Workingeffectivelywithclinical psychologists

Advances in Psychiatric Treatment (1996), vol 2, pp. 219-225

Working effectively with clinical
psychologists

John N. Hall

Most clinical psychologists and psychiatrists health, children and young people, and learning
already work together constructively and co disability - account for about 80% of all clinical
operatively, although guerrilla warfare may
descibe the situation in some areas. This outline of psychology posts. Within the mental health field
issues affecting work with clinical psychologists, clinical psychologists may also work, for example,
looking not only at a mutual awareness of each in the field of substance misuse - possibly
others' profession-specific knowledge and clinical associated with specialised services to HIV-
positive patients - or in the growing field of
skills, but also at an understanding of mind-sets
and value systems, is aimed at further improving forensic psychology. In all specialities, psychol
working effectively together, while not glossing sopgeisctisalmisaeyd bueniwt oorrksienrgviicne,aocroimnma u'cneintytratle'amse,rvinicea
over actual and potential areas of role-confusion
and conflict between the professions. accepting GP referrals. In smaller Health Districts
organisational patterns for services to smaller
Who are clinical psychologists, and specialities vary quite markedly, so an incoming
what do they do? consultant needs to clarify exactly how psycholo
gical staff time is assigned to these specialities. One
Thirty years ago, when I began my training as a feature of the growth of clinical psychology has
clinical psychologist, no-one could have foreseen been the increased proportion of posts outside
either the major changes in the shape of the mental psychiatry, most obviously in the fields of neuro
health services, or the developments in numbers logy, physical disability, and general medicine
and in treatment skills within the profession of (such as pain management, and oncology), so
clinical psychology over that period (Hall, 1993). psychiatrists should be aware of any local clinical
Since psychiatrists work with flesh-and-blood psychologists working outside the mental health
psychologists, it is more practical to speak of their services who may be a useful resource.
attributes and work, rather than finely hone an
abstract definition of clinical psychology as a Training and career paths
discipline. The number of clinical psychologists
working in Britain has grown rapidly over the past Training structures for clinical psychologists have
25 years - in 1970 there were 362 full members of changed very rapidly in the past few years. Entry
the Division of Clinical Psychology of the British to postgraduate training courses is highly compe
Psychological Society (BPS),and in 1996there were titive, so that the majority of trainees bring with
2982members, most of whom work in the National them several years experience either as nursing or
Health Service in Britain. Despite this growth, there care assistants or as assistant psychologists, and a
remains a serious national shortage, currently significant proportion have postgraduate degrees
running at about 25% of all posts - although or another professional qualification. Since 1990
current personnel procedures make it difficult to three year courses have become mandatory, and in
establish accurate vacancy figures. the last two years most courses have moved
towards a 'practitioner doctorate' qualification -
Within the NHS, three specialities - adult mental
typically Doctor of Clinical Psychology. Special

John N. Hall is Professional Ad viser in Clinical Psychology and Consultant Clinical Psychologist at the Warneford Hospital, Oxford,
OX3 7JX,and Honorary Senior Clinical Lecturer in Clinical Psychology, University of Oxford. He was a member of the Department of
Health Manpower Planning Advisory Group project on Clinical Psychology, has coedited with John Marzillier What is Clinical
Psychology?, and between 1988 and 1993 was the Consultant Adviser in Clinical Psychology to the Chief Medical Officer.

APT (1996), vol. 2, p.220

'lateral transfer' training arrangements exist for psychological theories lead to explanations of
disordered behaviour which use language and
British professional psychologists experienced in practice concepts not found in medicine - an
another field of applied psychology who wish to example being the Personal Construct Theory of
transfer to clinical psychology,many of whom have George Kelly (1955), which views clinical inter
previously been educational psychologists, ventions as mutual problem-solving between a
typically with an excellent knowledge both of research supervisor and a student, rather than as
c'shtailtdermenent aonfdequoifvatlheenceed' uiscaatlisooniaslsuedsytsotefmor.eigAn treatment by a therapist upon a patient.

