framed within the context of a variety of different
approaches. We are also taught throughout our
training to be scientist-practitioners, which not
only permeates each aspect of what we do, but
also contributes to our ability to inform practice,
evaluate our work, and the work of others to the
benefit of clients and service development.
The extent to which individual clinical psychologists share what they do in their roles with the
team might depend on the emphasis the role takes
and the service setting. A lack of formulations
shared with other staff, for instance, within the

Clinical psychology: professionally diverse

As clinical psychologists work within a variety of
settings, it would be reasonable to assume that
perceptions of clinical psychologists can differ
across these settings. Within a psychology-specific
team, the issue of beliefs around what psychologists do is likely to be reduced. Other areas we
work in include but are not limited to: inpatient,

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context of adult services where the focus is often
more individual, might impact upon team-members opportunities to enhance knowledge of the
role of clinical psychology. If someone is seeing a
large amount of clinical cases, this might reduce
their capacity to undertake service evaluation and
research. Conversely, if the clinical psychologist is
seeing more complex clients, they may see fewer
people, again bringing in to question team perception of them.

that I think there is a great deal of variance in terms

of roles, settings, clients, complexity, etc, but within
that we need to maximise opportunities to promote understanding of our role.
During one of my doctoral training placements,
I sat in through a number of psychology meetings during which the psychologists were trying
to justify the need to have separate psychology
meetings. The service managers felt these were unnecessary. Indeed, if this has to happen, I suspect
its fair to say that we dont know why we need to
have separate psychology meetings, or to some
extent, possibly, what makes us so special. Who do
we think we are? Perhaps we have lost sight of our
own professional identity to a degree.

The added value of clinical psychologists?

Perceptions of our role

I can only talk about what each professional group
might think about clinical psychologists from my
own personal experience and unfortunately, I
am biased within that. I suspect that our nursing
colleagues wonder why we get paid on a band
6 during training when they qualify on a band 5.
Perhaps rightly so; we are unqualified at that stage
and cannot take on our own caseload. We dont see
as many people, and were not even trained in any
specific therapy when we qualify! They might see
20-30 people per week and be specifically trained
in e.g. cognitive-behavioural therapy within a year
of qualifying. No wonder my friend was wondering
what these psychologists did that was supposedly
so special, and who they were.
Each professional is individual and it would be
unfair of me to label one particular group as feeling a particular way about psychologists without
evidence to back it up. What I will say, however, is

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We do have aspects of what we do that enable us

to tackle certain areas; our scientist practitioner
training makes sure of that. Without evaluation,
we would not know how to improve services, what
works, what doesnt. We can work with complex
cases, as highlighted in Aspire 5, and we can apply
different approaches dependent on need (Kiff,
2009). Our input might prevent children being
placed in care within child services, which saves
the taxpayer thousands for each case. We may also
act within a consultation or supervisory role for
other professionals. We can apply our clinical skills
at a service level to change and improve practice
(New Ways of Working for Applied Psychologists,
2007). These are critical roles for clinical psychologists in the changing coalface of the NHS. We need
to make these roles clear, tangible and quantifiable.
While these roles are more economical; there is
little added value in paying us on a band 7/8/9 to
be expensive therapists, such roles are obscured
by the bums on seats approach to seeing clients.
There is a pressure for each professional group to
see more and more clients, but essentially, while
complex clinical work should undoubtedly be
a part of our role, in large part our added value
is through these more leadership/consultation/
development based roles. If we do not have time
or capacity to justify, promote, or develop or even
place ourselves into these roles, then as a profession, we are left with a dim future! With clinical
psychology becoming more thinly spread, this task
becomes yet more arduous where does the time

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come from? We need those bums on seats! Or so
we are told. In some services, mental health roles
are almost made generic, including ours. Merges
like this, while helpful to team working and reducing hierarchies, will undoubtedly push professional
identities and the concept of adding quality further away.
During my years on clinical training there has been
a shift toward leadership, teaching and supervising
others as above. It seems that training is, at least
in part, tackling this need. However, I question
how well this will be received in the changing NHS
climate of austerity, particularly with the difficulties
and possibly professional reticence we have experienced in promoting ourselves thus far.

