Clinical

Psychology
Issue 24 April 2003

For David Smail

Editorial Collective: Lorraine Bell, Jonathan Calder, Lesley Cohen, Simon Gelsthorpe, Laura Golding,
Garfield Harmon, Helen Jones, Craig Newnes, Mark Rapley and Arlene Vetere.
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 Clinical Psychology
Issue 24 — April 2003

Special Issue: For David Smail

Editorial
Craig Newnes 3

David Smail: A personal appreciation

Jim Meikle 4

An appreciation of David Smail

Paul Moloney, Joanne Everill, Paul Kelly, Ikbal Bahia and Rachel Cox 7

My friend David Smail

Dorothy Rowe 11

I want, therefore I am: A tribute to David Smail

Mark Rapley, Alec McHoul and Susan Hansen 13

Some thoughts on How to Survive Without Psvchotherapy by David Smail

Miller Mair 20

Can the past achievements of clinical psychology be maintained in the ‘modernised’

NHS? Reflections of a quarter century working in Nottingham
Julia Faulconbridge 23

The dangers of vulnerability

Mary Boyle 27

Drug companies and clinical psychology

Elina Baker, Craig Newnes and Helen Myatt 31

Addressing power
Jan Bostock 36

Smail’s contribution to understanding the needs of the socially excluded: the case of
Gypsy and Traveller women
Lucy Appleton, Teresa Hagan, Pete Goward, Julie Repper and Rachel Wilson 40

An audit: do the people I see ‘get better’?

Guy Holmes 47

Building bridges and community empowerment

Iyabo A. Fatimilehin and Linda Dye 51

Columns
Self-help
Felix Q. 56

1
2
Editorial: For David Smail

L
uck is a crucial factor in getting on in life. Professionals and professions are, no less than
Graduate education as a means of escape others, influenced and shaped by distal powers
from dull or physically draining jobs was, we rarely examine as we get overwhelmed by all
perhaps, more available to my generation than too proximal powers. We are inhibited from ex-
subsequent, post-Thatcher, students. For those amining the forces behind the medicalisation of
of us needing them, student grants were rela- distress as queues of people knock at their GPs’
tively generous. Fees were pre-paid and accom- doors demanding counselling and psychology.
modation cheap. I fell into psychology and then We find ourselves acting in utterly different ways
had the good fortune of ending up in with clients and friends, as if they are different
Lincolnshire as a probationer clinical psycholo- species and, in promoting ourselves as healers, it
gist. Local connections with the Psychology and is hard to see what forces us to oppress. Smail’s
Psychotherapy Association led me to its journal, work can do much to illuminate these paradoxes.
Changes, and seminars featuring, amongst others, He remains an inspiration. Here’s to you David.
David Smail. Long may you run.
At just the right time I was asked to review
Psychotherapy: A personal approach. There Craig Newnes
was a clarity in this book which I have come to
see as a hallmark of David’s approach. His use of
existential philosophers and ideas was, some-
how, both intellectually appealing and applica-
ble to clinical work in a way that made sense.
Visit the Society’s
Making sense – of power, therapy, unhappiness
and oppression – is a gift, and one David has
website:
willingly shared with many via writings, con-
versations, teaching, supervision and his web-
site. www.bps.org.uk
Like the best teachers Smail inspires and gives
people permission to try new things: from ac-
knowledging that talking about work at home is
a natural form of supervision to being straight-
forward in any critique of the current state of
psychology. He led me back to Sartre, on to
Polanyi and via Forsyth to a critique of modernist
psychology, the importance of meaning in ther- Advertise in
apy, the impress of power and the potential of
collective action. I looked forward to reading his
Clinical Psychology
latest book with the enthusiasm I usually reserve
for novels and felt privileged to review them all Contact Jonathan Calder on 0116 252 9502
in Clinical Psychology Forum and elsewhere. or joncal@bps.org.uk
The tributes in this special issue are testament
to David’s capacity to inspire friendship, cricket
teams, reflective practice, community psychology Notices of Division, SIG
and engagement with serious political, cultural and Branch events
and economic analysis of what ails and oppresses
appear free of charge
us. His idea of the impress of power even gives
clinical psychology a means of analysing itself.

3
David Smail: A personal
appreciation
Jim Meikle, Queen’s Medical Centre, Nottingham
L
est anyone should confuse this with an
obituary, let me say at once that David is in
good health and enjoying his ‘retirement’
(he still holds an honorary part-time contract at
a local Student Health Centre in Nottingham).
Although he retired from the NHS in 1998, he
continues to write and apparently spends a con-
siderable time both surfing the net, nurturing his
website and responding to e-mail from all over
the world. Those who worked with David will
perceive the irony here, since his attitude to
computers before his conversion was distinctly
Luddite.
I was a callow Probationer when I met David for
the first time. He came to Nottingham for a pre-
interview visit in 1968. Amazed that anyone pur-
porting to be my boss could look so youthful, I
had no intimation then that this was the beginning
of a long professional association and friendship.
Born in Putney, David spent his formative years
in leafy Wimbledon and apparently first came to
prominence following a courageous rescue of a
tortoise from a house-fire which made the local
paper. This is undoubtedly how he acquired his
enthusiasm for seeing his name in print.
He was, by the way, born on April 23, which is
both St George’s Day and Shakespeare’s birthday.
Those of you who believe in horoscopes will un-
doubtedly see this significant for what was to
come. He will tell you that he also shares his
birthday with Prokofiev, which may also have a
bearing. Slayer of establishment dragons, lucid
commentator on the human condition, musician –
it all makes sense. (The significance of also sharing
it with Shirley Temple is less clear: I’ve never seen
him tap-dance and he wouldn’t be easily per-
suaded to become an ambassador for the USA).
He obtained his first degree at UCL and, at
around this time, was a semi-professional jazz
drummer. By all accounts he was also well trav-
elled but, like so many drummers, his creativity
4
required regular fuelling. David has more hazy
memories of more continental cities than anyone
I have met.
He cut his first professional psychological teeth
working in market research, where he rapidly
discovered that making up results did not pro-
vide intellectual fulfilment. So, turning his back
on the possibility of making his pile, he entered
clinical psychology, training first at Horton
Hospital in Epsom and then at Claybury Hospital
in Essex. He also obtained a PhD, the subject of
which was the Thematic Apperception Test.
By then married to Uta and with a baby son, he
learned how to get by on the handsome starting
salary of £600 per year.
When he arrived in Nottingham he had already
published his first book, The Treatment of
Mental Illness (1969), in association with Tom
Caine. This work established his critical stance
towards contemporary practice and guaranteed
that relations with local psychiatrists were always
going to be interesting. That the work was re-
search based and firmly rooted in academic
traditions, entailed that their obvious anger and
suspicion had to be well restrained.
All this was at a time when the NHS was not
obsessed with counting everything and when
you could actually go to a pub at lunchtime.
David was a highly competitive darts player who,
on reflection, probably won more than he lost.
There were needle matches between the NHS
and University of Nottingham with the latter
represented by Geoffrey Stephenson (Prof.
Stephenson, recently retired from the University
of Kent) and whichever member of his depart-
ment of near-professional standard, could be
persuaded (bribed?) to accompany him. Derek
Rutter (now also Professor) was one such, I recall.
Despite (or because of) such diversions, the
Nottingham psychology service rapidly spread
to take in the north of the county so that David

was heading an Area Service well before the
Trethowan Report (1977) advocated such things,
while the service adopted a ‘specialism’ structure
before they became commonplace.
When ‘Top Grade’ became available (the equiv-
alent of the present B Grade), David was the
youngest clinical psychologist in the country to
hold the title. Soon after, he set up a clinical
option in the psychology department of Notting-
ham University, through which he was later
awarded an honorary Chair.
Initially an enthusiast for dynamic psycho-
therapy, David was highly critical of the behav-
ioural hegemony which characterised clinical
psychology in the seventies and early eighties and
once again found himself outside the mainstream.
A founder member of The Psychology and
Psychotherapy Association (PPA) and the first
editor of its newsletter, he became one of the
relatively few sources of influential support for
those who could see the limitations of the be-
havioural approach but did not wish to make an
equally unacceptable leap into psychoanalysis.
He went on to be twice Chair of the Psycho-
therapy Section of the BPS. Since it was largely
the widespread adoption of behavioural meth-
ods, together with the acknowledgement that it
was psychologists who should carry them out,
which had advanced the professional status of
clinical psychology, David was never flavour of
the month within the profession and his views
were often treated with deep suspicion.
Now with two teenage children, David became
more distracted than I can previously recall. His son
proved to be a cricketer of considerable ability,
playing for Notts Colts and later Oxford Uni-
versity. David would dash off from work to watch
him play and these were particularly happy
times for him.
However, David is not what you would term
clubbable, so his own cricketing talents have re-
mained largely under a bushel. There are stories,
though, of epic matches between the male
Smails and the male Stephensons which would
rate inclusion in Wisden. I played cricket with
David twice and found him to be a medium-
paced bowler of nagging accuracy. (The last time
was a in a rain-aborted match against local psy-
chiatrists, organised by the much-missed Richard
Marshall.)
Clinical Psychology 24 – April 2003
Although David made his contribution to ortho-
dox research, increasingly he came to hold the
view that ‘cumulative fragmentalism’, as George
Kelly (1955) put it, was not the way to advance
knowledge and he found inspiration from wider
sources, including novels and European sociology.
Those who have followed David’s writing will be
aware that he has never been afraid to change or
modify his views in the light of his own experi-
ence and he has increasingly rejected the belief
that patients can either be talked out of or think
themselves out of their predicaments, however
skilful the therapist. He demanded a more com-
plete account of the distress he encountered in
his patients and insisted on due recognition of
the political and economic forces acting upon
them, thereby developing a framework for the
practice of Community Psychology.
In the late eighties, and with the north of the
county now served by its own District service,
David successfully negotiated the move of the
Nottingham District Service out of the then
Mental Illness Unit and into the Community Unit
in the belief and expectation that from there he
could build a comprehensive community-based
service, free from domination and interference
by psychiatry.
However, although he came to understand it
well and has subsequently written penetratingly
about postmodernism, David was, I think, like
the rest of us, taken by surprise by the force behind
the changes which accompanied it. What followed
within his NHS practice was mainly sadness and
frustration at his, or anyone else’s, inability to
prevent the destruction and fragmentation of the
service he had built up over many years, by
mindless and mediocre functionaries who could
not recognise a concept, even at close quarters,
and who would panic if they found themselves
nurturing an original thought. His treatment by
management was shabby and shameful – a re-
flection of the current attack on intellectual
activity, which should continue to worry all of
us.
So what has characterised David’s contribution
to clinical psychology? Well, until anyone who
valued intellect and rationality got sidelined by
postmodernism, David was a major force in the
shaping of clinical practice and service delivery
within the NHS. He remains one of the most
5
Meikle

persuasive talkers and influential writers of his References

day. Always concerned to identify and articulate
the moral context of clinical psychology, he has
an unerring nose for dogma, even when well
concealed in scientism or cloaked by uncritically
accepted practice. He writes with both unusual
clarity and consistent ability to hold interest in
a field where narcotic output is rife. His appeal
is to professional and lay reader alike.
Dorothy Rowe I believe, got it precisely right
in her foreword to David’s book The Origins of
Unhappiness (1993) when she referred to him
as a ‘Touchstone’ for clinical psychology (back
to Shakespeare!)
Caine, T. M., and Smail D. (1969) The Treatment of
Mental Illness: Science, faith and the therapeutic com-
munity. London: University of London Press
Kelly, G. A. (1955) The Psychology of Personal Con-
structs. New York: Norton
Smail, D. J. (1993) The Origins of Unhappiness: A
new understanding of personal distress. London:
HarperCollins
Threthowan, W. H. (1977) The Role of Psychologists
in the Health Services. London:HMSO.
Address
Clinical Psychology at City and Queen’s, Sherwood Health
Centre, Elmswood Gardens, Nottingham NG5 4AD

Division of Clinical Psychology

Quality and Effectiveness Subcommittee
Vacancies have arisen on the Quality and Effectiveness Subcommittee (QUEST) for people who
are interested in contributing to the development of clinical psychology as a leading edge
profession for the delivery of quality health care services that are based on research and the
needs of the individual.

Terms of reference of the Committee are:

❍ educating and advising the profession on the development and implementation of audit and
quality practice;
❍ establishing guidelines for quality client-centred care and professional practice;
❍ identifying and disseminating innovative examples of good practice;
❍ working with other professions and organisations in developing and implementing
multidisciplinary quality initiatives;
❍ commissioning and managing projects on important aspects of quality care and practice;
❍ stimulating activities relating to audit clinical effectiveness and Research and Development
within the profession.