clinical psychologists when they have satisfied An associated issue is the nature of psychological
training requirements: a Trust may not employ an institutions, notably the British Psychological
overseas clinical psychologist in a qualified Society (BPS),which is the major British academic
capacity who does not hold such a statement. and professional body for all psychologists, and
the professional body recognised by the Depart
After initial qualification many psychologists ment of Health. Drawing on early philosophical,
will acquire additional qualifications, either medical, and educational roots, it was originally,
academic (usually a part-time PhD on a clinical and remains, a learned society, with internal
topic, or a part-time masters degree), or clinical structures that reflect this as well as a professional
(usually an advanced training in a specific institute. Within the BPS there are interest-based
therapeutic approach, such as the Oxford Cognitive 'Sections' open to all members, such as the psycho
Therapy Course). Given this range of backgrounds,
it is well worth psychiatrists finding out what prior therapy, and history and philosophy of psychology
experience any new psychological colleagues have s'Decivtiiosniosn. sT',heroethaerre tahlsaon athneumCbleinricoafl pDroifveisssiioonna-l
had, as they may possess skills or experience of
value to the service, over and above that required including the Occupational, Criminological &
within a particular post. The grading system for Legal, Counselling, and Educational & Child
psychologists usually follows the nationally agreed Psychology Divisions, for which there is no parallel
1990 Whitley Council procedures (DoH, 1990). within the Royal College of Psychiatrists. While
There are no nationally agreed grade titles to these structures - themselves under review - can
correspond with a specific set of spine points, so a lead to difficulties in identifying which BPS and
particular grade title - such as senior or principal College subsystems should interact on particular
- does not currently give a clear idea of the level issues, they also further contribute to the range of
of experience of the post holder. practice assumptions and applied knowledge from
which clinical psychologists draw. This range of
Clinical psychologists as orientations and backgrounds of clinical psycholo
applied psychologists gists may sometimes be uncomfortable, but it has
certainly transformed important areas of psychia
An important issue in understanding the way in tric practice, and continues to offer creative
uwnhdiecrhstacnldinictahle p'wsyocrlhdo-lvoigewist's frofmuncwtihoinch itshetyo potential for new forms of clinical understanding
start. Unusually among health-care professions, and interventions.
bachelors level degrees in psychology are non-
vocational, so that unlike medical and occupational Roles of clinical psychologists
therapy students, psychology graduates have not in psychiatry
been socialised into the health-care world. An
explicit assumption in psychology is that explan Clinical psychologists can occupy a number of role
ations should first be sought from 'normal relationships with psychiatrists: as clinical
psychology', before looking for explanations colleagues, as management colleagues, as teachers
assuming abnormality - a good example is the and trainers, and as researchers and evaluators (see
controversy about the nature of psychotic exper Manpower Planning Advisory Group 1990).
ience, as expounded by Bentall et al (1988). The
knowledge base to which clinical psychologists Clinical colleagues
appeal encourages cross-fertilisation with the
worlds of developmental, social, occupational, and For most psychiatrists the role of clinical psycho
physiological psychology, as well as other logist as clinical colleague will be the most familiar,
disciplines such as sociology or physiology. Some where they are seeing the same patients and

Working with clinical psychologists APT (1996), vol. 2, p. 221

working in the same team, offering both direct construct theory approaches to the present
clinical services and 'consulting' together. Most dominant cognitive-behavioural orientation (CBT)