What can we do?

In our day to day practice we can share formulations with colleagues, hold case discussions to
promote concepts of formulation and evaluation,
co-work cases, supervise and informally chat with
colleagues, perhaps share office space with them
when we can so we are seen as accessible and part
of the team. More broadly, as a profession, we need
to have a serious think about our role within the
context of the NHS and how we can change the
perception of our profession from being somewhat
poorly defined. A united approach is called for.

Conclusion
So regarding my friends previous comment, I
dont think this is his ignorance, but a professional responsibility to promote what we do that has
been somewhat neglected in the areas in which
we work. It is not the first time I have heard someone question what we do and I do not think it
will be the last. Fundamentally, fellow colleagues
should not be asking who is that and why is she
here? when a clinical psychologist turns up having
worked there for considerable time, albeit sporadically (undoubtedly due to being thinly spread).
As I write this, I find myself thinking that a focus
group with a range of NHS staff would be incredibly useful to conduct. We could then find out more
directly about how we are perceived, and consider
ways in which we could helpfully promote what we
do, which would be directly relevant to the understanding of our fellow colleagues.
The impact of others not understanding our role
fully is far-reaching in its effects it will affect us in
clinical, professional and organisational ways and
will affect the clients and teams we work with. We
have many skills, only some of which are outlined
here, that we can capitalise on. First, however, we
need to address the broader issues of quantifying
our added value and promoting ourselves in terms
of what we do and how we can be helpful. The fact
that in many areas, we perhaps have not given this
due consideration, might lead to the current difficulties we are faced with, which makes it harder
to do. It becomes a vicious cycle, and usually were
pretty good at dealing with those, right? Lets start
now!

References
British Psychological Society. (2007). New ways of
working for applied psychologists in health and
social care: Working psychologically in teams.
Leicester: BPS.
Kiff, J. (2009). The Kiff Curve: An integrative model
for thinking about the provision of clinical psychology. Clinical Psychology Forum, 204, 46-50.

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Rumour Mill
Spatch

Rumour: You have to be a genius to get onto training

Answer: No

There are a lot of strange ideas about the require-

ments and aptitudes for clinical training. On the

surface it looks formidable; applicants are expected to be shining in clinical, academic and research
areas and be reflective, personable, and naturally
adapt to a range of clinical settings like a duck to
water. When you read about successful applicants
they all seem to have amazing CVs and sound so
knowledgeable on the forum. Its so competitive
and a doctorate at that, which surely must mean
trainees have to be very, very smart.

However, if one was to look at a cohort of trainees, while they may have some experience and
competency in research, academic and clinical
settings they are by no means an expert in all
these areas. Similarly, although most trainees will
be bright they are not required to have a genius
level IQ. For better or worse, the majority of clinical psychologists tend not to win Nobel prizes,
invent new fields of knowledge or crack unsolvable problems (if intelligence is actually associated
with these things, which I am not sure it is). In fact,
one may even argue that such a person may find

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it difficult to deal with the humdrum routine of

everyday clinical work. Its essential to remember
that CVs are written in a way to show off a persons
most notable achievements, and people pick up
the language and knowledge as a result of being
around more clinicians, gaining experience in
various posts, and reading a few books rather than
being great intellectuals. Also on the forum people
have a tendency to talk or post about what they
know (and remain quiet when they dont), so what
you are hearing is the combined knowledge of a
collective, with none of their weaknesses or the
areas they dont know. What trainees (and qualified psychologists) will be is generally competent
in a few areas, but by no means exceptional at
everything. All will have strengths and weaknesses,
some learning needs and make use of training to
develop their skills across three years. Most do find
it hard, if only because they are forced to do things
they may be weak at or not used to. What trainees
are; are usually driven, motivated, conscientious
and open to learning. They are encouraged to be
reflective and communicative which, for the client, is probably much more important than being
clever.

