Sunday, 9 December 2007

What is Clinical Psychology?

According to H J Eysenck, Emil Kraepelin ought to be recognised as the founder of clinical psychology, because of the methods he used.        But I always imagined that the first clinical psychologist - in terms of an embodiment of the logos of the discipline - was Pierre Janet

Perhaps I can get the meaning of the title's question into focus by distinguishing it from readings which invite answers such as the following:

Wikipedia: "Clinical psychology includes the scientific study and application of psychology for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration."

British Psychological Society: "Clinical psychology aims to reduce psychological distress and to enhance and promote psychological well-being. A wide range of psychological difficulties may be dealt with, including anxiety, depression, relationship problems, learning disabilities, child and family problems and serious mental illness. To assess a client, a clinical psychologist may undertake a clinical assessment using a variety of methods including psychometric tests, interviews and direct observation of behaviour. Assessment may lead to therapy, counselling or advice."

These answers tell you what clinical psychologists do, but they don't tell you how they do it. Or better, they don't tell you about the spirit in which it is done, the fundamental attitude towards its object (e.g. the client in emotional distress) adopted by the psychologist. In this and related posts I want to consider this question - the question of what might be called the
logos of clinical psychology. I shan't be supposing that every or even any clinical psychologist - defined in terms of someone with the requisite qualification - manages to embody this logos for much of the time, even when practicing clinically. Yet it is, at least, the form of that particular disclosure of the individual human being, imminent within the possibility of a distinctly clinical psychological practice, actualised when and where ever it is, that interests me.

"Ah", I hear someone say, What you mean is the model the psychologist uses." The
scientist-practitioner model, for example, or the reflective-practitioner model. These are descriptions of the ways of being a psychologist - the psychologist as applying scientifically gathered knowledge to the psychological needs of the client, for example, or the psychologist as thoughtfully directing their practice through reflection on their own ongoing experience. And yes, that is nearer to the sense of the question, but still not quite there. For these are prescriptive models for psychological practice. What they give us are precisely models. Whereas what I am after is a reflective account of what good clinical psychological practice is, of the logos immanent within it, not an external guiding model of how it should be conducted.

"But how do you know there is any such 'logos'?" I hear another psychologist ask. Such a response is perhaps almost a reflex these days. "If you want theory and fundamentals, then turn to the model. If however you want to uncover 'fundamental attitudes' then, well, all we have are the shifting sands of attitudes of psychologists feeling one way or the other towards their patients, in this or that setting, from this or that training, with this or that character." Now if there's one thing I want to achieve in this particular blog posting, it is the recognition that this kind of institutionalised reflex response may well contain a kind of prejudice, a prejudice which excludes without reasoning a kind of patient attempt to uncover meanings which one may be embodying without realising it.

Let me say up front: "Of course, I don't know that there is any such logos". But, well, lets look and see. I'll suggest something, and you tell me what you think. Have I uncovered something or not? What I do want to avoid is a kind of thin 'empiricism' or 'positivism' which too often seems to lodge itself in the
culture of clinical psychology, a tendency which questions the value and meaningfulness of questions which cannot be easily answered with recourse to either a definition, or to a fact (ideally a scientifically derived fact), or which, if such options are not available, is simply dropped into a 'pending' tray until the chance arises to collect such a fact (through an experiment, say). A beguiling straightforwardness is the name of the positivist's game, limited patience with vagueness one of its key parameters. 'How could you test that?' is a core mantra of positivist psychology, the implication being that, if you can't, then the question needs refining. The idea that there might be a non-perspicuous essence to the discipline, then, is something which is unlikely to convince the positivistically minded. What is essential comes from a combination of the definitions within the explicit models, the guiding theories that have been proposed, and the established facts of psychological science. From such a perspective, the attempt to unearth a hidden logos to clinical psychology might seem like nothing other than an unacknowledged strategy of foisting one's own explicit model onto the discipline, whilst pretending that it is not merely an idiosyncratic personal perspective on it, but rather something essential in it.