aspects of their work together will be guided by (Hawton et al, 1989). CBT encompasses a very
local unwritten precedent and practice, tacitly broad range of procedures, including, for example,
negotiated informally and implicitly over particu problem solving and anger management, and
lar cases and incidents, often over a number of subdivides into, for example, schema-focused
years. These relationships usually work well when
staffing is stable and when workload is contain approaches, and is being integrated with dynamic
able, but may come under pressure when new approaches, an example being Cognitive Analytic
colleagues take up posts, or when workload and Therapy (Ryle, 1989).
the associated stress become unacceptably high. It
is always helpful for a team to put down on paper Many clinical psychologists have interests in
their working assumptions, consulting together to family or group methods or in a creative therapy,
produce clear and succinct clinical protocols, such as drama therapy, and a proportion pursue
available to providers and users of services alike. further training as dynamic therapists. Particularly
Key issues to clarify are referral procedures, in smaller Health Districts, away from a teaching
communication guidelines, clear assignment of centre, the clinical psychology service may contain
responsibility for action, and agreement about who the only staff with an advanced training in
should see which category of patient - this psychological therapies. In such circumstances the
obviously depends on good communication about psychology service may become the natural base
the clinical skills and interests of each team for clinical nurse specialists and counsellors, so that
member. it becomes in effect a multidisciplinary psycholo
gical therapy service.
What patient groups do they see?
It is a matter of concern that the present emphasis
Within each major patient group, clinical psycho on community services means that insufficient
logists will typically see a subset of patients, which attention may be paid to the milieux in which
should reflect those conditions most amenable to patients pass their waking day, and there is
a psychological intervention. Thus within the considerable scope for psychologists to work in
'acute' adult mental health field, clinical psych residential care settings, and to offer a range of
services in day settings, as well as work with
ologists are likely to see those with serious anxiety- individual patients in these settings. Clinical
related conditions, such as obsessive-compulsive psychologists may also be a resource for particular
tasks. Thus clinical psychologists may be skilled
disorder and phobias, for example. Within the in carrying out large-scale surveys of populations
learning disability field, they are likely to be
involved with both high-need patients, who may of patients to identify their needs; they may be
skilled at designing treatment manuals and
present with highly demanding challenging information booklets that are readable and user-
behaviour, as well as with a community team,
working with staff in residential and day settings friendly; or skilled at designing assessment
as well as with patients and their carers in their methods, such as rating scales and questionnaires.
own homes. Many clinical psychologists and There are many pitfalls in designing these mea
psychiatrists develop special interests in less sures, and from bitter experience I know that even
common conditions, such as compulsive gambling, experienced psychiatrists can design measures
and it is often helpful for a patient to see someone which are difficult to use in practice.
with special expertise in their problem, who may
not be in the team where the patient has presented. Management colleagues

What treatments and interventions do they Until the advent of general management within the
offer? NHS some 10 years ago, it was not possible for a
clinical psychologist to venture into the higher
Over the past 20 years or so there has been a rapid reaches of NHS administration, although a small
growth in the range of available psychological number achieved substantial influence locally by
interventions, and newly-qualified clinical psycho virtue of their clinical skill and sapiential authority.
Since then a small number of psychologists have
logists will typically be trained in a number of become full-time general managers, including a
these. Characteristically psychological interven
tions have developed from the classical-conditio number of NHS Trust Chief Executives. More
ning and operant-conditioning models of learning commonly, senior psychologists act part-time as

underlying, for example, token economies, passing locality managers or team leaders, in a planning
through social-skills approaches and personal capacity, as clinical directors, or hold responsibility

APT (1996), vol. 2, p.222

for Trust-wide functions, such as audit or quality. much use if no-one reads or applies it, so creating
research-awareness within a service is valuable so
The senior psychologist in a Trust may also act as that research can be critically evaluated for its
manager for other professions, such as occupational relevance to local problems.
therapists. In all of these roles, it is important that
general managers, psychologists, psychiatrists, and As far as conducting research is concerned, much
others alike, agree clearly the lead tasks to be can be carried out collabora tively, so the concep
performed, obtain the time and resources to do a tual, clinical, design, and statistical skills of both
decent job, ensure that professional lines of advice professions are brought together. Collaboration can
and accountability are clear, and communicate take place in every aspect of study, so both
clearly with others. This in turn assumes that professions are mutual resources to each other. The
managers are sensitive to clinical issues, and of recently introduced changes in the training of
course are around for long enough to implement clinical psychologists mean that those now
changes properly. qualifying have more experience of clinical research
and so should become a more useful resource in
Teachers, trainers and supervisors this field. Apart from traditional clinical research,
which will itself become more necessary with the
Most qualified clinical psychologists are to some emphasis towards demonstrating good outcome
extent trainers and educators. A clinical psycholo and establishing 'clinical effectiveness', there is
gist who has been qualified for two years is eligible
to supervise trainee clinical psychologists, so likely to be more pressure towards what used to
trainees are often encountered while on placement. be called 'Health Services Research', now subsu
A good experience in a placement is itself one of
the best recruiting aids, so psychiatrists have every med under such titles as quality, audit, and
incentive to be nice to trainees, particularly where evaluation. Far more sophistication locally in
recruitment is difficult! SHOs and registrars should developing Trust 'R & D' policies will be required,
have some direct contact with psychologists during
basic training, which may include direct clinical where again a clinical psychologist may be a useful
supervision of cases by a psychologist. resource.