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The Communications Papers: Noise!

Adrian Brady

Many, many moons ago; in my undergraduate

years; I was taught communications by a very
inspiring woman by the name of Barbara. Sadly,
though her work inspired me greatly, her family
name has been lost to me as the ravages of time
continue to play merry hell with my memory.
Barbara was the first person, to not only introduce
me to the subject itself but also to the concept
that everything is a communication. This notion
has stayed with me throughout my life and although now I would qualify this statement somewhat; it is at least ostensibly true. Communication
is a descriptor that can be applied to anything
providing that a receiver is both extant and aware
of the message communicated.
The problem for the statement in my view is only
that a receiver; if extant; is often unaware that a
communication is taking place. If; for example;
you see a tree, the chances are you are also seeing
myriad messages play out in front of you, from
reddening leaves to heaving boughs. Some of
these messages are dependent not only on the
tree itself but also on the time of year of course,
some on such natural forces as the wind and still
others may be dependent also upon the health of
the soil it grows in. However many dependencies it
may have as a medium however, a tree can be seen
as a strikingly verbose media system if you know
what to look for. The fact that we pass such wonderful communicators on a daily basis without a
thought for what they can tell us indicates not their
effectiveness for communications, but instead perhaps our inability or desire to decode the messages
they actually send.
If it is true that everything is a communication (at
least in potentia); then it is most certainly true that
communication is potentially subject to noise.
Noise is not what stops us from noticing a communication; as we might when we pass by a tree
without really noticing it; noise is what stops us
from understanding what it is the sender is trying
to convey.

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Noise is one of the easier ideas to grasp in communications theory and youll come across the idea
made manifest in your everyday life quite frequently. In professional lingo noise is oft referred to as
communications barriers. Noise is absolutely anything that impairs the transmission of a message
from a sender, to a receiver.Noise is something
everyone in psychology will come across at some
stage, from the simpler functional noises, such as
the background chatting that stops you from being
able to have a conversation; to the more complex
emotional noises inherent in your profession.
An example of such a noise may be that of a racist;
he who allows the colour of a persons skin to affect
his perception of the individual will undoubtedly allow this to also colour his reception of any
message originating from a sender with different
coloured skin. This noise is something that affects
the more compassionate among us too, those who
have no such predilection to judging people by

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such things as a particular race; in talking to the
racist we recognise that he is more likely to use
words which elicit a strong emotional response
and this may make it harder for us to analyse his
communicative output fairly due to the bigotry
we fear he may espouse. This psychosocial noise
is an emotional barrier and is distinct from the
background chatter that constitutes the functional
noise we would more easily recognise in everyday
life.

receiver paradigm, where Emotional is inside. Its

important to note here though that many theorists would argue this definition quite aggressively.
My emotional noise definition resolves around the
construction of meaning rather than the construction of the message and for some therefore it is
largely irrelevant to the process; I would however
argue that this misses the entire point of what
constitutes a message, which, if Barbara was right
is potentially anything.

Most theorists will tell you there are several types

of noise and although there is no such thing as
a definitive list, my own list of noise types is two:
Functional and Emotional. A functional noise is
any other message which takes; or attempts to
take precedence over another, such as others
chatting in the background as you try to take
a phone call. Emotional is anything elicited by
ourselves and our expectations of others behaviour. Functional then is outside of the sender and