The Committee has recently undertaken the task of responding to the new funding arrangements
for NHS Research and Development arising from the Culyer report. The Committee is also the
Steering Group for the BPS Centre for Outcomes, Research and Effectiveness (CORE)

Further information can be obtained from John Hall, Chair of the Committee, through Gwen
Ward at the Society office who will also supply Statement of Interest forms to interested people,
telephone 0116 252 9517 (direct line).

Statement of Interest forms should be returned to Lesley Dexter at the Society offices..

6
An appreciation of David Smail
Paul Moloney, Northern Birmingham Mental Health NHS Trust,
Joanne Everill, South Birmingham Mental Health NHS Trust, Paul
Kelly, South Birmingham Mental Health NHS Trust, Ikbal Bahia,
Black Country Mental Health NHS Trust, and Rachel Cox, Shropshire
County Primary Care Trust, on behalf of the West Midlands
Community and Critical Psychology Interest Group

H
istorians of applied psychology (and par-
ticularly psychotherapy) have indicated
how, almost from the inception of these
disciplines over a century ago, their adherents have
consistently oversold their claims to expertise
in the ability to modify (and even transform)
people’s lives (Clegg, 1998; Danzigger, 1993;
Rose, 1989). This situation may be no less true
today – when claims proliferate for the existence
of rigorously evaluated psychological therapies
that can be reliably deployed in the clinic so as to
yield beneficial personal change (see Department
of Health, 2001). These assertions may be linked
to those market forces that are shaping health
care and that more than ever require clinicians to
justify the ways in which they earn their living
(Davies, 1997; Rogers & Pilgrim, 2001). A critical
reading of this evidence base, however, suggests
that it is not nearly as sound as is often supposed
(e.g. Dineen, 1998; King-Spooner, 1995). Indeed,
the effectiveness of individual psychotherapy
may be limited for many reasons. Perhaps most
often, because many people's problems may be
much more a function of the noxious social en-
vironments in which they live than they are fail-
ures of individual insight, motivation or learning
(Davies, 1997; Godsi, 1998; Pilgrim, 1997 ).
Most practitioners working in public (NHS)
psychotherapy services are likely to be aware of
these realities to one degree or another. Yet few
therapeutic psychologists seem to have addressed
these commonplace observations in any sys-
tematic or theoretically coherent way. It is here
that the writings of David Smail may be particularly
notable. Over a span of almost 30 years, David
has drawn upon his clinical experience within
NHS settings, and also upon sociological and crit-
ical realist perspectives on mental health, in order
to explicitly link the experience of personal dis-
tress with the operation of oppressive social and
institutional power.
In his characteristically measured and ethically
reflective prose, David has sought to develop a
psychology that faithfully reflects the experience
of ‘ordinary people’, and that minimises the
potential for psychotherapy to harm them by
adding to their confusions about the likely origins
of their troubles. On both ethical and scientific
grounds, this would require the psychologist to
work more actively in solidarity with their
clients, in order both to help them to clarify the
extent to which their experiences offer meaning-
ful insights into their social and material environ-
ment, and to increase their access to external
social powers and resources wherever this might
be feasible (Smail, 1987; 1991). Similar positions
have been charted by some advocates of feminist,
multiculturalist and narrative psychotherapy and
by community psychologists, who have attempted
to eschew the individualism of most traditional
psychological treatments (Coppock & Hopton,
2000; Fanon, 1986; Holland, 1995; Orford, 1992;
Stoppard, 2000; White & Epston, 1990).
David’s writings are therefore part of that select
band prepared to suggest that, first, the emperor
of ‘official psychology’ has no clothes (or at least
only the skimpiest of underwear), and second,
that there remains a potential for dedicated and
sincere psychologists to nonetheless inadver-
tently work against the interests of their clients –
in developing and using psychological theories
that encourage the latter to locate environmentally

7
Moloney et al.
generated distress as a form of putative internal
psychological breakdown (cf. Kline, 1988; Masson,
1989; Pilgrim, 1997).
Despite the trenchant nature of David Smail’s
criticisms of much of psychotherapy as currently
practised, it seems evident that these observations
have not arisen out of any pre-existing rejection
of therapeutic ideology by the author. Instead, a
careful reading of the development of David’s
ideas (e.g. Smail, 2001; 1987; 1978) makes it clear
that it has been gradually forced upon him as a
result of his clinical experience and his commit-
ment to writing with humility and honesty about
what he has found there. Indeed, for the thera-
peutic psychologist, David’s descriptions of the
complex workings of power offer fruitful in-
sights into the predicaments of individuals from
diverse groups. These range from beleaguered
middle-class professionals working in public service
to the lives of harassed production-line workers,
isolated and oppressed housewives, and, of course,
that large minority of dispossessed and down-
trodden individuals within our society who are
forced to survive on low wages and meagre state
benefits (cf. Child Poverty Action Group, 2001;
Erenreich, 2001; Vail et al., 1999).
Perhaps unsurprisingly, David’s writings raise
difficult questions for the psychotherapist. For
example, what would psychotherapy be like if it
was recognised that the helpful elements consist
largely of comfort and clarification (but not nec-
essarily the resolution) of the client’s problems.
What would this mean for a psychology that for
the most part tries to treat people rather than
attempt to help them understand and then per-
haps begin to do something about the world in
which they live? It is clear that David recog-
nises the immense (not to say daunting) prac-
tical, professional and moral hurdles that will
constantly attend any kind of psychology that
tries to take these issues seriously (e.g. Smail,
1999; 1996).
It was as a result of wrestling with these kinds
of issues throughout our training and practice
that we were prompted to form the Midlands
Regional Critical and Community Psychology
Interest Group (CCPIG). Here, David’s writings
seemed to offer a particularly cogent and com-
pelling framework in which it was possible for
us to begin to make sense of some of our own
8
thoughts and impressions about the nature of
personal distress and its ‘treatment’. There was a
common feeling that our various trainings had,
on the one hand, not paid enough attention to
the role of social and material inequalities in
the genesis of psychological problems and, on the
other, had neglected questions of therapist power.
For example, there seemed to be little thought
given as to why so many clients from socially and
economically deprived areas did not seem to get
all that much better as a result of psychotherapy,
or seemed to benefit in ways not predicted by the
dominant models and theories, or why the most
oppressed, marginalized and deprived individuals
appeared to be overrepresented in our client
case loads.
As David notes, social solidarity is itself a form
of positive power, and many of the clients of
psychological services become emotionally dis-
tressed in the first place because of its absence.
Indeed, the CCPIG was set up initially as a source
of solidarity by a group of clinicians who were
either not yet qualified, or who were newly qual-
ified and (as the sometimes lone voice of dissent
within the mental health systems in which they
were working) had often experienced feelings of
isolation and powerlessness. In both this respect
and in regard to the wider and more formal aca-
demic and applied work of the group, David’s
encouragement has been (and continues to be)
invaluable. Indeed, we have been lucky enough
to have the personal support of David for our
meetings. He has travelled from his home in
Nottingham to Birmingham to engage in conver-
sations and debates that have been inspiring and
sustaining of us as a group, and that have added
richness and sometimes controversy to our meet-
ings. David’s ideas on the therapeutic value of
comfort and clarification have also been at work
in both the creation and subsequent life of the
CCPIG, in that it has sometimes felt hard for
many of us to survive in a professional world that
is often unsupportive and occasionally actively
hostile to more radical and critical approaches to
applied psychology.
Throughout, David has listened to our experi-
ences and to our ideas, and has helped us to think
about constructive ways to co-exist with (and
sometimes to challenge) the current mental health
systems in which we work. By the same token,

David has never tried to impose his thoughts,
and has listened to all viewpoints with the re-
spect and humility that seem to characterise him
both as a person and as a psychologist. Of
course, within David’s work the personal and
the psychological are always linked, and he has
openly shared some of his key professional in-
sights and experiences (including those of mar-
ginalization) both with the group and with wider
audiences. Such honesty has been refreshing to
witness and inspiring and informing of us as
group members as we struggle to find ways of
putting a more critical and ‘environmentalist’
psychology into practice.
We have also been grateful and appreciative of
David's kind and unstinting support in relation to
the practicalities of developing the group, such
as his having presented at group meetings, and
his continued assistance in the development of a
group website. Such involvement is testimony to
David’s commitment to the creation of a psy-
chology in which in which a wide range of ex-
periences and ideas may be respectfully
explored, and in which marginalized voices may
be heard. We hope our appreciation of David's
contribution to the CCPIG and of his affect upon
each of us as individual practitioners is evident
within this paper.
In conclusion, David’s ideas are inevitably chal-
lenging for those therapeutic psychologists (i.e.
all of us) who are increasingly under pressure to
demonstrate that they possess supposedly well
established technologies of personal change, and
it can be disheartening to find that some practi-
tioners appear to equate his ideas with ‘pes-
simism’, ‘depression’ or ‘negativity’. Yet it may
be argued that in one fundamental sense David's
writings are far from pessimistic. This is because
the real pessimist will accede to the dominant
cultural and institutional pressures when they
perceive that it is in their interests to do so.
Rather, David’s work has consistently pointed to
the possibilities for a therapeutic psychology in
the broadest sense. This would be a therapeutic
psychology that places personal distress firmly in
a social and political context, that realistically
confronts the limitations and pitfalls of its own
role, and that, where possible, seeks to help in-
dividuals and communities to articulate their ex-
perience of their world (including its potential
Clinical Psychology 24 – April 2003
for pain) and perhaps work towards making that
world a more tolerable place in which to live.
This is a task that will require considerable
changes to both the theoretical bases and prac-
tice of several psychological disciplines. This is
also a task that is surely likely to generate quite a
lot of work for the therapeutic psychologist for
many years to come, and at no small thanks to
the labours of David Smail.
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King-Spooner, S. (1995) Psychotherapy and the white
dodo. Changes,13, 45–51.
Kline, P. (1988) Psychology Exposed: or The em-
peror’s new clothes. London: Routledge
Masson, J. (1989) Against Therapy. London: Fontana.
Orford, J. (1992) Community Psychology: Theory and
practice. Chichester: Wiley
Pilgrim, D. (1997) Psychotherapy and Society. London:
Sage
Rogers, A., and Pilgrim, D. (2001) Mental Health Policy
in Great Britain: A critical introduction. London:
Palgrave
9
Moloney et al.

Rose, N. (1989) Governing the Soul. London:
Routledge
Smail, D. (2001) The Nature of Unhappiness. London:
Robinson.
Smail, D. (1998) A century of psychotherapy. In L.
King (ed.) Committed Uncertainty in Psychotherapy:
Essays in honour of Peter Lomas. London: Wurr
Smail, D. (1996) Psychotherapy and tragedy. In R.
House and N. Totton (eds) Implausible Professions:
Arguments for pluralism and autonomy in psycho-
therapy and counselling. Ross on Wye. PCCS Books.
Smail, D. (1993) The Origins of Unhappiness: a new
understanding of personal distress. London: Harper
Collins.
Smail, D. (1991) Towards a radical environmentalist
psychology of help. The Psychologist, 4, 1, 61–64.
Smail, D. (1987) Taking Care: An alternative to ther-
apy. London: Dent
Smail, D. (1978) Psychotherapy: A personal approach.
London: Dent
Stoppard, J. M. (2000) Understanding Depression:
Feminist social constructionist approaches. London:
Routledge
Vail, J., Wheelock, J., and Hill, M. (1999) Insecure
Times: Living with insecurity in contemporary soci-
ety. London: Routledge
White, M., and Epston, D. (1990) Narrative Means to
Therapeutic Ends. New York: Norton
Address
The Underwood Centre, Underwood Close, Marsh
Hill, Erdington, Birmingham B23 7HD

Division of Neuropsychology: Post-Qualification Training Day

Awareness of Deficit After a Brain

Injury or Dementia
Friday 25 April 2003
London Voluntary Sector Resource Centre, Holloway Road, London N7
Convener: Dr Linda Clare
Topics to include
Neuropsychological models of awareness and role of psychosocial factors — Linda
Clare
Psychiatric models of awareness and insight — Ivana Markova
Metamemory — Chris Moulin
Theory of mind — Ilona Roth
Awareness under anaesthesia — Mike Wang
Domain-specific awareness — Peter Halligan
Self-awareness after brain injury — Rudi Coetzer
Working with awareness in brain injury rehabilitation — Lesley Murphy

For further information contact:

Dr Michael Oddy, Brain Injury Rehabilitation Trust, 32 Market Place, Burgess Hill, West
Sussex RH15 9NP; Tel: 01444 237287; e-mail: birt@disabilities-trust.org.uk