Clinical psychologists may also have a formally Clinical psychologists and you
agreed time commitment to formal post-basic
courses - such as family therapy - or to the training An underlying theme of this article is that clinical
and supervision of other health-care professions, psychologists and psychiatrists - and all other
such as community psychiatric nurses or coun professional colleagues - should be a resource for
sellors. More experienced psychologists - usually each other. Our knowledge and experience should
at B grade - and consultant psychiatrists are an be available to each other, and our necessarily
limited personal range of specific skills should be
important resource for both their own and each able to complement each other, so that we can offer
others' continuing professional development after a patient the person best equipped to help them.
This requires space for non-competitive conver
initial training. It is unfortunate that there is often sation and to explore issues of mutual concern. This
little shared teaching between trainees of both cannot happen without time and places being given
professions, and most continuing professional to it, whether it is within team meetings, or via pub
training is usually pursued through the profession lunches and snatched cups of coffee!
of origin. Multidisciplinary continuing education
is an excellent means of bringing minds together, Areas of tension
although psychiatrists may not realise the often
pathetically small amounts of money available to Despite major improvements in relationships
non-medical staff for continuing professional between psychiatrists and clinical psychologists,
there remain areas of tension, and it would be idle
development. to assume these do not exist.

Researchers and evaluators Statutory responsibilities and
protection
A glance at either the British Journal of Psychiatry or
Psychological Medicine, quite apart from journals Clinical psychologists do not carry major responsi
such as Behavioural and Cognitive Psychotherapy or bilities under the 1983 Mental Health Act (MHA).
the British Journal of Clinical Psychology, shows how
much published research in the mental health field
is done by psychologists. Published research is not

Working ivith clinical psychologists APT (1996), vol. 2, p. 223

While my own view is that many B grade clinical deadlines. Some psychologists and psychiatrists
psychologists could accept responsibilities under have not fully absorbed the implications of the
the Act, and while some act as Mental Health Act new-look NHS - whatever its merits and demerits
Commissioners, they do not have to carry the - and do not seem to realise the damage they do
burden of MHA duties, with all that means in terms
of emergency assessments and on-call rotas. It is to their own credibility by continuing to fight
personalised battles against reasonable changes
then easy for some psychiatrists to say that clinical agreed by Trust Boards and local purchasers.
psychologists do not know what life is really like,
and for 'I am the RMO' to be produced as a trump Who is responsible for what?