If we return to our tree as mass media analogy,

then a functional noise could be someone chopping down said tree. It would make it very hard I
wager to attribute the heaving of the boughs to
the wind were someone hitting it soundly and
continuously with an axe; certainly the message
would still be there, but the noise is impairing
transmission, the introduction of a new message
has impaired the transaction of the old (how do
you know if its the wind or the axe heaving the
boughs?) As for emotional noise of course, one
could argue that you arent going to listen to
anything a tree has to say if you suffer from dendrophobia.
That you have a box to try and separate your
examples of noise into though is largely irrelevant,
that you recognise it for what it is, is not. Noise can
play an important part in our lives and if we dont
recognise it as such and take steps to mitigate, it
can make picking up the whole of a given message a lot more difficult.
You have no doubt already come to the conclusion that noise plays a big part in psychology, as
indeed it does. A lot of what you may have to deal
with in a therapeutic environment we might call
noise. Im sure you can imagine just how much of
an effect someone cutting down a tree outside
your office could have on a therapy session, but
imagine how it might be for someone hearing
voices. What is it then that is defined as the message and what as the noise? Is the therapist the
message and the voices the noise or vice versa?
Perhaps that depends on your perspective or perhaps it depends on who at the end of the day is
most convincing... perhaps it depends a little upon
both.

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Book Review

A Comprehensive Guide to Suicidal Behaviours: Working with Individuals at Risk and

their Families
Peach

This book provides a thoroughly engaging

and informative overview of one of the
most difficult and sensitive topics in mental health. It is well evidenced and takes a
sensitive non blaming attitude towards suicide. Written by experts in the field, suicide
is examined through an interdisciplinary
approach that looks at the individual and
social and cultural context of the communities they are embedded. In particular, the
authors make a compelling case for the role
that the family can play in suicide prevention, whilst also carefully avoiding the attribution of blame. It is aimed at professionals
who work with people at risk of suicide
and succeeds at providing enough relevant
information for this audience.
However the clear writing style makes the
book accessible to anyone with a passing
interest in the subject area. The historical
and cultural context of suicide is explored
with the examination of suicide in the bible
and the arts. Although this chapter is very
interesting it delves very deep into history
which initially seemed off tangent. However the authors do well to relate historical
examples to our understanding of suicide
in the modern day context thereby successfully integrating these chapters within
a wider context of the book. In addition to
the historical overview of suicide, practical

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information is provided for professionals

on psychotherapeutic techniques and a
description of how to discuss suicidal ideas
with a person at risk. The material provided
consists of very clear, simple questions to
ask and important issues to consider. These
sections in particular would prove to be a
useful basic framework for professionals
working with people at risk of suicide. Some
fascinating points are addressed throughout, such as the concepts of legitimate and
illegitimate suicide, also the cultural and
moral comparison of individual suicide vs.
martyrs/suicide bombers with the consideration of how these acts are perceived
both within a particular culture and outside
of it. Despite the potential for controversy,
the authors provide a carefully considered
thought provoking comparison. The multiple viewpoints from which these points
are considered adds to the credibility of the
book and makes for a very interesting read.

