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Child in the BalanceZombies and Consciousness
The editors have asked a multitude of practitioners to answer a question for trainee psychologists, namely, what is correct and proper for a psychologist to try and achieve in treating within a biopsychosocial context and psychological context. The attempt therefore is to try and clarify what and who might constitute a competent practitioner. In a world where universities are increasingly hiring teaching staff who are often pure academics on the basis of how much money they have raised and can continue to raise for research, and thus keep their departments funded, this is not a bad question. Others, in psychiatry for instance (see Miller) there is evidence based practice, and there is also practice based evidence as to what works, and why, and with whom. As the biopsychosocial model asks, why has this patient produced these symptoms at this time of their life, and what to do about it within the domain of psychotherapy. For the editors, this means psychologists must be scientist-practitioners, integrating academic theory, clinical practice, and an evolving research base delivered within and ethical and reflective (that word again) framework.
The headings of the chapters reflect the arenas of practice in which the editors believe psychologists are to engage, in the UK at least. Themes that emerge, according to the editors anyway, are those of awareness of social context, the need for responsive and reflective practice, and respect for diversity and user perspectives. Hence, they draw on both pure academics as well as clinicians, in a short book, given the scope. The headings are: Philosophical, ethical and practical underpinnings, areas of clinical practice which include working with children and young people (yes, they are not the same thing), working with chronic ill-health and disability, working with adults with mental health problems across the lifespan, working with special populations, and finally, professional practice.
The first part sets out clearly the expectations of who and what a clinical psychologist really is, once trained. The training in the UK model is set out, and an emphasis is on the clinical training staff and the academic staff usually working together in a partnership. This will then provide the training for how psychologists will think and act. Several times the editors warn that the scope is so wide that the book cannot be constructed as comprehensive, so they have drawn on those they believe are experts in their field to contribute, sometimes as teachers, sometimes from their own experience as clinicians. The embarkation point is this that of professional competencies, covered in the next chapter, and having been reflected on before. The competencies here are relevant to both the UK and the USA both, and both dwell on and itemize the competencies that they consider both desirable and essential. I for one am impressed, given the comments I made earlier, by their statement that in an evidence based competency approach there is a danger of defining competencies as a collection of specific skills, which may lead to a focus on training technicians rather than competent and capable professionals who have the capacity to think critically, evaluate and develop new and innovative methods. This is a critical comment that really deserves a larger platform in this and other works.
The next chapter explores the historical and conceptual bases for the profession, as well as their recurrent theme, what constitutes reflective practice, as well as new proposals for the way forward. Again, a tiny mention is made of the discrepancies between the DSM-pathology approach, and the value of an approach towards self efficacy, personal strengths, hope and optimism: definitely a major theme to be explored elsewhere, but so pivotal now in the 21st century. Again, despite its apologies for brevity, these are huge areas of concern and value. The next chapter is devoted to research, and evaluation, and we then move to working with children and young adults.
There is a brief discussion of the UK context, and then a chapter on self harm in young people. This latter one is useful and sensitive, perhaps not to the extremes many practitioners may have seen, but nevertheless to the more common limited extremes seen in general practice. A particular chapter now is devoted to those growing up in some form of care, and then an intensive approach to childhood fears and anxieties. This would include a single and intense session, lasting even beyond 3 hours, which of course is questioned here. Despite the biopsychosocial approach framework mentioned briefly before, I see no signs of it here, such as the use of heart rate variability training and other biological measures to for instance reduce fear or phobia or nightmares, and so on. No mention either of neurofeedback for instance either, but purely a cognitive and behavioral approach, in keeping with the limited scope of the book. In a similar vein, the Pediatric services, delve into the social-ecological systems around the sick child, as clearly the client is seldom living in an independent existence, and this changes the avenues of service delivery. Since this chapter is skewed toward health services, pain and disease are focused on here. Continuing further, the next chapter deals with cognitive behavior therapy with children and young people. Despite the faddish desire of researchers to rush to research CBT, given the manualized approach to CBT makes it a particularly attractive target, recent work has, the author here points out, begun to question the additional value of CBT over other approaches, particularly medication. Clearly, the adult toolkits have to be modified to meet the developmental stage and skills of the child. Thus, the evidence base is not as well populated as we might want it to be, certainly not with the traditional randomized control trials, leading to questions as noted about comparative efficacy. The positive gains of CBT have thus not been consistently proven in this way, although clearly it works. The author continues to examine CBT in terms of the indicated age cohorts, the cognitive aspects of behavior therapy cross over into CBT and so on. Despite the proven value of research-based CBT, the actual delivery outside of the controlled setting, the level of difficulty and complexity of the patients, the challenges of the verbal versus behavioral aspects, the complexity of comorbidity in the social area around the child, all impact on the pragmatic aspects of delivery in this group of vulnerable individuals. There is much to be learned yet.