card in a clinical discussion, and easy for some The hoary old chestnut of consultant responsibility
clinical psychologists to attack psychiatrists for for everything still comes up again and again.
responsibilities imposed on them by Parliament. There is still a need to unpack the overlapping
The present Chartering arrangements for clinical concepts of medical, clinical, professional, and
psychologists (under the terms of the BPS Royal consultant responsibility, and duty of care, and
Charter of 1965) offer a high standard of protection concede that members of individual professions
for the public, although the BPS is currently will be sued according to the extent to which they
preparing an outline Parliamentary Bill for are responsible for any negligence. The fact that in
statutory registration of all professional psycholo some districts there is, for example, no medical
gists. There is little incentive for psychologists to input into substance misuse teams, or no specialist
additionally register as psychotherapists with the consultant input into learning disability services,
UK Council for Psychotherapy, unless they practice indicates that Trusts consider that some services
privately. can be run without a responsible medical consul
tant, and that other professions can exercise full
Coping with managerial and responsibility for such services. This is not to say
organisational boundaries that this necessarily offers the best service to the
population; simply that the old principle that there
Until very recently, medical staff were responsible must be a consultant responsible for all clinical
to an often remote District Medical Officer, usually services is no longer tenable.
drowning under paperwork, so that it was
extremely difficult to find a common administrative A specific issue relates to patterns of leadership
point at which inter-professional issues could be within community teams. Hidden under vague
and usually unarticulated phrases such as
discussed. The advent of Trusts means that medical 'consultant-led CMHTs', and concepts such as
staff are now employed by, and budgeted within,
the Trust in which they work, so that both team-leader and team coordinator are a range of
psychologists and psychiatrists are now usually
subject to the same Trust Board, although some odd arrangements for coping with different aspects of
managerial arrangements exist, sometimes because team-work, such as liaison with GPs, monitoring
local managers are aware of 'bad blood' between
clinical activity within contracts, communication
services. There is bound to be some variation in with the host NHS Trust, and budgetary control.
managerial arrangements, but they should all offer Given that some teams are teams in name only,
a clear route for negotiating assignment of staff and and would be better described as networks, there
clinical time, perhaps through a formal service are bound to be a number of workable patterns of
agreement. team leadership, so to advocate one model of
leadership simply denies reality.
The emergence of NHS Trusts, and new patterns
of within Trust management, mean that organi A subterranean tension partly justified by issues
sational boundaries between specialities may have of clinical responsibility is that of salary differen
changed, not always with an improvement in tials. A conundrum: consultant psychiatrists
continuity of care for users, and should be reviewed (especially those with merit awards) are paid more
from time to time. Points of transition in care are than clinical psychologists; clinical psychologists
often of high risk to the patient, so it must be clear are paid more than clinical nurse specialists; a
how transfer of clinical responsibility is effected, nurse specialist may be working autonomously
and it is essential that psychologists and psychiat and may be more skilled in an area than a
rists alike are clear about who is responsible for consultant: justify this state of affairs. This issue is
what managerially, and understand the local becoming real in deciding how to provide
planning and contracting cycles and associated psychological therapies, and maybe should be
more openly discussed?

APT (7996), vol. 2, p.224

Coordinating psychological Some head-on discussion of these issues, particul
therapies arly relating to agreed clinical prioritising criteria,
could defuse what some psychiatrists see as
A contentious issue is that of responsibility for psychologists opting-out of this pressure by
psychotherapy within a Trust. Given the burden of allegedly unilaterally choosing their own clinical
general psychiatry, specialised work in the criteria. Various other stratagems may help, such
psychological therapies area is appealing, and as early assessment before going on the waiting list
seeing attractive areas of work being hijacked by or carefully considered negotiation with referring
other professions cannot be welcome. The length GPs on how to use any counsellors attached to their
of time it took for the BPS and the College to practice; but there is no easy or quick solution to
produce the joint 1995statement on psychological increasing demand for an inadequate resource.
therapies suggests that it was not all plain sailing.
That statement, while welcome as a statement of Summary
service standards, does not address the very
obvious issue of direct inter-professional competi Have clinical psychologists been cuckoos in the
psychiatric nest? They now certainly exist in the
tion in this area, compounded by the growing NHS in numbers and at a level of experience and
numbers of counsellors, some of whom are very competence which means that psychiatrists in all
well-trained, attached to GP practices. It would specialities must positively address how to relate
appear that clinical psychologists and psycho to them, when they have not yet done so. The two
therapists occupy the same space (in terms of a two- professions have to accept different mind sets, and
work to create open communication. We have to
dimensional analysis) by severity of and the broad contribute to the creation of practice agreements
nature of presented problems, but differ in terms rooted in the foreseeable reality of high demand,
of the range of interventions they offer and the formal contracting for services, prioritisation of
specific problems for which those interventions are high-need cases, and demand for good outcomes
most effective. and effective interventions by patient, referrer, and
purchaser. We are capable of together offering a
I suspect that patients want a skilled therapist, range and choice of services from a communality
and are not too bothered about the profession of of interest and mutual respect.
origin of the therapist. Given that advanced
training in most therapies can be undertaken by References and reading
both clinical psychologists and psychiatrists, it is
hard to see the justification for a highly qualified Bentall, R. P., Jackson, H. F. & Pilgrim, D. (1988) Abandoning
psychologist being clinically responsible automati the concept of schizophrenia: some implications of validity
cally to a possibly less experienced consultant arguments of psychological research into psychotic
psychiatrist, although there is clearly a need for phenomena. British Journal of Clinical Psychology,27,303-324.
meaningful coordination of services and assign
ment of resources. What patients want, and Department of Health (1990) Whitley Council Agreement on the
certainly what GPs want, is clear and honest Remuneration of Clinical Psychologists and Assistant
information on therapies available and waiting Psychologists employed by Health Authorities. AL <SP) 3/90.
times, and skilled therapists, and what they do not London: Department of Health.
want is local sniping and point-scoring between
Hall, J. N. (1993) Clinical psychology in context. Clinical
professions. Psychology Forum, 61, 3-10.