So, without pretending to know in advance whether I am uncovering or foisting, let me at least put forward a suggestion. My suggestion is that there is something deeply ironic in such a clinical psychologist's positivistic response to the phenomenological attempt to unpack the logos of clinical psychology. It is ironic because an essential part of what it is to practice clinical psychology, I want to suggest, is to be able to notice and step back from, and encourage the client to step back from, the narrative structures which have, without the client realising it, framed their experience. Of course one listens empathically and respectfully to the story that the client presents, in the terms in which it is presented. That is perhaps even the most important thing. But it isn't enough, and doesn't distinguish the psychologist from, say, the counsellor. For what the psychologist's client needs, perhaps why they have come to you as a clinician, and what their sometimes extraordinary trust in you has to do with, is: a quite different perspective. They have come because they are stuck, because their own many attempts to solve their problems have not worked. There is perhaps a dawning recognition that there something 'underneath' all of the problems they have faced and all the solutions they have tried, something which needs unearthing. We might or might not describe that as the 'unconscious'; here at least I wish to avoid the implications of a motivated unawareness that that term brings with it. The psychologist's job - for which their fundamental guiding sensibility or logos prepares them - is the unearthing of such hidden frames of meaning, and the ability to not get caught up in them, the ability to notice them in the first place, and the ability to bring into the foreground, for the client, what had previously tended to frame their entire perspective on their difficulties. Hence the client's extraordinary trust: they hope (and perhaps fear or resent) that the psychologist will know their mind better than they themselves.

Let me first touch on the irony before returning to the claim about the logos which will later be unpacked with an example. The irony is that, whilst in practice clinical psychologists are experts at not getting caught up within the frame of the client's experience and self-understanding, the influence of positivism has, I believe, meant that psychologists have been unwilling to stand outside certain framing assumptions of their own self-understanding as professionals. The spirit of positivism provides certain criteria for meaningfulness - ideas must be readily intelligible within an agreed framework, must be testable, or be true by definition. The biggest and well known irony here of course is that the positivistic criteria do not pass their own test. They cannot be read off uncontroversial definitions of meaningfulness, and it is hard to see how they could be brought to the test. The idea of trusting a philosopher, or even of trusting one's own 'inner philosopher' (i.e. trusting in their own capacity to ask and answer philosophical questions), someone with the capacity to notice the tacit acceptance of intellectually or theoretically framing assumptions - does not in my experience come all that naturally. (cf Hubert Dreyfus on 'breadth' psychologies.)

But yes, back to the claim about the logos of clinical psychology. The point can I believe be made for a variety of different therapeutic strategies - narrative or behavioural or psychodynamic or mindfulness or systemic or neurological or what have you, although it is really the way the theories are used rather than their content that matters for the point I am making. But let's start with a simple behavioural case.

Someone is depressed, caught up in an experience of the world and a self-image structured by rumination, deprecation, and pessimism. They are lost within their own thought, and the emotional grammar of the narrative they are living has no place in it for openness, hope, spontaneity or laughter. Now for such a person in such a state, reflective listening does help, of course it does, as does acknowledging the reality and validity of their feelings. Sometimes this alone, along with the sense of recognition and acceptance as the person they are that such listening conveys, may be enough for the client to themselves spontaneously recollect the missing 'grammar', and thicken or shift sideways the narrative of their life. But at other times the relentless inwards focus and negativity is hard to shift through listening alone. Simply arguing with them about their value judgements, or encouraging them to argue with themselves, may also occasionally help, but will often be unhelpful. And the reason it is often unhelpful is that it just urges a change within the story, and does not enable a different kind of story altogether to be told.

An example. Here would be two tunes unhelpfully in the same key as the client's that a clinical psychologist who is failing to embody his or her logos might play: Try to help the client find reasons for living (love, walks, nature, sport, children). Or try to help them recollect the good deeds they have done which constitute their entitlement to their life. These responses might provide momentary relief, and they might well work for the mildly depressed, but they are not what the client who is seriously stuck in a frame really needs. They do not enable the client to change the frame. The basic assumptions underlying the narrative: that a meaningful life is one lived for reasons, or that one has to earn one's entitlement to the gift of life, are left unchallenged.