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countries pertaining to suicide websites is
A chapter dedicated to some of the comdiscussed. The chapter ends with a good list
mon myths, fears and assumptions about
of suggestions from the authors about how
suicide with clear logical evidence provided to mitigate some of the risk of the internet
to debunk many of these ideas is particuin suicide.
larly excellent. They address many of the
misconceptions that make suicide a taboo
Further suggestions from the authors are
topic of discussion. Most significantly, the
made in the final chapter in the book which
authors stress the importance of attempted is dedicated exclusively to suicide prevensuicides and how the dismissal of such acts tion techniques. Interventions on both a
as attention seeking behaviour should be
local and community level and also national
avoided and instead should be recognised
and international scale are outlined, with
as an indication of need.Another chapter
some consideration given to indigenous
describes the different classifications of su- populations. The multilevel approach the
icide such as hard methods (violent means authors take to their interventions is very
e.g. shotgun) vs. soft methods (non violent useful as it considers the issue of suicide on
means e.g. overdose) and completed vs.
both a micro and macro level. Despite the
attempted suicide. The authors importantly usefulness of these suggestions, a major
highlight how such labels can trivialise the criticism is that the authors fail to explain
nature of the act. Given the emphasis the
what prevents these interventions from
authors stress on the social and cultural
already being in place; or; if they are already
context of suicide, the failure to consider
in place, why they are ineffective. Although
different cultural classifications of suicide is it is not expected that the authors have all
a disappointing oversight. Nonetheless, the the answers it is a large oversight that the
authors highlight that within other cultures practicalities of implementing interventions
suicide is still a taboo subject and under
is not given more considerationIn concluresearched and this may go some way to
sion, A comprehensive guide to suicidal
explaining the lack of exploration of other
behaviours is a very interesting read and
cultures in some chapters. The dual role of
successfully achieves its aim of providing a
the internet in the propagation of suicide
broad overview of suicide. The theoretical
and the potential utilisation for suicide
information and understandings of suicide
prevention is explored in a later chapter.
are well balanced with practical tips and
This is very relevant given the significance
advice for professionals. Considering the
of the internet and digital media in society. breadth of information covered, the book
Particular attention is given to the danger
succeeds at being commendably concise,
of online suicide pacts and websites that
clear and useful. Overall this book is a very
promote suicide. This is particularly intergood read for anyone working with people
esting as real life case examples are deat risk of suicide or with a general interest in
scribed and legislation in various different
the subject matter.

www.ClinPsy.org.uk

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Review: WASI 2nd Edition

Greg
The Wechsler Abbreviated Scale of Intelligence
(2nd Edition) is a short cognitive assessment
consisting of four subtests, two examining Verbal
Comprehension and two examining Perceptual
Reasoning. The test is designed for participants
aged between 6 years and 90 years old. It should
be noted that the following review is of the use of
the test rather than of its validity or reliability, evaluation of which is far beyond my capabilities.
There are four subtests which make up the WASI-II:
Block Design, Vocabulary, Matrix Reasoning and
Similarities. All subtests which anybody who regularly uses the Wechsler range of tests will likely be
familiar with. As such the test is simple to administer if you have any previous experience with any of
the related tests.
The main difference between the WASI-II and other
scales, such as the WISC-IV, is the discontinue rule.
The discontinue rule in the WASI-II is lower, thus
participants are not subject to the disheartening
task of having to answer up to five consecutive
items which they do not know the answer to. This
is something which can be a particular issue on the
WISC IV when participants may get 4 items incorrect, followed by answering one correct, leading
them to have to complete another 5 items. During
this time participants may start hoping for a natural disaster so they can be removed from a situation where they are asked to consider the meaning
of Garrulous, Dilatory or Aberration.
The record forms are clear, simple and easy to complete. However, the Abbreviated in the Wechsler
Abbreviated Scale of Intelligence may well refer
to the record form as well as the test itself. Unlike
record forms for other tests in the series there is
no space to record discrepancy analysis, despite
the tables for calculation being provided in the
manual. Furthermore, while it is particularly useful
that a table for calculating age equivalent scores

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is provided, again there is no space to record this

on the form. Maybe this is me being anal, but I just
feel I would have more satisfaction if there was a
neat box to place the age in rather than having to
scribble it alongside raw scores.
The WASI-II comes with a manual which is easy to
navigate. Once again, if you are familiar with other
tests in the range, the manual is in the same format and as such is simple to get to grips with. Yet,
unlike other manuals, this one comes in paperback.
Often I find it useful to stand the manual up. This
way I can complete the record form behind it, and
I can be sure participants will not be able to see
the answers. This manual falls both short and over
in this respect. Likewise, the stimulus book is also
a paperback and so cannot be stood up to allow
participants to view the contents with more ease.
Having discussed the WASI-II within our team it
was hypothesised that the format makes it more
generous to people with Learning Disability and
meaner to those with very high IQ. This was based
on the idea that having only four subtests may
make high/low scores less unusual to sustain. This
was a speculative idea but could make an interesting research topic.
Despite these issues with manufacturing overall
the test is simple to administer, score and interpret. This is particularly true if you have done so
with any of the other tests. Yes, Pearson could do
with being less stingy and spend an extra couple
of pounds on providing more robust materials
and adding a supplementary analysis page to the
record form. But, with the less stringent discontinue rules and the same consistency of design as the
other tests in the range I would highly recommend
its use.