Coping with high demand Hawton, K., Salkovskis, P. M., Kirk, }., et al (1989) Cognitive
Behaviour Therapy for Psychiatric Problems. Oxford: Oxford
Almost universally, psychiatrists and clinical University Press.
psychologists face a high level of demand for their
services. In both in-patient and day settings this Kelly, G. A. (1955) The Psychology of Personal Constructs. New
York: Norton.
results in high occupancy figures, which may in
turn result in worrying difficulties in maintaining Manpower Planning Ad visory Group (1990)Manpower Planning
a safe environment and an active therapeutic Advisory Croup Report on Clinical Psychology. London:
milieu. For out-patient and community team work Department of Health.

this results in very long waiting lists for clinical Marzillier, J. S. & Hall, ]. N. (1992) What is Clinical Psychology?
psychologists, possibly compounded by the Oxford: Oxford University Press.
proportion of patients who refuse psychotropic
medication, which can become a cause of conflict. Royal College of Psychiatrists and The British Psychological
Society (1995) Psychological Therapies for Adults in the NHS -
A Joint Statement. Council Report CR37. London: RCPsych.

Ryle, A. (1989) Cognitive Analytic Therapy - Active Participation
in Change. Chichester: Wiley.

Working ivith clinical psychologists APT (1996), vol. 2, p. 225

The Division of Clinical Psychology of the BPS publishes Clinical e registration by the United Kingdom Council
Psychology Forum monthly, which is received by all clinical for Psychotherapy (UKCP)
psychologists who are members of the Division. This journal
is similar in style to the Psychiatric Bulletin, and contains both 4 What postgraduate training is required for a
brief technical articles on matters of clinical practice, and also psychology graduate to be employed as a
opinion pieces on controversial topics, including those qualified clinical psychologist in the NHS?
covered in this article. a any clinical psychology training in Europe
b any doctoral-level clinical psychology
Multiple choice questions training in the world
c any British training as an applied
1 How many clinical psychologists are members psychologist
of the Division of Clinical Psychology? d three years supervised probationary
a about 2000 experience
b about 5000 e clinical psychology training approved in
c about 7000 Britain
d about 3000
e about 6000 5 What is one consequence of recent changes in
the training of clinical psychologists?
2 What is the current dominant conceptual a more emphasis on management
orientation of clinical psychologists? b more emphasis on specific therapies
b behavioural c more emphasis on teaching
a cognitive-behavioural d more emphasis on clinical research
c cognitive-analytic e more emphasis on non-psychiatric areas of
d psychodynamic work
e family systemic
MCaQnswers1abcdeFFFTF2abcdeFTFFF3abcdeTFFFF4abcdeFFFFT5abc
3 What is the current procedure for the profession
al registration of clinical psychologists?
a registration under the terms of a Royal
Charter
b registration under the terms of an Act of
Parliament
c registration under the terms of the Council
for Professions Supplementary to Medicine
d registration by the Whitley Council