To return to the behavioural treatment of depression. What the psychologist does who is embodying her logos is, I believe, to focus not on the thoughts and feelings that show up within the client's frame, but rather to consider the maintaining factors of the frame itself. And this first involves the taking of an attitude to the client which, whilst respectful, is noticing of the simple fact that they do have to do here withh a frame, with one amongst others. The client is feeling unmotivated, and can't find any reasons to get on with their housework. The psychologist knows that motivations don't typically precede any and all action, but are rather created in and through a living engagement with the world. So activity is prescribed, activity which will break the frame in which the world is set over against a self which itself has retreated even from a body now experienced as a heavy obstacle. Activity which will instead develop a frame of meaning which discloses the world under a different aspect. Activity which encourages the taking of the world or of others for the object of thought and experience, and not the self. Activity which does spring first from a reflective 'top-down' recognition of the reasons in life for which that activity should be done, but activity which constitutes one strand of the unfolding of a life, which 'bottom-up' unfolding itself generates the missing meaning.
It is this capacity to notice and to operate at the level of the frame rather than the content which, I want to suggest, constitutes the logos of the clinical psychologist.

Many things stand in the way of the clinical psychologist's self-understanding. For example, the definition which heads this report seem at least tacitly to suggest that it is the clinical psychologist's scientific approach which is essential to their identity. What I want to suggest is that this often satisfies only because it touches on the right issue whilst theorising it in a wrong way, albeit a wrong way which satisfyingly generates kudos by trading on the prestige of the natural sciences. That is to say: what is essential to the 'scientific' approach in its clinical applications may not the extent to which it grounds the practitioner's interventions in the evidence base, but rather the extent to which it enables the practitioner to maintain a firm grip on the need to not only understand the client's own perspective, but also to more cooly consider the framing assumptions of that perspective. (cf Jonathan Lear's subjective objectivity.)

This is what seems valuable to me in the above-mentioned therapeutic approaches and the frutiful metaphors they employ which constitute the foundations of their theorisations of human distress. Whether it is seeing the client as in the business of embodying narratives which are less optional than they had considered (narrative therapy), or bringing out the framing role of the total systemic pattern determining the behaviours of individual family members (systemic family therapy), or understanding the significance of helping the client to alter their relation to their thoughts and feelings, rather than attempting to alter the thoughts or feelings themselves (mindfulness therapies), or looking at the environmental reinforcers of behaviour rather than, say, only at the meanings the subject understands their experience to hold (behavioural therapy), or encouraing the 'mentalisation' (recognition as such and feelingful acknowledgment) of feelings which otherwise overwhelm and are 'projected' onto the world (psychodynamic therapy) - may not matter so much as the simple fact that what they are offering is an opportunity to step outside of the framework inhabited by the client and to work directly with this framework.

It is then, I think, simply wrong to view the different therapies just mentioned as simply holding to different 'theories' of the origins and maintaining factors of psychological distress. That is a shallow understanding of their value, which value I suggest is not simply to theorise, but rather to promote what the narrative therapists describe as the 'externalisation' of the client's framing narrative. Able to see the frame, the skilful psychological therapist is able to help to open up a gap for the client between themselves and their framing assumptions. Inevitabilities which were not even noticed as such now become options amongst others, and the client is freed from the tyranny of the endless stories which their depression, for example, told them about who they were. Sometimes the psychologist invites the client to join them in this recognition of the role of the tacit frame, and to actively and cooperatively set off on the somemtimes frightening journey of shifting it. Or at other times the psychologist may feel they need to take an 'expert' role, introducing changes to the frame themselves. Whatever one thinks about this, however, it is surely not defining of the psychologist's logos, but rather simply determines the individual preferences of the clinician.