10
My friend David Smail
Dorothy Rowe, Highbury, London
S
uffering, so it is said, brings people together.
Suffering certainly brought David and me
together. We battled the managers who
wanted to turn the NHS into a business, and we
battled the forces of unreason and cruelty in the
psychiatric system. We had many setbacks, but
pigheadedness and our mutual support of one
another kept us going. Of course, we added to
our troubles because we never learned how to
suffer fools gladly, and we certainly never en-
countered any shortage of fools.
We got to know one another when the heads
of the different psychology departments in the
Trent Regional Health Authority began meeting
regularly in order to develop a university-based
training course for clinical psychologists. Our
first task was to persuade the managers, who
would then have been hard pressed even to spell
the word ‘psychologist’, that psychologists were
necessary. Once our group had achieved this feat
we had to agree among ourselves on a syllabus
for the course. David and I soon found ourselves
together in a minority of two.
David’s idea for the course was that the stu-
dents should begin by studying how psychology
grew out of philosophy. Thus the students would
learn that many of the issues central to psychology
have in fact been well known to philosophers
down the ages. These were epistemological issues,
such as the relationship between mind and body,
and language issues, such as reification where
verbs, for example ‘behaving intelligently’, trans-
mute into things, for example ‘intelligence’, thus
leading to the assumption that if a noun exists
then there must be an actual thing to which the
noun refers. This erroneous assumption has led
to years of wasted effort in the search for ‘intelli-
gence’, ‘schizophrenia’ and the like.
I could see the wisdom of such an approach to
clinical psychology. This was how psychology had
been taught to me at Sydney University in 1948,
and it helped me understand that history,
whether the history of nations or the history of
an individual, is in essence the history of ideas.
However, the other members of our group had
little time for discussions about ideas. The train-
ing course they wanted to create was one which
taught students to be practical problem solvers.
Their views prevailed, not just in this course but
in all the degree courses for clinical psychologists.
I wonder now how different clinical psycholo-
gists would be if David’s ideas had prevailed.
Perhaps if this had happened I would never en-
counter, as I do today, clinical psychologists who
believe that Borderline Personality Disorder is a
real entity. However, a knowledge of the history
of ideas would have deprived cognitive therapists
of the pleasure of making their entirely novel and
unique discoveries such as that the relation be-
tween client and therapist is pivotal to outcome,
that depression is a refusal to mourn, and that
mindfulness produces calmness and wisdom.
Not all clinical psychologists were deprived of
a knowledge of the history of ideas. Some were
lucky enough to get posts in David’s department
of clinical psychology in Nottingham. Amongst
those psychologists who knew that there is more
to life than solving practical problems there was
keen competition to work with David (no one
ever worked for David). I have met many psy-
chologists who, at some point in their career,
have worked with David and they all share one
feature. When they speak of their time with David
it is with a sense of gratitude, of privilege, of in
some way being blessed. Most of all, they speak
of him with great affection.
The needs of our work may have brought
David and me together, but we soon had another
shared interest: writing. Not so much the task of
writing, but the business of dealing with publish-
ers. Writing a book is easy compared with getting
it published, then coping with the machinations
and inanities of the publishing world, and, worst
of all, making sure that your book is available to
possible purchasers. I have always flung myself
energetically into the publicising of my books,
while David treats such matters with his usual
amused reserve. As a result, my books sell in some-
11
Rowe
what greater numbers than do David’s. The sales
figures bear no relation at all to the books’ intrinsic
merit.
There are some marked differences in our
readerships. Mine are a heterogeneous collection
of individuals while David’s readers see themselves
as a very special elite. It is not just that they
know that they have stumbled upon a very great
treasure. They also know that they are among the
few who are wise enough to recognise what a
great treasure David’s books are. His readers judge
their fellows according to whether or not they
read and appreciate David Smail. Whenever I en-
counter a member of this elite – which can be in
the far-flung reaches of Australia or South Africa,
as well as across the length and breadth of the
UK – I find that they have only the mildest of in-
Division of Clinical
Psychology
North Thames Branch
Dates for your 2003 diary!
Monday 2 June (meeting)
Friday 14 November (conference)
Friday 12 December (meeting)
Meetings from 2 to 5 p.m. at the British
Psychological Society’s London offices,
33 John Street, London WC1N 2AT
(nearest tube is Chancery Lane).
Refreshments available.
Enquiries to Asha Desai, Branch
Secretary, on 0208 583 3529 or 2530.
12
terest in me until I disclose that I know David and
claim him as my friend. Then I enjoy, momentarily,
a little reflected glory.
It is extremely rare for a David Smail reader to
express the slightest reservation about his books.
If a reader does do this, it is only to say that per-
haps, sometimes, it seems that David is just a little,
just a smidgen, pessimistic.
David has never gone in for the upbeat end-
ings and cheerful titles that my editor demands.
However, I think the difference is more than just
my compliance with editorial policy. I think it
reflects a basic difference between David and
myself. The iniquities, cruelties and the sheer
perversity of people never surprise me, though I
often deplore them. Everything in my life as a
child told me that this was the way the world is.
But it is not universally so, and thus when I en-
counter generosity, unselfishness, love, fun, wit,
friendship, hope and joy I rejoice. David’s view
of life, I suspect, was based on the expectation
that life would be fair and just, and then events
proved him wrong. Rather than risk another
such disappointment, he views the world pes-
simistically, while I blunder on with what my de-
pressive clients would call my foolish optimism.
But I am guessing. I can imagine that when David
reads this he’ll smile his sweet, wry smile and
say, ‘Oh, I don’t know.’
Some pessimists protect themselves against
other people’s pain by being unaware of it or by
claiming that other people do not suffer, and thus
they lead a comfortable life. They expect the
worst and the world never disappoints them.
This is not David’s way. He knows what burden
of sorrow most people carry. He does not make
a display of his awareness of other people’s suf-
fering and of his pity for those who suffer. Some
people use their pity to denigrate and belittle
those whom they pity in order to increase their
own standing as a person of virtue. David sees
those who suffer as his equal. He expresses his
awareness and his pity softly, gently, and so
those who come close to him – his clients, his
colleagues, his family and friends – feel under-
stood, cared for and supported. No wonder we
all love him so.
Address
drowe@aol.com
I want, therefore I am: A tribute to
David Smail
Mark Rapley, Alec McHoul and Susan Hansen, Murdoch University,
Perth,Western Australia
A
s the new millennium dawned, The
Avalanches’ song ‘Frontier Psychiatrist’ –
with its chorus, ‘That boy needs therapy’ –
was an international smash hit (Avalanches,
2000). In the following year, The Guardian re-
ported that Ludwig Wittgenstein, Albert Einstein
and Bill Gates all share (or shared) a ‘mental dis-
order’ called ‘Asperger’s syndrome’ (Gold, 2001).
In the year 2000, self-help book sales in the USA
alone were worth $5.63 billion (Paul, 2001). In
Australia, the 2001 league table of expenditure on
the government-subsidised Pharmaceutical Bene-
fits Scheme saw Zyprexa, an ‘anti-psychotic’,
come in fifth (at an annual cost of $118 million)
and the ‘antidepressant’ Zoloft at number 10 ($64
million) (Kerin and Hickman, 2002: 6). Drug com-
panies in the USA spent more than $2.5 billion
on ‘direct to consumer’ advertising in 2001 alone
(Mintzes, 2002). The helpful ‘facts about Zyprexa’
offered by manufacturer Eli Lilly on the drug’s
own webpage (www.zyprexa.com) states that
‘over six million patients in 84 countries world-
wide’ have been prescribed the drug ‘since its
market entry in 1996’ and that its ‘successful im-
plementation’ in the UK was honoured by the
granting of the Queen’s Award for Enterprise in
Innovation in 2000 (Eli Lilly, 2000). More recently,
Kjaergard and Als-Nielsen (2002) reported a sig-
nificant positive relationship between the results
of so-called randomised controlled drug trials and
pharmaceutical company funding of the studies
in question.
Elsewhere, in the Medical Journal of Australia,
Peter Harradine, Sidney Williams and Steven
Doherty (2001) describe anti-psychotic-induced
Neuroleptic Malignant Syndrome as a routinely
missed condition that is a ‘major cause of mor-
bidity and mortality’ (Harradine et al., 2001: 594).
American psychiatrists Eri Kuno and Aileen Roth-
bart (2002) report that black Americans diagnosed
as schizophrenic are nearly twice as likely as non-
black citizens to receive depot administration of
older and more dangerous ‘typical’ anti-psychotic
medication. In a story headlined ‘Death knell For
recovered memory’, the February 1998 issue of
Psychotherapy In Australia reports (in the ‘Trade
Talk’ section) that, in 1997 in the US, Patricia
Burgus was awarded $10.6 million in an out-of-
court settlement after psychiatrist Dr Bennett Braun
fraudulently persuaded her that she had ‘recov-
ered’ memories of satanic child sexual abuse. Like-
wise, Lynn Carl was awarded $5.8 million after
being persuaded by psychiatrists at a Houston
hospital that she had 500 personalities and had
been abused by satanists after she was admitted
for ‘depression’.
In Britain the number of prescriptions for anti-
depressants rose from under 10 million per annum
in 1991, to a staggering 21 million a year in 2000.
The World Health Organisation (2001) estimates
that by 2020 depression will be the single largest
cause of global morbidity. Every year, the US has
19 million people suffering from ‘a depressive
disorder’ and holds a National Depression Screen-
ing Day every October ‘in over 3000 hospitals,
schools, retirement homes and doctors’ offices
across the country’. Prospective depressives are
advised to ‘complete a short, written test and dis-
cover if you have any early symptoms of depres-
sion’ (Colors, 2001/2002: 98).
Writing in The Lancet, a worried Dr Alexander
B. Nicolescu III (2000) calls for prophylactic
treatment with SSRIs of all people admitted to
hospital, for any reason, in case they could be-
come depressed. In the BBC report ‘Modern
mums suffer from sleep deprivation’, 56 per cent
of women said their sleeplessness led them to ‘a
state of despair’ (BBC, 2002a). And the compan-
ion piece, ‘Sleepless mums “like drink drivers”’
warns that this should not be confused with
13
Rapley, McHoul and Hansen
‘post-natal depression’ – in which case a doctor
should be consulted (BBC, 2002b). Deborah
Hope (2002) reports in The Australian that the
study of ‘suicidal’ Israeli sand rats offers a new
understanding of human ‘genetic depression’, and
the consequent hope expressed by Ian Hickie, the
chief executive of Australia’s national depression
initiative, that this will lead to a new class of anti-
depressant drugs.
This is truly ‘the Antidepressant Era’ (Healy,
1997). Recent estimates suggest that nearly 20
per cent of male Britons are diagnosable with a
‘mental disorder’ in any given week (Double,
2002). And in Australia, psychiatrists estimate
that their GP colleagues are ‘failing to recognise’
the presence of ‘mental disorders’ in upwards of
56 per cent of the cases they see (Hickie et al.,
2001). Richard Reeves, in The Guardian (2002),
notes that 40 per cent of Britons think life is
worse now than it was five years ago and asks
why ‘we feel so bad’. SANE Australia (corporate
slogan ‘Meeting the Challenge of Mental Illness’)
issues a ‘Factsheet’ which claims that ‘mental ill-
ness is common’. It continues: ‘Twenty in every
hundred people will experience some form of
mental health problem at some time in their
lives’ (SANE, 2000), and publicly reprimands
Unilever Australasia for its Sunsilk shampoo com-
mercial which SANE’s ‘StigmaWatch’ campaign
claims stigmatises the ‘depressed’. Unilever with-
drew the ad (Gauntlett, 2002).
The New Scientist (2000: 3) editorialises that
‘the human condition is now so thoroughly med-
icalised that few people can claim to be normal’.
Double (2002) tells us that the number of psy-
chiatrists employed in Britain’s NHS has climbed
to nearly 3000, a doubling in 22 years. The global
explosion of ‘mental disorder’ – and this conse-
quent ‘need’ for more and more psy-profession-
als – can perhaps be gauged by the exponential
growth of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental
Disorders, the DSM-IV (APA, 1994), which now
contains no fewer than 357 different ‘mental dis-
orders’, compared to the modest 106 forms of
known madness in the first edition. Shyness –
which is, along with smoking, now a psychiatric
condition – is ‘the third most common psychiatric
disorder in the United States, after major depres-
sion and alcohol dependence. Lifetime prevalence
14
has been estimated at 13.3 per cent’ (Double, 2002:
901-902). Shyness is not now simply a matter of dif-
ficulty with interpersonal relationships. Instead
‘social anxiety disorder’ (or ‘social phobia’) is an
officially recognised ‘mental disorder’ with its
own celebrity endorsement – Moynihan (2002)
reports that ‘US professional football sensation
Ricky Williams’ was being paid by GlaxoSmithKline
to promote Paxil® (paroxetine).
Similarly, being a child can now be a form of
psychopathology ‘with estimates that between 3
and 4 million [American] children and teenagers
have been diagnosed with attention deficit
hyperactivity disorder (ADHD) and prescribed
amphetamines’ (Baldwin, 2000: 453), and pre-
scription rates in Britain increasing by a factor of
15 in the three years between 1994 and 1997. In
the US, the number of children between the ages
of two and four using anti-depressants doubled
between 1991 and 1995, despite such chemicals
not being approved for use on children under six
(Colors, 2001/2002: 102).
In Western Australia, it is estimated that three-
quarters of all school classrooms contain chil-
dren taking psycho-stimulants, with a survey of
Australian doctors indicating that eight per cent
have prescribed psychostimulants, and 10 per
cent have given sedatives, to children under the
age of three (Hewitt, 2002: 8). The 19 February
2001 issue of Australian Woman’s Day fea-
tures regular health ‘expert’ Dr David Worth an-
swering readers’ questions about asthma, the
pill, and dentistry for those with heart mur-
murs. The health page also contains two ‘fact-
files’, ‘Nosebleeds — What can be done about
them?’ and ‘What is ADHD?’ Dr Worth tells his
readers:
ADHD stands for Attention Deficit Hyperactivity
Disorder, a condition found in children where
they’re inattentive, mischievous and slow learners.
Once other causes, such as hearing or eyesight de-
ficiency, have been eliminated the ADHD diagnosis
must be accepted and treated. It is caused by a
genetic lack of chemical activity in the part of the
brain involved in concentration and retaining
information … Amphetamine and Ritalin stimulate
affected parts of the brain to allow the learning
process to proceed … Frequent dosing is essential
and the dose required varies. Psychological