Chronic health conditions, namely, comorbidity has become a problem area for psychology to enter, and the next chapter focuses on Oncology, long a field for the psychotherapist. With an emphasis on understanding the patient experience and managing distress, there is surprisingly little being offered in this chapter. Pain is a similar arena, given its subjective and ubiquitous nature, and the next chapter touches on this as well. CBT is again touted without reservation this time, and of course there is and are a multitude of alternatives to a holistic approach to pain management, giving us little new to work on here. Here is a subject rich in metaphor and subjectivity, a vital and expensive part of medicine, addiction to medication, complex team engagements, and brevity here is a disservice to the reader.
We then journey into Neuropsychological rehabilitation following acquired brain injury, which is really amazing for such a book, and to be lauded. The amount of information given here is quite extensive, but in the Miller terms (above), words like grief, loss, confidence, PTSD and other vital elements of the human experience and family experience are ignored, and I think too important to be ignored even for the sake of brevity. Brain injury does not happen to individuals, but to everyone who knows and loves them, and this is a vital part of their management. Nevertheless, this is probably clouded by the neuropsychological approach which often heavily leans towards the pragmatic aspects of TBI, rather than the psychological devastation wrought. Another lapse here is the absence of referral to the most vexing brain injury of all, namely Mild TBI and concussion, malingering and role enactment. These are crucial, and deserve a chapter on their own. Overall, this book is terribly positive, so the words malingering, simulation, negative response bias, and so on….not here, and not anywhere else.
A systemic approach to people with learning disabilities is next, referring to social constructionist and narrative approaches. There are few references these days to works such as Anderson’s and Goolishian’s, Cecchin’s and others which are such a blast from the past it creates a visceral response and forced flashbacks to the family therapy movement and my own training in the 80’s. Post modernism dominates this chapter, a really unusual place to find such musings, and terribly interesting. Rikberg Smyly has published in this are herself, so not surprising that she takes what is really a deconstructivist approach to this labeling, despite the Family Process journals rotting in her basement. Surprisingly, she still expects this old and familiar model to emerge more succinctly in the future, and one is forced to wonder where British psychologists were hiding when Bateson did his fireside chats, and Professoressa Dottoressa Mara Selvini-Palazzoli and her Milan gang (including Gianfranco Cecchin) were wreaking havoc in families where one person was psychotic or suffering from anorexia. I am thrilled of course to see this valuable and enchanting work resurfacing, and hope my American colleagues, now in their fifties and sixties at least, can remember how lovely Paul Dell and others were when they first fell through the floor of ontology and questioned epistemologies and epistemological confusion. In this latter vein, I doubt many young therapists today will understand what Selma Rikberg Smyly is talking about, but they should make the effort to avoid epistemological confusion, and good for her too. And while they are at it, the work of Maturana, Varela, De Ridder and others should be resurrected. If the young therapists working with learning disability can follow these arguments, and immerse themselves in complex postmodernist ecosystemic theory, they will do some serious good, and come to a conclusion: Selma, you rock. She of course has a similar chapter in an entire book on the theme, namely the Baum and Lynggaard 2006 edited book, “Intellectual disabilities: a systemic approach” published by H Karmac Books Ltd. Others may certainly have an inkling of this approach, as Acceptance and Commitment therapy, mentioned in this book as a third wave therapy, have Jay Hayley, Milton Erikson and others of the same era to thank for much of their successful re-entry as third wave therapies. Above all else, and in keeping with what this book seems to reiterate over and over, Hayley and others were convinced of the value of simply observing, of reflecting, the basis of the habit of science: So nice to see it emerging here and there in this book.