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Clinical Vignettes

Spatch.

Life in psychology moves fast and the path to qualifying is filled with
adventure and happenstance. Out of the hundreds of stories out there in the
naked city, here are some of the people you may meet, or may even have
been, on the journey.
No 2. The Assistant Psychologist.
Its 9:00 am Monday morning and even though
its first thing, you can barely remember what you
are supposed to be doing. In the tiny grey painted
cubicle that serves as the teams store room/ left
luggage depot/ your office you flick on a pre-historic computer (complete with Windows 98) and
listen to it whir into motion. Its too early to try
to go out and grab a cup of coffee from the staffroom vending machine. In fact thats probably a
good thing. You think that things have started to
live in that machine.

Its one of those days you wonder what you are

doing here. The pay is so little it could almost be
theoretical, the hours are deadly and you have the
nagging sense that you are trading your youth on
a daily basis. You noticed your first grey hair in the
toilet mirror yesterday, and arent altogether that
surprised. But its your first gig and you need the
experience desperately. It has been now 25 minutes and the computer is slowly warming up, but
you know its going to be another five before you
get to log in and check your email. Your boss (a
curious phrase, as the team dogsbody technically
everyone is your boss) has sent you a request for
20 copies of the standard inventories and to have
them ready by 10:30am. Seems simple enough

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right? The reality is that each 49 page copy is thick

enough to choke a dinosaur, and the photocopier is ancient enough and slow enough to have
featured in the Flintstones. For a split second you
think it may be quicker to draw each copy out by
hand. It will take most of the morning to do 20, and
they want them by 10:30 am? Yeah, right. More like
10:30pm.
Next door you can hear Monica, one of the Community Psychiatric nurses, laugh uproariously
about the events of the weekend. No doubt it will
be the latest chapter in the saga of Monicas lovelife that some would call colourful and others
alarming. Not for the first time you are grateful to
be on this side of the wall. If you were to leave your
cubicle and relocate to the main team-base, you
would have to deal with the ongoing turf war that
makes the Bosnian civil war seem like a mild disagreement. The medics guard their window seats
jealously from the nurses, who begrudge the OTs,
who in turn are a bit iffy about the dieticians. The
only thing that holds them together is the fact that
everyone blames the social workers. The territory is
demarcated like Berlin after World War II only substituting the printer and dying pot plants with, the
barbed wire and machine gun emplacements.
You decide to at least make an attempt to make
the copies, which will keep your supervisor happy.
You creep up onto the fourth floor, the domain of
Regina the Dragon. Although her job description is
that off secretarial support for the whole place, the
whole team realise that the only way to deal with
her is to use a mix of bribery, pleading and coercion. She spots you, and the chair swivels with an
unearthly speed.
What are you doing here and why? she asks, in
the manner of a Gestapo officer.
I am just using the copier.

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Aspire
You dont have an account number This cannot
be denied.
I am using Valeries, its for her
You...arent...Valerie she finishes. Looks like game,
set and match to Regina, but you have one last
serve.
Fine, I will go back downstairs and tell her. You say
feeling like an 8 year old snitching. She sulks for a
moment and then nods her head.
Dont make a habit of this! she warns darkly. You
wont. You have no intention to repeat this if you
have any choice in the matter.
You try to get the copies done as quickly as possible. You practically have to babysit the vintage
Olivetti, feeding it like a restless, squirming child in
a high chair, until it jams its mouth shut defiantly
refusing to eat any more. Sadly it decides that it

wants to stop part way through copy 18. You try to

hold back the tears, but before you can think of it
too much, Abraham one of the other CPNS comes
up and pipes up. Val wants those copies now. And
by the way you have to update the room booking
database this afternoon. You reply I am supposed
to have supervision... but its too late. Trying to
find supervision around here is like trying to find
Eldorado. The trainees get in first, the others, then,
you... if there is time... and you are lucky. You keep
telling yourself you won this job over hundreds of