treatment and family support are important in the
management of this condition (Worth, 2001: 45).
Being ‘inattentive, mischievous and slow’, it
would seem, is now a factual matter of brain bio-
chemistry for the medical profession (not to men-
tion a handy ‘factfile’ to be offered to concerned
readers of Woman’s Day). Likewise, the pharma-
ceutical industry describes going bald as a ‘medical
condition’ (Moynihan et al., 2002) and advertises
solutions via ‘www.seeyourdoctor.com.au’ posters
on suburban buses. ‘Healthcare e-commerce’,
according to market researchers, will be worth
$370 billion by 2004 (Paul, 2001). Supporting
and promoting ‘healthcare e-commerce’ is ac-
complished by a range of clever marketing
schemes on the web, as well as on the buses.
Type ‘www.luvox.com’ into a web browser
and you are redirected to a site called
‘www.ocdresource.com’, and a very helpful
webpage providing two options — ‘The Resource
Centre (general info)’ and ‘Club OCD (young
people)’. ‘Club OCD’ — a fun webpage for kids —
fails to mention the connection between taking
Luvox and serious disturbances in young people
(Breggin, 2002) but reassures the young surfer
that ‘blaming yourself for Obsessive Compulsive
Disorder is like blaming yourself for the colour of
your eyes’. Another handy hyperlink (via the
brand name Luvox®) takes us to a page which
suggests:
Obsessive Compulsive Disorder comes in many forms,
any of which can overpower someone’s life. But
LUVOX® Tablets have proven effective in reducing
symptoms of OCD, and are widely prescribed for
the condition (www.ocdresource.com).
In June 2002, eminent psychiatrist Professor
Norman Sartorius editorialised that the ‘stigma of
mental illness begins’ not with the uninformed
and ordinary malice of the public but with the
‘behaviour and attitudes of medical profession-
als’ (Sartorius, 2002: 1470). In March of the same
year, Pfizer was publicly reprimanded by the
British Pharmaceutical Industry Association for
breaching the industry code of conduct by trying
to persuade GPs to prescribe Ziprasidone, an un-
licensed ‘anti-psychotic’ drug. Psychotropic med-
ication was also at the centre of the 7 February
Clinical Psychology 24 – April 2003
2002, story ‘Pet-owner resemblance evidenced
in science’ shown on the Australian Broadcasting
Corporation flagship current affairs programme,
The 7.30 Report. The story described the break-
through understanding of human misery afforded
by the administration of SSRIs to ‘Noah the Dog’.
The story features both ‘Noah the Dog’ and
Professor Judith Blackshaw – ‘an animal behav-
iourist on a quest to solve human misery’ – who
told viewers that:
Depression and anxiety are terrible states of mind
and unfortunately a lot of people suffer from them
… The big thing we’re trying to achieve is to show
people that the species of animals are very similar.
A depressed person – and, of course, there’s a lot
of depression in the world – and a depressed
animal are very similar. For example, I had a cat
who died from depression (ABC, 2002).
This putative inter-species continuity in misery
is cemented by the next segment of the story.
‘One cam day’, described simply as a ‘veterinar-
ian’, explains how ‘depressed’ dogs can be
helped, and presumably this is intended to offer
some reassurance to their identically afflicted
owners:
Well we’re giving Noah a medication called a selec-
tive serotonin uptake inhibitor, which is one of the
new vogue anti-anxiety medications that we use on
dogs and cats to solve a variety of behavioural
disorders that they can experience. So these
medications are good for these dogs. It leaves them
normal. They’re not tranquillisers, they’re not seda-
tives, they’re just medications designed to tip out
that anxiety in their behavioural profile and make
them feel so much more calm and at ease with
normal everyday life (ABC, 2002).
This is madness. And there’s the rub. Not
feeling ‘calm and at ease with normal everyday
life’ is precisely the problem of the present,
and not just for cats and dogs. As New Woman
has it in April 2002: ‘part of the change in the
way that we move through life comes from the
pressure to “live”. No longer can we simply
“exist”’ (Tait, 2002: 75). And to ‘live’, to have a
‘lifestyle’ rather than merely a life, we must
consume.
15
Rapley, McHoul and Hansen
Indigeo ergo sum – I want, therefore
I am
As a snapshot of our present this presents an
amazing portrait. Serious TV current affairs pro-
grammes unironically (and completely uncritically)
screen stories suggesting that because ‘depressed’
dogs do well on SSRIs, then people will do like-
wise. The pharmaceutical industry produces a
(dangerous) pill for every ill, and record numbers
of people apparently swallow them. Popular
magazines inform their readers that fictitious
‘disorders’ of myriad shapes afflict them and
their children, and that the answer is – a pill with
its own webpage and ‘Club OCD’. Self-help books
fly off the shelves and yet, despite this, misery and
madness are inexorably increasing. The ranks of
the psy-professions continue to swell, and the
numbers of ‘chemically imbalanced’ citizens soar.
The ‘helping’ professions abuse the trust (and
the brains) of their ‘clients’, and with every pass-
ing day another aspect of life becomes accepted
as a ‘medical problem’. Science is, we are told, a
story of progress; but our greatest scientists and
philosophers are retrospectively diagnosed as
‘mentally disordered’. Our politicians declare a
‘war on drugs’, and the psy-professions prescribe
(in many cases identical) drugs in record quantities.
And, with the exception of a small literature – to
which, in books such as Taking Care and The
Origins of Unhappiness, David Smail has been a
tireless and distinguished contributor – there is
little political protest.* A paradox. How on earth
has this come to be?
The answer to this question is immensely com-
plex, and here we can do little other than sketch
some of the outlines. One part of the answer
lies in the failure of counter-politics in so-called
liberal democracies, and another lies in the self-
conscious efforts of the psy-professions to pre-
cisely this end. That is, the production and
marketing of the idea that the inevitable alien-
ation, dispossession and injustice inherent in
consumer capitalism is an individual and per-
sonal – rather than a political and economic –
problem is, and has been from the beginning, a
* Also see Newnes, Holmes and Dunn (1999; 2001),
Bracken and Thomas (2001), Boyle (2002a) and
Double (2002) for excellent contributions to this liter-
ature.
16
central self-assumed task of the psy-formations.
As David has put it:
Our disillusion with and widespread rejection of
what passes for politics these days – that is, for the
most part, the acquisition and manipulation of
power by large interest-groups – leave us exposed
to ideologies at least as dangerous as those
recognized as political. For the marketed ideology of
interiority, the world of ‘third ways’ where public
opposition is supposed to be at an end and the in-
terests of all can be reconciled, where exhortations
to ‘personal responsibility’, ‘naming and shaming’
and other forms of sanctimonious moralizing take
the place of government, all these take us in to a
realm of make-believe where there is only an
illusion of control, and where the real, material
principles of social reality threaten to run riot
(Smail, 1999; our emphasis).
The consequences of inhabiting this world of
make-believe are all around us. In the west we
inhabit a world saturated with advertisements,
expert pronouncements and agony aunts all
singing from the same song sheet.
Choice is always possible. We can ‘just do it’.
We are ‘worth it’. We must internalise our hap-
piness. We must dump our emotional baggage.
The presidency of the USA is within the grasp of
the lowliest in the land. If we just work hard, we
can have whatever we want. The class system
doesn’t apply any more in Cool Britannia. In
Australia we must aspire to being ‘relaxed and
comfortable’. À la Michael Jackson, if we are dis-
satisfied with even the most fundamental aspects
of ourselves, they are changeable at whim. While
being ubiquitously present, misery and madness
are not an acceptable part of being human.
There is a technical solution for every problem
with which we are confronted. Material circum-
stances determine our happiness and nowadays
celebrity is ‘normality’. Look at Posh and Becks –
ordinary everyday folk can acquire more money,
possessions and property than they know what
to do with. We can all have our 15 minutes of
fame, and not wanting it is probably an illness.
Success can be anyone’s and failure is ‘no fault’.
Consuming will make us whole. Poverty, vio-
lence, discrimination, unemployment, racism
and abuse have no contribution to make to mad-