I want to note one consequence of the approach towards the essence of clinical psychology that may strike some as strange, perhaps even absurd. This is that cognitive therapeutic attempts to promote change in beliefs, or psychoanalytical attempts to foster straightforward insight, are excluded - almost by definition, as it were - since they work at the level of what shows up or is hitherto hidden within the frame. I am not convinced however that this is all as bad as it sounds. For, on the one hand, the cognitive behavioural tradition has itself come to question the value of cognitive restructuring, instead promoting the value of changing the client's relation to their thoughts and feelings, rather than trying to change the thoughts and feelings themselves. On the other hand, psychoanalysis is hardly reducible to a form of clinical psychology, and in any case typically depends only to a small degree upon insight. Taken in a relatively pure form it provides a forum for regression and renewed development, an intensive relational encounter between analyst and analysand, the development of play and mental flexivbility, the analyst's containment of the client, their metabolisation of the client's projective identifications, etc. And that is simply another enterprise altogether than the one I have described as clinical psychology. Nevertheless, in applied forms, psychodynamic psychology has also moved away from the idea of change occurring through insight, to that of the importance of (for example) mentalisation. And here once again we have the idea of the client coming to an altered relationship with their feelings. Where what is important is to be able to develop the capacity to recognise one's feelings as feelings, as containing a perspective, information, as representing other people and relationships fairly or unjustly. The client thereby gradually becomes able to stop being lost in their feelings, looking out through them unawares, and instead to appreciate them for what they are - as containing perspective. As psychoanalytic psychotherapists from Irving Yalom to Anthony Bateman have suggested, what may then be important about interpretations, when the therapist does give them, is more the process of mentalising that they embody and inspire than the particular content they carry. (Interpreted another way, it could be argued that actually what any 'good' insight interpretation achieves is just this: the moving of a desire or fear that had been structuring a client's world from the framing background to the visible foreground - into the 'clearing' as Heidegger would say. Perhaps it is only the ways in which we have tended to theorise what insight interpretations are that causes the appearance of incompatibility mentioned above.)

If this really does capture what I have called the 'logos' of clinical psychology, why has it been hard to recognise it? Why does this fundamental skill, of combining the counsellor's 'subjective' empathising with the psychologist's 'objective' 'externalising', not feature in the definitions on the BPS website, or in the textbooks? I suspect several reasons:
  • Psychologists learn this skill unawares, on the job. They develop it as a clinical skill, and are hardly aware of doing so. In part it is a skill which develops naturally, simply through having the clients they do and from learning the therapeutic models they learn (which implicitly promote the skill in question).
  • The power of 'positivism' or 'empiricism' in psychology means that ideas of the clinical psychologist as fundamentally a scientist practitioner - or the emphasis in post-positivistic understandings of the clinical psychologist as fundamentally guided through inner reflection, or as developing a new product for the client through mutual co-constructions - maintain their status. We can also cite the prestige of the natural sciences - or of hermeneutic accounts in the human and social sciences - as responsible for this.
  • It is hard to maintain the capacity to become empathically aware of the client's framing assumptions (although noting one's countertransference may help). And it may seem disingenuous to define 'clinical psychologist' in terms of something they often fail at, and easier to define them in terms of the people they serve or the general job they do. (We need to remember cases where we are inclined to describe a 'good' X as an X the essence of which is more fully realised.)
  • It might feel morally easier (less uncomfortable) to disown the power which comes from holding onto one's understanding of the client's framing assumptions, the phantasies which structure their world - and to humbly throw oneself into a kind of non-expert co-traveller relationship with the client.

So let me finally return to the question of the logos of the clinical psychologist. When I ask a clinical psychologist what it is to be one, they typically say: "Ah yes, a clinical psychologist's identity comes from their being a jack of all trades. I do assessment, formulation, this or that therapy (hey, I get to choose depending on the circumstances), neuropsychological assessment, consultancy, supervision, etc...". But, you know, I'm not convinced that the essence of clinical psychologist is so distributed, and so reducible, as that. It seems to me that what is forgotten here is something essential and something important about the clinical psychological identity, something which makes itself manifest in all of the psychologist's activities, all of their therapies, and in their inter-professional dealings as well. At its best, clinical psychology is the pursuit of a kind of subjective objectivity, the creation of a space for thought, the ability to step into, but also see the outside of, the client's frame. Irrespective of the therapeutic 'model' or the nature of the work being undertaken, it is the ability to use these in the service of 'externalisation', in the service of the creation of 'mental space', which, I am claiming, constitutes the logos of the psychologist.