This does not stop Judith Samuel from introducing Intensive Interaction as an approach for people with profound and complex learning difficulties in the next chapter. This is a much more engaged pragmatic approach, involving contingent response and hi levels of interaction. The heterogeneity of this group of clients however makes the gathering of an evidence base problematic, and my sense is of this interaction is that it requires some boutique solutions on the ground. The need to often engage with audiovisual equipment and also with the ethical complexities of touch, with an often disinhibited group, makes this a daunting field for young practitioners, and probably the rest as well. Much of the research cited is from Samuel herself, and a collaborator, Nind, so this is a difficult approach.
The adult section follows, with early intervention in psychosis leading the way. Obviously teamwork is key here, around engagement, assessment, and interventions, but there are psychologists working outside of teams as well.
I lamented the lack of family interventions above in TBI, but the next chapter focuses on these in Psychosis. The family therapy model is followed, namely the depathologizing of the patient and the recovery model has made an increasing inroad on the field with the ill person an intimate part of both family and treating team. The approach is however more psychoeducational than interventionist. The problem in this service delivery is however clearly the lack of training in the curriculum of most universities, and this will hamper the adoption of these techniques, which, as in TBI, is a shame.
As with cognitive behavioral therapy on the internet, Bibliotherapy and self guided therapy is an interesting field, which can be effective, and this is the subject of the next chapter. Beyond this however is the following chapter, which finally mentions IAPT, the British healthcare initiative to allow non-psychologists with minimal training to deliver mental health care under supervision from a professional clinical psychologist. In this way, a psychologist might supervise 50 lay psychologists to deal with thousands of patients, with some evidence to support this and alleviate demand in the general practitioner, primary delivery setting.
Delivery of culturally sensitive therapy to black and minority communities is challenging in any rainbow nation, and this is dealt with next, but as usually the case, very briefly.
The bane of most psychologists lives, and some of them avoid these clients like the plague, are those who attract the label of personality disorder. A controversial diagnosis at best, there is tacit acknowledgement that traditional treatment settings and approaches are somewhat toxic and unsafe for the patient, and need revision and more modern and informed assessment and engagement, as well as organizational management.
Systems-informed approaches color interventions with the older patient group, and this is well covered in the next chapter. Given the nature and impact of culture and environs for this group, co-creations of therapeutic systems seems a reasonable idea, rather than just individual pathology approaches. The following chapter looks more closely at a macro view of working with this group, and the book then moves on to working with special populations. By now we are only 270 odd pages into this book, which illustrates its compactness.
PTSD after pregnancy or childbirth is a most unusual subject, handled next. It would seem harsh and silly to create PTSD and Depression as categories for what most would regard as grief, or complicated grief, but the author makes the point that significant feelings of worthlessness, suicidal ideation, terminal insomnia, with significant psychomotor retardation would be discriminators from acceptable grief. It’s a hard discussion at best.
Transition problems in a health system attract the attention of one chapter, and then eating disorders are confronted in the next. Upsettingly, in the updates on cognitive theories, there is no mention of fairly robust evidence that those who are seriously under or overweight actually have frontal-executive function difficulties which certainly might go a long way to explain why CBT fails so often, and why drop- out rates are high: re-feeding appears to work to support CBT and other approaches. This appears to be yet another gap in psychology as a field understanding and applying a true bio-psychosocial model. Bio doesn’t only mean illness or condition, it also should mean bodybrain itegration.
No psychological text since Freud would be complete without a chapter on sexual health, and Graham comes to the rescue.
The rest of the book covers professional issues related to the practice of psychology as a profession with its supervision and organizational issues.
The book is really a vital source for most early practitioners, not too heavily of value for those beyond newly qualified or poorly experienced, but interesting reading for everyone and certainly a gap filler for most. I am not sure how any UK psychologist could be without one on the shelves, but USA based psychologists should certainly consider it as a worthy purchase. What it lacks because of brevity it makes up for in covering multiple areas, without being too Anglocentric. It could improve on itself with a second addition, or a companion edition, but as it is, is a good buy.
© 2010 Roy Sugarman
Roy Sugarman, Director: Applied Neuroscience, Athletes’ Performance USA