ness and despair; ‘it’ (whatever ‘disease’ it hap-
pens to be) is ‘a chemical imbalance in the brain’.
Our parents have no influence on the way we turn
out in the world. Driving in an inconsiderate man-
ner, fidgeting in class and feeling sad are medical
problems just like diabetes, cancer and nose-
bleeds. Psychologists understand unhappiness
and they can help. If we just adopt some ‘Good
Thinking®’ (Australian Psychological Society,
2002), she’ll be right mate. If we buy the cleverly
‘marketed ideology of interiority’, the world will
be fair, just and equitable and we will be happy
(ever after). Misery and madness are not moral
problems, but rather biological conditions. That
boy needs therapy. And all the time the material
principles of a market-based social reality no
longer merely ‘threaten to run riot’….
In his ‘case study’ of the 1980s David sug-
gested that:
Consumerism is, of course, not just a phenomenon
of the eighties, but the necessary ideology of an
economic system which depends for its survival on
limitless expansion of the market … The most im-
portant social function of the vast majority of the
population of a country such as Britain is to consume.
It is true, of course, that so far our lives as social
beings are ordered, perhaps even fundamentally,
by public ‘forms’ of morality which arise more
from our common humanity than from the dictates
of consumerism, but such ‘forms’ have become
tacit, unofficial, and survive only as the embodied
practice of a collectivity of individuals who no longer
have access to any coherent, clearly articulated,
statement of them. The only values which are made
manifest to someone living an everyday life are
Business values … The ultimate Business logic is,
then, to reduce the average member of the
consuming class to an addict of the mass market,
locked by the nervous system into an optimally
cycled process of consumption, rendered immune
to unprofitable distractions, dissociated from any
form of solidarity which might offer resistance to
the function of enjoyment (Smail, 2002).
And sustaining our incomprehension of this is
a task assiduously, enthusiastically and tirelessly
attended to by psy. Every day, in every way, we are
found – find ourselves – wanting. For psychology
has largely abandoned any pretence it might once
Clinical Psychology 24 – April 2003
have had to stand for social justice or the rights
of the poor, the miserable and the dispossessed.
Instead it has become, nakedly, a business. Where,
once, on a romantic reading, psy may have been
concerned to understand and to help ‘patients’,
now the disciplines concern themselves with
‘trade talk’, ‘market share’ and ‘consumers’.
But despite this, what Michel Foucault has
called the ‘positivity’ of the ‘knowledges’ pro-
mulgated by the psy-disciplines – their incredibly
rapid popular uptake and dissemination, and the
power wielded by that knowledge – shows little
sign of waning. Such positivity is, of course, in
direct proportion to the strength of the disci-
plines’ claims to deal in timeless truths. And the
truth which psy has helped us to tell ourselves
about our selves over the last couple of hundred
years is predicated on a double truth claim. Psy
claims adherence to a code of quasi-medical
‘ethics’ and hence claims to tell moral truths:
the adoption (or at least the proclamation) of the
use of scientific method lays claim to epistemic
truth. Hence the pervasiveness, powerfulness and
apparently commonsensical quality of what
David has called this ‘realm of make-believe’. But
these claims to truth are, as David has also pointed
out, are, sadly, bogus. The profession, by the psy
disciplines, of an ethical code is a sham and the
use of scientific method is little more than a
rhetorical gambit designed to shield from close
scrutiny the increasingly bizarre claims that psy
makes about what we are, what we can or cannot
be, and the dis-eases to which we are prone.
In the preface to The Order of Things Michel
Foucault (1970: xv), via Jorge Luis Borges, describes
a mythical and outlandish categorisation scheme
contained in a ‘certain Chinese encyclopaedia’
for the animals of the world –those that belong
to the Emperor, those that are embalmed, those
that have just broken the water pitcher, those that,
from a long way off, look like flies, and so on –
and reflects upon the ‘stark impossibility’, for us,
of thinking that. Here we would like to follow
the example he and David have offered, and to
suggest that the way that we have come to think
ourselves in the present is also an outlandish –
if unacknowledged – marketed mythology.
How has the evidently widely shared subscrip-
tion to our current myth of ourselves been
achieved? The answers to these questions can
17
Rapley, McHoul and Hansen
only be found by a careful examination of the
means of production, distribution and ex-
change of the ultimate consumer product, the
‘illusion of control’ that psy insists is the final so-
lution to what it means to be human. Indigeo
ergo sum.
Acknowledgement
This paper is an edited version of a chapter from
Beyond Help: A consumer’s guide to psychology.
(The chapter is entitled ‘That Boy Needs Therapy’.)
We thank the publishers, PCCS Books, for their
kind permission to republish this extract in its
present form.
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tel: 0115 969 1300 ext. 40625
Clinical Psychology 24 – April 2003
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Address
School of Psychology, Murdoch University, Murdoch
6150, Western Australia
19
Some thoughts on How to Survive
Without Psvchotherapy by David
Smail
Miller Mair, Resident Fellow, Kinharvie, Glasgow
D
avid Smail is very direct, definite and un-
qualified in much of what he writes. It is
sometimes shocking to be spoken to in
this way. He does not bend and ingratiate himself
in order to be thought well of or to net as widely
sympathetic a professional audience as possible.
This can be seen as arrogance or simple minded
dogmatism, but it is neither.
What he does is to respect his readers’ intelli-
gence, as well as his own sense of truth, by writing
what he believes to be worth saying. He clarifies
much that is uncomfortable for many in the psy-
chotherapeutic world to hear. The common
courtesies of the psychotherapeutic clans tend
to hide or slide past many of the fundamental
issues that he tackles head-on. There are many of
us who do not want to hear what he says because
we have professional, financial and other interests
in keeping ourselves and our worlds intact.
While this book stands on its own, offering
startling glimpses of life-going-on-just-as-the-
psychotherapeutic-stone-is-lifted, it is also a further
stage of development of an alternative psycho-
logical approach (understanding ourselves in the
context of the wider pressures and power struc-
tures of our society). This is the sixth book in
Smail’s continuing exploration of how we can
become psychologists who really seek to explain
what affects and influences our experiencing (feel-
ings, thoughts and behaviour), rather than simply
being empathic or belittling by overoptimistic
claims to psychotherapeutic powers we don’t
really possess.
Smail, as a sensitive, thoughtful and knowledge-
able man with more than 30 years of psychothera-
peutic experience within the NHS, is not to be
easily dismissed as ‘simplistic’ or ‘pessimistic’. He
is a remarkably perceptive writer, deeply respect-
ful of those who have sought psychological help
20
and passionately committed to the creation of a
better society through the gradual struggles of
people to understand more adequately what causes
psychological misery. He shows how readily we
mislead ourselves by offering accounts of events
which are too narrowly self-centred and internal.
The thesis which he elaborates in many illumi-
nating ways is that psychological distress ‘is not
a problem of the person or of the ‘self’, but is a
problem presented for the person by the world'
(p.38).
He says important things about how completely
we are shaped and held, changed and damaged
by social, cultural and material pressures vastly
greater than our individual lives can easily recog-
nise. He makes a convincing claim that much of
our psychological understanding, built on the basis
of the model of the consulting room (where little
is available but the feelings and expressions of
the few individuals enclosed therein), is quite in-
adequate and dangerously misleading as regards
serious psychological inquiry into what assails us
and contributes to human distress.
He argues powerfully for the crucial importance
of wider (distal) influences (in terms of economics,
politics, physical resources, cultural opportunities
and limitations) which have far greater sway over
us than we easily or willingly recognise. Our ten-
dency is to note and blame the sorts of events
that immediately impinge on us (the proximal in-
fluences), and attribute far more importance to
them in our explanations than is legitimate. Even
though our proximal accounts have their own
validity, he argues that much wider and more
objective assessment of the contexts of people’s
lives has to be noted if we are not to be swal-
lowed up in self-centred blaming of ourselves or
others on the one hand and foolishly grandiose
hopes for therapeutic magic on the other.

It is not that everything Smail says is right. His
every sentence encourages you to take issue,
argue, struggle to understand and engage. How-
ever, for me at least (and to mix my metaphors
thoroughly), there are so many nails being hit on
the head so clearly and cleanly that a sense of re-
freshment and enlightenment (a real sense of
light streaming in and a lightening of loads) is an
ongoing and remarkable aspect of reading this
book. There is such an honesty of endeavour in
these pages. It is such a relief, as a clinician, to
read someone saying what you know makes sense.
This experience starts at the beginning of the
book and continues throughout. Right away he
speaks of the professional confusions, ambiguities,
disputes and differences that lie hidden below
the surface of the seemingly benign and coherent
mental health services (who else writes in this
way?). He goes on to open up to question and
constructive scrutiny many of the major psycho-
logical and philosophical issues that trap us in
our attempts to understand ourselves (as persons)
and in our psychological work (as professional
psychologists and psychotherapists).
Smail is unique in combining depth of psycho-
logical and psychotherapeutic experience within
the NHS (rather than in the selective and limited
context of private practice) with clarity of philo-
sophic analysis. He expresses difficult ideas in an
elegant way, always rooted in clinical experience
and practicality. His ‘ground clearing’ examina-
tion of personally and professionally confusing
concepts (such as ‘blame’ and ‘explanation’, ‘in-
tentions’ and ‘reasons’, ‘responsibility’ and
‘obligation’, ‘will power’ and ‘introspective com-
mentary’) should be required reading for psy-
chologists, psychotherapists and many others.
His belief is that we are repeatedly misled and
handicapped in both practical and theoretical
undertakings by the intellectual and moral con-
fusion which permeates much of our thinking
about psychological distress and the possibilities
for change.
Why is this book of particular importance?
1. David Smail articulates a significant alternative
to the currently fashionable approaches to psy-
chotherapeutic theory and practice. This book
presents the achievements of many years of
profound thought in such an enjoyably clear
Clinical Psychology 24 – April 2003
manner that it could (and should) be used in
every relevant training course in the country.
2. In combining psychotherapeutic experience
and philosophical incisiveness, Smail offers a
model of serious thoughtfulness concerning
important practical issues. In this way he illus-
trates an approach to psychological inquiry
which is especially appropriate for his subject
matter and very different from the experi-
mental approach which is more familiar to
professionals and trainees.
3. This is an intentionally disillusioning book and
is therefore of particular importance when psy-
chotherapeutic and counselling approaches are
becoming so widespread and are so steeped
in illusions of many different kinds. Some
people find Smail’s message deeply distressing,
undermining and depressing. Others respond
with a sense of relief, renewed optimism and
hope in what may be achieved if we can free
ourselves of many handicapping confusions.
Both groups are encountering ‘disillusionment’
and responding very differently. Major chal-
lenges are presented here with a clarity which
offers significant opportunities for reappraising
practice and inquiry in psychotherapy.
4. Unlike almost any other current psychologi-
cal writer, Smail articulates and shows the
relevance of recent political, economic and
cultural changes for understanding many of the
experiences of personal distress that have
been presented in psychotherapeutic (and
many other) contexts over the past few years.
In this way he helps to make visible and
thinkable what would, for most of us, remain
mysterious or unimagined. Many of the powers
and pressures of the wider world are given ‘a
local habitation and a name’, rather than re-
maining as ‘airy nothingness’ and therefore
impossible to address in any meaningful way.
5. At a time when the pursuit of truth has been
all but overtaken by the marketing of any
psychological approach which will sell, Smail
offers repeated challenges (in the style of his
presentation and the content of his concerns)
to stop, think, question, argue, engage and con-
21
Mair

tinue to struggle for better understanding and
clearer awareness of the powers which shape
and damage us and the realistic possibilities
we have for change in how we live together.
The whole point of this book he says has been
to emphasise the fact that we are all in boats not of
our own making, and hence that there are other
ways of understanding personal distress than
merely seeing it as the kind of failure to cope
with, or ‘manage’, our personal life and relation-
ships which is best addressed by some variety of
therapy or counselling. It is not only far truer,
but also, I think, more productive, to see psy-
chological distress as an indication that there is
something wrong with the world than it is to in-
terpret it as a sign of some inadequacy or defi-
ciency of the self. This is not a cop-out, and in no
way absolves us from struggle. It just indicates
that our struggle should be directed at other tar-
gets than our ‘selves’ (p. 228).
Address
Kinharvie, Glasgow

British Psychological Society Psychology Of Women Section

Women & Health Postgraduate Prize – 2003
To be awarded for a 3000-word article that is based upon a piece of original postgraduate work. The
article must be clearly related to the work carried out as part of a postgraduate thesis or dissertation
and discuss some original findings. The article should be relevant to the theme of Women & Health and
must not have been published previously.
You could win
❍ A £200 cash prize.
❍ Two years’ subscription to the leading international journal Feminism & Psychology.
❍ The opportunity to present your prize winning research at the 2003 POWS Conference, where the
Women & Health Prize will be awarded (conference registration fees will be waived).

❍ Publication of your submission in the POWS Review (subject to the normal peer review process).
Who is eligible?
UK-based postgraduate students who have submitted their thesis or dissertation in the last 12 months.
In line with the theme of women and health, submissions are particularly encouraged from students
researching in the areas of health psychology, clinical psychology, nursing and midwifery.
How to enter
❍ You need to submit a short abstract (max. 250 words) or your article by the 30 April 2003.
❍ Feedback on your abstract will be given by 7 May 2003.
❍ Subject to acceptance of the abstract, the deadline for submission of the full article will be 1 June.
Please submit four copies of the abstract and (if accepted) four copies of the article. All abstracts and
completed articles will be reviewed by three members of the POWS committee plus one external
expert in the area of women and health.

❍ The winner of the prize will be notified by 15 June 2003 and the prize will be awarded at the POWS
Conference 8-10 July 2003.
Please forward all submissions to: Kate Milnes, Division of Psychology and Sociology, Ramsden
Building, The University of Huddersfield, Queensgate, Huddersfield HD1 3DH; Tel: 01484 472763;
e-mail: k.milnes@hud.ac.uk
Please contact Kate if you have any questions about the POWS Women & Health Prize.