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other applicants, its your first step on the way to

the promised land - the holy grail of clinical training. Its the main thing that keeps you going.
You motivate yourself enough to go down and
load up the database. Its worse than you imagine,
the database hasnt been updated for three weeks.
This will necessitate braving the no-mans-land
team base and getting everyones room requirements for the day which will elicits grumbles of
resentment and the inevitable What do you mean
I havent booked it? I just need a room. I dont care
if someone else wants it I NEED it. Repeat 12 times
and rinse.
This pales into insignificance when entering the
bookings into the relentlessly unforgiving database system originally set up when some long
gone previous assistant psychologist set it up using a cryptic method taken from the Da Vinci code.
Data entry is no mean feat as the system will not
tolerate any errors, and one wrong number entry
will mean its back to square one. You start to hate

this database with a vengeance.

By now its lunchtime. In a macho display of
one-upmanship everyone takes pride in eating
in under 10 minutes. Lunch is for wimps, and the
hardcore members eat at their desks declaiming
those that sit in the staff room as being sissies and
having too little to do.
At least its only a year right?

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Gillystrations

by Gilly

In the face of steep competition, applicants try more 'traditional' methods...

The Caption
Competition
The last round of
budget cuts hadn't
left any psychologists
in the department so
the admin staff had
to improvise.
BenJMan

www.ClinPsy.org.uk

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Provided by CatBells, eponymous85, BicycleClips, sar302, WorkingMama, mali, FuzzyDuck and Campion.

All her hopes on the DClin were hung

So the graduate merrily sung
Ill brush up on my Freud!
But was rather annoyed
When the course said Sorry - youre too Jung!
There once was a young psych assistant
Whos methods were rather persistent
Every hour shed pester
For an offer from Leicester
Til her chance of success was quite distant.
Its new application season
When future trainees lose their reason
Every second they check
Theyre a nervous wreck!
Til the clearing house says theyve released em .
A young lad I know whos high aiming
He wanted to get on to training
But preceptorships rare
Stability no longer there
His interest is sadly now waning.
Working for the NHS
Can at times cause considerable stress
You ask Is this worth it?
Do Assistants deserve it?
The answer - quite probably yes!
Not enough stress in your week, you sigh?
In the grand scheme of life youre small fry?
For a shot at a job
That is not in a pub
For the DClinPsy now apply!
Theres a redundant psychologist called Fred
Who toiled years helping fix peoples heads
But the clinical commissioning consortia,
Ordered cost savings south of the border
And purchased e-therapy modules instead.

www.ClinPsy.org.uk

For those attempting the dreaded Clin Psych race

Be prepared for the trials and tribulations you may
face
It can be a lottery and you may get 4 Nos
But theres always next year my friend so give it
another go!
Feels like Charlie with the golden ticket if you get
that elusive place.
I could not make my mind up between
psychodynamic therapy and CBT
and as much as I try
to finally decide
my subconscious is analysed anyway
The BPS had a CP in a muddle
as she thought signing up was a doddle
while she browsed and she searched
and fell behind on her work
turned out twas the Biopsychosocial Model.
Binet had the strangest behest
Sorting children by brain? You doth jest!
He came up with a few
different questions to do
thus began the first named IQ test.
There was a girl with a 2:2,
for the DClin a terrible stew.
Would working be best?
Put a masters to rest?
She didnt quite know what to do.
Freud was a young man like no other,
so incredibly close to his mother,
one day from his lip
came a terrible slip
for he said her name stead of another.

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