22
Can the past achievements of
clinical psychology be maintained
in the ‘modernised’ NHS?
Reflections of a quarter century
working in Nottingham
Julia Faulconbridge, Nottinghamshire Healthcare NHS Trust
A consideration of how clinical psychology,
especially community psychology, has grown
within the context of the NHS and how the
circumstances which enabled this may now be
being eroded.
I
was given my first post, as a probationer clini-
cal psychologist, by David Smail in 1975. At
that time there were, I think, a total of eight
of us covering all specialities across the entire
county of Nottinghamshire. We would attend
meetings of all psychologists in the Trent Region
where we would know everyone who was pre-
sent. I currently run a Community Child and
Adolescent Service for Nottingham which has
twice as many staff for one specialism than were
in the whole department that I joined. These
days, I do not even know all the psychologists in
Nottingham, let alone the Region. The vast in-
crease in the number of clinical psychologists em-
ployed within the NHS over the last 27 years has
been mirrored by a phenomenal expansion of
the nature of the work which we take on. I want
to consider some of the conditions which enabled
that to happen, with particular reference to com-
munity psychology.
On leaving university and starting training for
my new career, I was full of youthful idealism
about the potential contribution of psychology
to people experiencing what was then referred
to as ‘mental illness’. This was the era of major
critiques of psychiatry by people like Erving
Goffman, Thomas Szasz and Ivan Illych that
seemed to have undermined the medical models
of psychological distress. The predominant psy-
chological model was still behaviourism, but
powerful arguments were being raised against
this simplistic vision of the complexity of human
behaviour by psychologists like Don Bannister.
The continued incarceration of people in long-
term institutions for the ‘mentally ill’ and the
‘mentally subnormal’ was increasingly being
questioned.
I was, however, disappointed to find that the
role which clinical psychologists were expected
to fulfil, mainly by psychiatrists who were the
primary source of referrals, was one of assess-
ment. This could be of intellectual functioning,
personality or vocational aptitudes, and the main
purpose was to provide the referrer with infor-
mation which they could use in their treatment
plans for the individual, although it was never clear
what use they actually made of it. There were the
occasional referrals of patients for behavioural
methods of treatment like systematic desensitisa-
tion, and it was in seeing such patients that the
inadequacy of the behavioural treatment rapidly
became apparent. I recall patients with severe
obsessive-compulsive problems for whom it was
clear that a different type of intervention would
be needed, but it was hard to know where to
start in working with them. As a naive proba-
tioner, understanding the nature of the world in-
habited by these patients was an overwhelming
task.
However, in David’s department the discipline
of clinical psychology was seen as fundamentally
an intellectual enterprise rather than an exercise
in pragmatism. Each week ended with a Friday
23
Faulconbridge
afternoon seminar which we all took turns to
present. The younger members of the department
often dreaded these because of the rigour with
which clinical issues were addressed at a theo-
retical and philosophical level; we were strug-
gling to cope with the demands of our work with
patients. These seminars are the ground on which
my practice of clinical psychology has been based
and I know that others who passed through the
department also share that retrospective sense of
the crucial importance of those and similar dis-
cussions within the department.
In the early years of my training, David was
writing his book Psychotherapy: A personal
approach and the ideas which formed this book
were discussed in the seminars. These discussions
and the book itself were the base on which I grad-
ually developed my own therapeutic approaches
with patients and which gave me a kind of map to
aid me in navigating the complexity of engaging
with another individual to try to help them find
a way through their difficulties.
The roles available to clinical psychologists
continued to expand and referrals for therapeutic
interventions began to predominate, together with
working to support other staff in the work they
were undertaking in wards, specialist units and
non-NHS settings.
I recall becoming increasingly frustrated with
the limitations imposed by working alongside
psychiatry and with people whose problems had
become entrenched by the time they were even-
tually referred to our service. There was also the
knowledge that the majority of people never made
it through the barriers imposed by traditional
referral pathways. David and other like-minded
psychologists in the department began to develop
work within primary care. The experiences of
working closer to people’s lives through that
work led to further the development of a com-
munity psychology model in Nottingham for
working with adults, children and adolescents.
The development of the critique of traditional
therapeutic models, which can be seen in
David’s subsequent books, is fundamental to the
community psychology approach.
The expansion of the horizons of clinical psy-
chology over the last quarter century has been
fostered within the NHS. Despite its many fail-
ings, it has provided clinicians with a working
24
environment which allowed us to use our theo-
retical knowledge, our clinical experience and
our creativity to develop types of provision which
have really affected positive change in peoples’
lives. There are clinical psychologists who write
about their work, and David is one of the fore-
most examples of this. There are also clinical psy-
chologists who conduct research. The majority
of clinical psychologists do neither, but their
accumulated knowledge and experience is passed
on to others through teaching, supervision and
consultation to the upcoming generations of
clinical psychologists and to others who work
with people with psychological difficulties. This
contribution is less easily seen, as it is not con-
tained in books and journals, but it is probably
the major source of influence that clinical psy-
chology has in the world at large. David has al-
ways been a major advocate of the transmission
of psychological knowledge through these
means as well as through his writing. His words
are often challenging, indeed threatening, to the
orthodoxies of clinical psychology, psychiatry
and other disciplines concerned with psycholog-
ical well-being.
Over the years that I have worked in the NHS,
it has always been underresourced and we have
worked against a constant backdrop of heavy
workloads and insufficient staffing. When posts
have been created they have been hard to recruit
to because of the low training numbers. Mental
health services have always been Cinderella ser-
vices, and provision for children and adolescents
comes even further down the list. Yet providing
resources to develop early intervention and pre-
vention services should be the way forward in
any logical health system.
Having lived through the Thatcher years and
the damage caused to the NHS, I would have
hoped that things would get better with Labour
governments. There have been welcome initia-
tives and some increase in resources, but I fear
that the circumstances which allowed clinical
psychology to develop over the last 25 years are
being lost. The gap between government rhetoric
and reality of work in the NHS seems to be get-
ting wider.
There have been a plethora of project-based
initiatives, providing short term funding without
long term guarantees. The political imperatives

have often meant that the rules have changed
faster than the projects can be developed. One
clear example of this was the development of
Health Action Zones, which were supposed to
develop innovative strategies for improving health
care in deprived areas. The remit was then
changed towards meeting targets on coronary
heart disease and cancer, and later the money
was withdrawn altogether. We had two success-
ful projects, one of which had to close, with a
loss of provision to a community which had come
to value it. The other, involving provision for
African-Caribbean families, has managed to keep
going temporarily by accessing other short-term
funding and at a cost of considerable amounts of
time spent trying to organise this. Similar changes
in the remit are now occurring with other initia-
tives like Sure Start and Children’s Funds, which
also have the problems of no guarantees of long-
term funding.
The development of new commissioning
arrangements within the NHS and the change of
emphasis on local decision making are having sig-
nificant effects on clinical psychology provision.
The commissioners do not usually have expert
knowledge of the field of clinical psychology and
they work in terms of mental health models of
provision with a traditional multi-disciplinary
teams approach. This is being reinforced through
NSFs, which consolidate this model as the blue-
print for NHS provision. Models of provision like
community psychology are not recognised or un-
derstood in my experience, and it is often not
possible to enter into intellectual discussion of
different models of care with decision makers who
are being driven by performance indicators, star
ratings etc.
It is certainly arguable that the diversity of pro-
vision which used to exist across the country
produced unacceptable inequities in-patient care.
However, one positive aspect of that diversity
was that it enabled clinical psychology to explore
ideas and innovate approaches across the range
of health services, leading to the considerable ad-
vances which have been made in a relatively
short span of time. The profession is almost un-
recognisable from the one that I joined and the
contributions which have been made to theory
and practice have led to significant changes in
other fields too. However, the space which allowed
Clinical Psychology 24 – April 2003
for this is being curtailed and, I fear, the creativity
of clinical psychology will go with it.
Within my own field of child and adolescent
work, there has been a significant change over
the last 18 months as many clinical psychology
departments have been closed and the staff
merged with child and adolescent mental health
services, traditionally led by child psychiatrists.
Where once clinical psychology could offer an
alternative to psychiatric approaches, it is now
being constrained within medical models.
Community psychology approaches, prevention
and early intervention strategies are being recon-
figured as outreach provision from mental health
teams. Whilst government documents speak of
increasing choice for patients, diversity is being
eliminated.
Elements of centralised control were beneficial
for professions of the size of clinical psychology,
as they served to protect us in an NHS largely driven
by medical and surgical imperatives. What seems to
be happening now is that local decisions being
made across the country are having the cumulative
effect of disempowering clinical psychologists as
a profession. There has always been a tension be-
tween psychiatry and clinical psychology – they
both complement and contrast with each other.
Throughout my professional life, there has been
a constant pressure from psychiatry to control
the work of clinical psychologists. When I first
began work in David’s department in the wake
of the Trethowan Report, the basis for the pro-
fession had been laid. We were a department in
which our head of department reported directly
to the area medical officer. Over the years, we
have slipped further and further down the
management hierarchies as these have been
built through successive NHS reorganisations.
There is a risk that, within a few years, all clini-
cal psychology will be provided from within
mental health provisions in mental health trusts,
a position which will continue to limit our abil-
ity to contribute to the necessary debate about
psychological distress and means of changing
it. There are also increasing moves to replace
professional heads of department with general
managers.
Government papers are being published which
highlight the need for the development of pre-
vention and early intervention models across health
25
Faulconbridge

and social care sectors and yet the real contribu-
tions which models of community psychology have
made are not being harnessed in this planning pro-
cess. If child and adolescent clinical psychology
is restricted to mental health teams, the potential
for influencing this vitally important development
is lost.
In the end, assessment and therapy services
can be provided within the private sector, but it
is hard to envisage that community psychology
could ever be developed in anything but the
public sector. If David were to be beginning his
professional life now rather than in the 1960s, I
doubt he would be able to develop his ideas and
disseminate his experience whilst being em-
ployed within today’s NHS. The past may be an-
other country but can clinical psychology
maintain its vigour in the country we are moving
into?
References
Bannister, D., and Fransella, F. (1989) Inquiring Man
(third edition). London: Routledge
Goffman, E. (1961) Aslyums. New York: Anchor Books
Illich, I. (1975) Medical Nemesis. London: Calder & Boyars
Smail, D. (1978) Psychotherapy: A personal approach.
Smail, D. (1984) Illusion and Reality: The meaning of
anxiety. London: Dent
Smail, D. (1993) The Origins of Unhappiness: A
new understanding of personal distress. London:
HarperCollins
Szasz, T. (1962) The Myth of Mental Illness. London:
Secker & Warburg
Address
Nottingham Community Child and Adolescent Clinical
psychology Service, Childrens Centre, c/o City Hos-
pital Campus, Hucknall Road, Nottingham NG5 1PB;
julia.faulconbridge@broxtowehucknall-pct.nhs.uk

T h e Clinical Psychology D a t a b a s e
with
The Psychologist Reference Database
A useful tool for trainee clinical psychologists, practitioners and
psychology departments.
A computerized reference database of articles in:
Clinical Psychology Forum from issue 1 (1986-2001)
Clinical Psychology from issue 1 (May 2001 onwards)
Division of Clinical Psychology Newsletter references from issue 1 (1967-1986)
Key Bulletin of The British Psychological Society clinical psychology references
(1950-1986)
The Psychologist (1988 onwards)

For further details of the database please send stamped addressed envelope to:
Mike Jellema, Chartered Clinical Psychologist, 47 Fern Avenue, Jesmond,
Newcastle upon Tyne NE2 2QU; Tel: 0191 281 0558 (evenings);
e-mail: mikejell@blueyonder.co.uk

26
The dangers of vulnerability
Mary Boyle, University of East London
O
ne of David Smail’s most important con-
tributions has been his analysis of the
damaging psychological effects of ideo-
logical, social and economic power on ordinary
people and especially the effects of processes which
obscure the operation of power. This short paper
is both a tribute to David and an attempt to high-
light yet another way in which power masks itself.
There was recently a regular column in the
week-end Guardian on ‘words that should be
banned’. It may have been semi-serious, but there
is nothing facetious in my suggestion that we
should think of removing the words vulnerable
and vulnerability from our vocabularies. The task
would not be easy, for these words have become
extraordinarily popular amongst professionals
and the public. It began, perhaps, at least in the
professional literature, with the vulnerability-
stress theory of schizophrenia, which quickly
spread to other ‘disorders’ such as depression or
drug misuse, until it seemed obvious that psy-
chiatric disorders resulted from a combination of
pre-existing biological vulnerability and environ-
mental stress. But the popularity of vulnerability
soon spread beyond the professional literature as
the public became used to media discussions of
professional failures to protect vulnerable chil-
dren or elderly people; we now have the con-
cept of vulnerable adults, which seems to apply
to most of those we might work with. The cur-
rent popularity of vulnerability is also well illus-
trated by the fact that one of the themes at the
2002 Conservative Party conference was ‘help-
ing the vulnerable’, a theme clearly intended to
elicit public sympathy, and votes, but a theme
whose use only makes sense in a social context
where the existence of ‘the vulnerable’ as a de-
serving social group is already widely accepted.
In other words, it was assumed that the conno-
tations of the theme would be well-understood
and be sufficiently positive to help turn the for-
tunes of the Conservative Party.
But why is vulnerability so popular? One way
of approaching the question is to ask what is
achieved by the idea of vulnerability, or to what
strategic uses might it be put? In the case of vul-
nerability-stress theories, one answer is fairly ob-
vious: vulnerability functioned to maintain the
primacy of biological accounts of ‘abnormality’
in spite of a lack of any direct supporting evi-
dence. But the increasing popularity of vulnera-
bility and, now, its explicit political use,
obviously calls for further explanation. We can
pose three questions about what is achieved by
the use of vulnerability which might illuminate
the situation: what kinds of identities are con-
structed by vulnerability? What actions do these
identities make reasonable or unreasonable?
And, who or what is protected from scrutiny by
the idea of vulnerability?
What kinds of identity are
constructed by vulnerability?
If language is simply a neutral and self-evident
representation of something in the world, then
vulnerability is an observation about a character-
istic or attribute of certain people. But if language
constructs rather than reflects the world, then
vulnerability can be seen as an invented social
category which is routinely applied in day-to-day
talk only to those groups who are already socially
and economically subordinate, for example, old
people, people with disabilities, women, chil-
dren and the mad. We could (but don’t) say that
white people are vulnerable to being racially
prejudiced; that men are vulnerable to viewing
women as sex objects; that professionals are vul-
nerable to exploiting those who trust them, and
so on. One reason we do not say these sorts of
things, and why vulnerability is usually named in
others, lies in the very negative identity which
vulnerability confers, some of whose compo-
nents are provided by the thesaurus and the
OED: helpless, defenceless, powerless, subjec-
tion, unprotected, in danger. But those who
name people as vulnerable, whether profession-
als or politicians, are implicitly constructing a
complementary identity for themselves which
27
Boyle
I’d suggest involves components such as strong,
protector, powerful, defender, helpful, trustwor-
thy. It’s not simply that the self-identity implicitly
constructed by those with the power to name
reality is much more positive, but that both iden-
tities carry with them potentials for action which
leads to the question:
What actions are made to seem
reasonable or unreasonable by these
identities?
For the ‘vulnerable’ person, reasonable actions
are to accept help and protection. For the pro-
fessional, politician or non-vulnerable member of
the public, reasonable actions are to give help
and protection. So, a set of behaviours associated
with passivity and, possibly, gratitude, are seem-
ingly reasonable for the vulnerable person, while
a set of behaviours associated with activity and
skill and, possibly, altruism, are seemingly rea-
sonable for those who name the vulnerable. Just
as important, the opposite behaviours would
seem unreasonable.
I’d argue that these complementary identities
could also support forcing ‘help’ on the vulnera-
ble person. The language we use to talk about in-
tervention highlights this – we talk about
complying with treatment (doing what you are
told). When we talk about non-compliance, we
construct another negative identity for those
who don’t behave in accordance with the first,
passive identity – an identity as someone who is
potentially deviant, perhaps disobedient and un-
ruly. And more recent talk of treatment adher-
ence and non-adherence rather than compliance
doesn’t avoid negative identities, with its impli-
cation of people who are unable to stick with or
persist at something. We could, of course, talk
about people who have decided or chosen not to
accept what is offered but that doesn’t fit easily
with the passive identities constructed by the idea
of vulnerability or, indeed, with our complemen-
tary identities as active protectors and helpers.
The apparently innocuous or even positive,
term vulnerability, which was presented as if it
were simply telling us something factual about
particular people, turns out to have more far
reaching implications not only in constructing
identities but in setting up a power relationship
in which one group is positioned as weak and in
28
need of protection and another group is posi-
tioned as strong and capable of providing that
protection. One result is that the idea of vulnera-
bility may end up reinforcing the person’s pre-
existing subordination and make it look as if that
is a natural result of their own intrinsic, or even,
in the case of vulnerability-stress theory, scientif-
ically determined characteristics. Another result
is that extensive systems of regulation and sur-
veillance may be set up, whose regulatory func-
tion is masked by the systems’ apparent accord
with the vulnerable person’s need for protection.
Who or what is protected from
scrutiny by vulnerability?
In the case of vulnerability-stress theory, the
focus of scrutiny has been the ‘vulnerable’ indi-
vidual – whatever else they’re protected from,
it’s not our scrutiny. This focus is made to seem
reasonable partly through word order: the the-
ory is stated as ‘vulnerability-stress’ with the im-
plication that vulnerability comes first, is more
basic, so that it seems reasonable to focus on the
person to identify the nature of this vulnerability
and perhaps to put it right. Even when vulnera-
bility is used more generally, the focus is still
mainly on the vulnerable person, a focus which
seems reasonable at least partly because of psy-
chology’s and psychiatry’s claims to have discov-
ered many negative individual attributes –
low-self-esteem, cognitive deficits, mental disor-
ders etc, which not only seem to explain the vul-
nerability but make it easy for us to accept
vulnerability as yet another attribute – a state-
ment about a person – rather than a relational
statement about what happens between people.
Vulnerability exposes only one side of this rela-
tionship, while protecting the other from
scrutiny. We can see this relational aspect clearly
if we take statements about individual vulnera-
bility and ‘translate’ them into statements about
relationships. On the left side of Table 1 are state-
ments of a sort easily found in the media and pro-
fessional literature, apparently about individuals,
or social groups, and which suggest that our focus
should be on these people or groups – how to
protect them, make them more resilient, and so
on. But if these statements are translated into
relational statements (with the two referenced
exceptions, not found in the media or literature)

Table 1.
Old people are vulnerable to hypothermia
Women are vulnerable to depression
People from ethnic minorities are vulnerable to racial
discrimination
Lone women drivers are vulnerable at night
Step-children are more vulnerable to abuse
Schizphrenics in high EE homes are vulnerable to
relapse if they don’t take their medication
Women patients are vulnerable in mixed psychiaiirc
wards
then a very different picture emerges in which two
points are worth noting. First, that the reasonable-
seeming focus of our scrutiny and potential action
is changed from the vulnerable individual to those
who seem to be damaging them. Second, in every
case, the people or groups who do not appear in
the statements about vulnerability, are in various
ways more powerful than their counterparts who
do. The disturbing conclusion is that the idea of
vulnerability runs the risk of systematically pro-
tecting from scrutiny the potentially damaging
activities of relatively more powerful social
groups. Since vulnerability is usually named in
others by those in positions of relative power, it
is perhaps not surprising that they should wish
to protect their privacy. But we should not un-
derestimate how helpful psychology and psychi-
atry have been to this process, with their
persistent focus on the individual and their pro-
vision of an extensive range of negative charac-
teristics both to explain vulnerability and to
foster its acceptance as an individual attribute.
Of course, attempts are sometimes made to
focus not on the vulnerable but on the poten-
tially damaging activities of those around them
and the results are interesting. For example, pro-
fessionals who tried to highlight the possible
negative effects of relatives’ behaviour on people
diagnosed as schizophrenic, found themselves
accused of ‘blaming relatives’ and swiftly re-
Clinical Psychology 24 – April 2003
The government doesn’t pay a high enough state
pension for old people to pay their heating bills
Miserable women live with oppressive men (Pilgrim and
Bentall, 1999)
White people discriminate against black people
Men attack women when they ae less likely to be seen
Step-parents are more likely to abuse step-children
than their own children
If you are unlucky enough to have relatives defined as
hostile, critical or overinvolved you will need to take
your drugs to help you cope with them (Johnstone, 1993)
Male psychiatric patients sexually harass and assault
women in mixed-sex psychiatric wards
treated behind the safe walls of vulnerability-
stress theory. When adults (mostly daughters) ac-
cused their parents (mostly fathers) of sexually
abusing them as children, they quickly found
themselves named as sufferers from the new dis-
order of false memory syndrome, a label which,
like vulnerability, serves to weaken, and which was
given credence by its medical pretensions and by
existing cultural assumptions about women’s ca-
pacity for deceit and suggestibility. And recent
media focus on perpetrators or potential perpe-
trators of sexual abuse turns out to mask as much
as it reveals: the potential for damage is safely
located in strangers rather than families, or in
employees with criminal records, rather than in
social and organisational structures which may
foster both hierarchies of power and their abuse.
Vulnerability, then, may allow those privileged
to name reality to feel and express beneficence,
which may of course be quite genuine, while ob-
scuring the operation of power from which they
may benefit. Naming others as vulnerable can
also be a refuge for those rightly wary of attack
for exposing the operation of power, but who re-
main concerned about the welfare of those in
their care. These factors may help account for
the general popularity of vulnerability but its ex-
ceptional popularity now perhaps needs further
explanation. It is unlikely to be accidental that
vulnerability’s popularity has grown at a time
29
Boyle
when increasing attention is actually being paid,
in the media and elsewhere, to the damage done
by (relatively) powerful groups – men’s violence
to women; parents’ abuse and neglect of chil-
dren; carers’ and professionals’ abuse of their
clients; governments’ damaging economic and
social policies, and so on. Vulnerability offers a
timely and reasonable seeming way of appearing
to respond to these problems while ensuring that
we need neither name nor change social, eco-
nomic or political systems which perpetuate them.
How might we resist this ? We could, first, stop
using vulnerable or vulnerability as if they were
intrinsic characteristics of a person or group, and
instead always say what potentially damaging
events people are vulnerable to. Then, rather than
simply naming the damage, we might gradually
name the systems or people who do the damage,
eventually making them the subject of our sen-
tences, as in some examples on the right-hand
side of Table 1. But we need to go well beyond
‘naming and shaming’ and highlight the power
systems in which those in the right hand column
find themselves embedded, for their power is rel-
ative, not absolute. We might also take up Paul
Gilbert’s recent suggestion (2002) and have a
‘Defeat abuse’, rather than ‘Defeat depression’
campaign. But we should not underestimate the
Faculty for Eating Disorders
Meeting: 30 April 2003
At the British Psychological Society’s London offices, 33
John Street, London WC1
All welcome but booking essential if lunch required.
Contact Dr Christine Openshaw, Faculty Secretary:
christine.openshaw@btinternet.com
30
scale of these linguistic tasks or the anxiety gen-
erated by them. I recently reviewed an article on
the problem of sexual assaults on mixed sex psy-
chiatric wards which did not once even hint at
who or what might be carrying out these assaults.
And in a recent study (in preparation) men and
women became almost incoherent when (gen-
tly) pressed to explain exactly why women were
reluctant to go certain places on their own. One
man simply said ‘I suppose it’s to do with them
being vulnerable.’ Finally, we should be alert to
attempts to deflect the focus of attention back
to ‘the vulnerable’ and be prepared to name and
resist this (inevitable) process.
References
Gilbert, P. (2002) Understanding the biopsychosocial
approach II: Individual and social interventions.
Clinical Psychology, 15, 28-32
Johnstone, L. (1993) Family management in ‘schizo-
phrenia’: its assumptions and contradictions. Journal
of Mental Health, 2, 255-69
Pilgrim, D. and Bentall, R.P. (1999) The medicalisation
of misery: A critical realist approach to the concept of
depression. Journal of Mental Health, 8, 261-274
Address
Department of Psychology, University of East London,
Romford Road, London E15 4LZ; M.E.Boyle@uel.ac.uk
Drug companies and clinical
psychology
Elina Baker, Somerset, Craig Newnes, Shropshire County PCT, and
Helen Myatt, Coventry and Warwick University
This article argues that the pharmaceutical
industry uses psychological techniques focusing
on shame and guilt to sell its concepts and
products to an ever-widening group of health
care professionals. Clinical psychology shows
signs of both joining and resisting this process.
D
rug companies have always advertised
their products to doctors. The extent of
such advertising can hardly be overstated:
in 1996 $450m was spent on drug company ad-
vertising in US medical journals and in 1997 sales
of SSRIs rose to $3bn (Los Angeles Times, 23
August 1997). Double (2001) has noted that
many psychiatrists and junior medical staff actu-
ally receive their so-called training in psychophar-
macology from drug company salespeople. In a
review of 16 studies of interactions between
doctors and drug companies, Wazana (2000)
found that meeting with company representa-
tives led to both positive attitudes towards
such interactions and non-rational prescribing.
In particular, attending meals paid for by the
pharmaceutical industry led to increased re-
quests for the drug promoted and receiving gifts
from drug companies was found to correlate
with the belief that such gifts did not influence
prescribing practice. This is of particular con-
cern because behaviour may be most influenced
in those who do not recognise their susceptibil-
ity (Katz, 2002). Respondents to Wazana’s re-
view indicated that without drug company
sponsorship, funding for activities such as train-
ing and research would not be available and sug-
gested that it should be the degree of the practice,
rather than the practice itself, which is questioned
(Tenery, 2000; Vollman, 2000).
The aim of any drug company or representa-
tive is to get more prescriptions for their drug:
representatives are highly trained in sales tech-
niques. Huthwaite International train sales reps to
achieve ‘Effective Social Influencing’ at corporate
events. One of the techniques they learn is per-
suasion. Reps are also taught to employ com-
mercial influencing skills in other circumstances
where the explicit aim of the interaction might
not appear to be persuasion, for example by
funding social events. Here, ‘developing the rela-
tionship’ is seen as preferable to ‘closing a sale,’
as the former is shown to lead to more sales of
expensive drugs in the long term (Huthwaite
International, 2003). The more time doctors spend
with drug company representatives, the more
likely they are to prescribe the newer, more ex-
pensive drugs (Wysong, 1998).
While there is no evidence available about the
impact of such interactions on professions with-
out prescribing powers, Ashmore and Carver
(2000) suggest that the pharmaceutical industry
recognises the importance of mental health
nurses in influencing prescribing decisions and
as potentially acquiring prescribing powers in
the future. This position is not dissimilar to that
of clinical psychologists: a survey of American
psychologists has revealed that over half referred
between 21 per cent and 60 per cent of their
clients for medication in the last year, and that 60
per cent of them saw prescribing as a logical
extension of their current practice (Ramirez,
2002). This might, in part, reflect the fact that drug
company-sponsored sessions are increasingly to
be found at American Psychological Association
events.
Ashmore and Carver (2001) discuss how mental
health nurses are exposed to drug company sem-
inars with free refreshments, promotional gifts
such as pens, diaries and mugs, and advertising in
professional journals. They raise the concern that
as a consequence, nurses may be the recipients
31
Baker , Newnes and Myatt
of information that has been found to be inaccurate
and biased. Research cited by drug companies,
for example, is only a fraction of that carried out,
and it is invariably only the results that suit the
vested interests of researchers or sponsors which
appear. Further, a UK government publication,
Effective Health Care, in reviewing the newest
so-called anti-psychotic medication concluded,
‘Most relevant trials are undertaken by those
with clear pecuniary interest in the results’
(December, 1999).
Promotional gifts may also trigger the social
tendency to reciprocate and maintain the product
in awareness through the constant presence of a
logo in the work environment. Clients too may
be influenced by the presence of such promo-
tional materials, and Ashmore and Carver describe
them as a subtle form of direct-to-consumer
advertising (currently illegal in the UK). Another
similar form of tacit endorsement more pertinent
to clinical psychologists is the drug company
sponsorship of educational materials. The
Psychotherapy Division of the American Psycho-
logical Association is currently involved in a joint
venture with one of the large pharmaceutical
companies to produce and distribute brochures
on mental disorders (Galves, personal communi-
cation, January 14 2003). Such materials, while
apparently useful, may place an undue emphasis
on medical models of causation and pharmaceutical
forms of treatment as well as conveying a subtle
message to the client about the attitude of their
mental health worker towards their medication.
It seems unlikely that drug companies would
invest in providing training and promotional
material to non-prescribing professions if they did
not anticipate a return (Tenery, 2000). Ashmore
and Carver suggest that there is a need for mental
health nurses to re-evaluate the nature of their
relationship with the pharmaceutical industry,
but also identify that it is difficult to establish
open and honest debate about the influence of
promotional material, as this would seem to be
questioning the integrity of those professionals
who accept it. It appears to us that these concerns
are of increasing relevance to clinical psychologists.
Local experiences
Until recently in Shropshire, pharmaceutical com-
pany reps limited themselves, within psychiatry
32
at least, to sponsoring psychiatrist and junior
doctor training. The past few years have seen a
gradual infiltration of CMHTs. Away days and
one-off training events have been sponsored, as
have two consultation exercises on psychological
therapy and primary care mental health strategy
development. Indeed, a draft proposal for a pri-
mary care mental health strategy includes the aim
of partnership with drug companies to continue
sponsorship. The rationale for such ventures is
little different from that found for many years in
primary care: ‘it does no harm’, ‘it doesn’t make
us prescribe more’, ‘nurses can’t prescribe any-
way’, ‘why shouldn’t we have some freebies? The
doctors have had them for ages’, ‘we can’t afford
training otherwise’, ‘we can’t afford lunches like
these’ and so on.
There is little argument against despite the
weakness of these positions (can we really not
afford Marks & Spencer sandwiches and a cup of
coffee?) and the acute embarrassment shrouding
the whole endeavour. Shame and embarrassment
are key here. Drug companies carefully select
young, clearly quite nice, salespeople who are
hard to turn down, impossible to argue with and
have an air of quiet solicitude that disempowers
those who might not want their money or
favours. They are often discreet (the psychologi-
cal therapies’ consultation event had a small, eas-
ily ignored advertising stand), happy to join in
with banter about the corrupting influence of
Big Pharma and offer gifts that have little mone-
tary value. This last has the paradoxical effect
that it would appear churlish to turn down the
proffered diary or, in one recent example, elec-
trical extension cable (with logo). Turning down
gifts is immediately uncomfortable; it goes against
a lifetime’s conditioning for many. To quietly resist
gifts is seen as rude: to publicly advocate avoid-
ing drug sponsorship is seen as high-minded or
just mad.
A local qualitative survey of experiences within
teams has resulted in some fairly self-explanatory
categories of response: money talks, gifts gladly
received, they’re in each others’ pockets, excep-
tions to the rule and more. It was noted that
salespeople would find out the team secretary’s
name and then falsely claim to have a meeting to
gain entry into the building. If the psychiatrists
are not keen, then nurses are approached. Few

members of the team openly disagree with drug
company sponsorship, but those who do often
do not reflect their views in their conduct; for
example, they eat cake provided by the drug rep
whilst protesting at the ideology behind the free
food. One psychologist reported that the team
asked challenging questions of the drug reps, seeing
the lunches as an opportunity to do this. The
survey also revealed hypotheses as to why gifts
were more readily acceptable to non-psychologists
including the possibility that psychologists are
perceived as affluent enough to refuse gifts and a
question about the extent to which team mem-
bers feel valued: are other staff so undervalued
by their managers that they have to accept these
gifts as a compensation?
Within another service, a record was kept by
the first author of the degree to which drug com-
pany merchandise and involvement was present
in the everyday functioning of the service. Over
the course of a month examples of such involve-
ment included:
■ the offer of four diaries, a computer mouse
and two mouse mats and a set of weighing
scales from drug reps and colleagues with
spares;
■ only drug company mugs being available to
both staff and visitors to the service;
■ a predominance of drug company stationery,
including pens, desk organizers, Post-it notes,
staplers, rulers and hole punches. Some items
(such as Post-it notes and pens) were not avail-
able without drug company logos;
■ if new stationery items were needed drug reps
were approached to provide them as money
was not available in the service budget;
■ a conference on DSPD funded entirely by a
drug company;
■ free snacks and sandwiches provided by a vis-
iting drug rep;
■ offers by drug reps to fund team lunches out
at potential conference venues or for special
occasions;
Clinical Psychology 24 – April 2003
■ the suggestion that as money was not available
from elsewhere an away day could be funded
by a drug company.
This involvement occurred in the context of fi-
nancial difficulties within the trust and a climate
in which any expenditure was scrutinized and,
where possible, avoided. It seemed that drug com-
pany involvement was accepted as it provided a
source of funding and resources that would not
have been otherwise available, an argument that
is often offered in defence of drug company
sponsorship (Tenery, 2000). It is clear that in
some services there is now confusion as to what
might reasonably be expected from employers
(e.g., stationery, training) and what has never been
provided as of right (lunch, coffee, mugs and pens).
Choosing not to accept items that are provided
by drug companies is difficult under such cir-
cumstances. The reactions of other staff to this
position are unpredictable, as it carries implied
criticism of their acceptance of the items. Other
staff also often construe rejection of drug com-
panies as a rejection of the use of drug treatments,
not just the way that they are marketed.
The future
Drug companies and their alliance with the psy-
chiatric industry will continue to be profitable.
The tricks of the trade are well known and highly
successful. For example, promoting the positive
benefits of medication in excess of the negative
in the early years of production is replaced by
emphasis on the search for better alternatives as
the manufacturing license runs out. Inventing
curable maladies for the essentially incurable con-
dition of being human will continue to appeal to
public and profit combined: Healy (1991), for ex-
ample, has suggested that so-called panic disorder
was overpromoted by Upjohn in order to sell
alprazolam. Similarly, the idea of preventable psy-
chosis is heavily sold with drug company support
for early intervention. And, of course, the industry
is not beyond simple bribery (Braithwaite, 1984).
There are, however, some signs that the in-
dustry is not having it all its own way: a review
by Jorm (2000) remarks, ‘The public’s view of
psychotropic medication is almost uniformly
negative, contrary to the views of clinicians and
to evidence from RCTs.’ Similarly, direct evidence
33
Baker, Newnes and Myatt
from users is less positive than the industry might
hope. Of 1400 people taking SSRIs surveyed on-
line by the National Depression and Manic
Depression Association, 25 per cent were still
depressed, 40 per cent lacked energy and 35 per
cent still didn’t enjoy anything (NDMDA, 1999).
Meanwhile the Agency for Health Care Policy and
Research found in a meta-analysis of 338 SSRI
trials that there was no difference between SSRIs
(at $66.41 per month) and tricyclics (at $5.50
per month). Further, 32 per cent responded well
to placebo alone. David Healy has achieved some
notoriety for his work linking SSRI use to suicide
(Healy, 2001). Finally, a local study (Grime et al.,
2002) revealed that service users were sufficiently
sceptical of drug company literature that they
required information independent of industry
influence.
There are notable critics of the power of the
drug industry but they have tended to be psy-
chiatrists (e.g. Breggin, 1991; Healy, 2002) and
service survivors (e.g. Crepaz-Keay, 1999) rather
than clinical psychologists (cf. Holmes and Newnes,
1996). Local resistance has included throwing
drug company merchandise away and advertising
the No Free Lunch website (www.nofreelunch.org
actively promotes non involvement of pharma-
ceutical companies and gives information on
corruption in the industry). Managers and team
members are regularly asked why they want the
industry so closely involved when the industry
has more than enough clout to ensure global
advertising without being actively invited in.
Team psychologists question the relationship be-
tween outcomes of pharmacological interventions
and funding (in the same way that this is ques-
tioned of psychotherapy). People strive to be
diplomatic about their views in order to maintain
relationships with the rest of the team while not
attending events funded by drug companies and
explicitly stating this as the reason for absence.
Such efforts are tiring and frequently swamped
by the pro-drug lobby. The whole is a good ex-
ample of what David Smail has termed distal and
proximal powers operating in tandem for the
purpose of profit. Drug companies have sold the
idea of depression as an illness to the extent that
people rarely question that it might need treat-
ment. The distal power of government lobbying
and corporate marketing strategy results in people
34
wanting the proximal power of presribed med-
ication to cure them. Similarly, the distal power
of cultural socialization and the more proximal
power of stressful working lives make it unlikely
that staff will resist the immediate power of per-
suasion and other techniques practiced by phar-
maceutical company salespeople. Clinical
psychology needs to take note of these powers
in the way it finds itself influenced by Big
Pharma; from our approach to ideas like brain
biochemical imbalances somehow causing dis-
tress relabelled as medical conditions to the
more immediate dilemma of whether to accept
pens and mugs.
References
Ashmore, R., and Carver, N. (2001) The pharmaceuti-
cal industry and mental health nursing. Mental Health
Nursing, 10, 1396-1402
Braithwaite, J. (1984) Corporate Crime in the
Pharmaceutical Industry. London: Routledge &
Kegan Paul
Breggin, P. (1991) Toxic Psychiatry. New York: St
Martin’s Press
Crepaz-Keay, D. (1999) Drugs. In C. Newnes, G. Holmes
and C. Dunn (eds) This is Madness: A critical look at
psychiatry and the future of mental health services.
Ross on Wye: PCCS Books
Double, D. B. (2001) Can psychiatry be retrieved from a
biological approach? The Journal of Critical Psychology,
Counselling and Psychotherapy, 1, 1, 27-30
Grime, J., Pollock, K., Newnes, C., Lillington, J.,
Hudson, M., Thomas, T., Mooniaruch, L, Baker, E.,
Mantala K., and Lewis, E. (2002) Medication
Information Project. Shrewsbury: Shropshire PCT
(available on www.shropsych.org)
Healy, D. (2002) Conflicts of interest in Toronto.
Perspectives in Biology and Medicine, 45, 2, 250-63
Healy, D. (2001) The SSRI suicides. In C. Newnes, G.
Holmes, and C. Dunn, (eds) This is Madness Too: A
further critical look at mental health services. Ross
on Wye: PCCS Books
Healy, D. (1991) The ethics of psychopharmacology.
Changes: An International Journal of Psychology
and Psychotherapy, 9, 4, 234-247
Huthwaite International (2003) www.huthwaite.com.
Retrieved January 2003
Jorm, A.F. (2000) Mental health literacy: Public knowl-
edge and beliefs about mental disorders. British
Journal of Psychiatry, 177, 396-401
 Clinical Psychology 24 – April 2003

Katz, D. (2002) The agony and ecstasy of free
lunch. The American Journal of Bioethics
(http://ajobonline.com_erbioethics.php?task=view&a
rticlaeID=540)
NHS Centre for Reviews and Dissemination (1999)
Drug Treatment for Schizophrenia. Effective Health
Care, 5, 1-12
Ramirez, B. (2002). Dissertation submitted for Doctorate
in Clinical Psychology, Wright State University. Retrieved
10 November 2002. www.apa.org/divisions/div55/
WR123.html.
Tenery, R. (2000) Interactions between physicians and
the health care technology industry. Journal of the
American Medical Association, 283, 391-393.
Wazana, A. (2000). Physicians and the pharmaceutical
industry: Is a gift ever just a gift? Journal of the
American Medical Association, 283, 373-380.
Wysong, P. (1998) Time with drug reps affects prescrib-
ing: study. The Medical Post
Address
mall.rats@virgin.net

Division of Educational and Child Psychology

Educational and Child Psychology special issue on

early childhood education and care
Call for Papers

With the revised Code of Practice, schools and early years settings will be catering for children with
a much wider range of educational needs, including those of children from low-income families,
from ethnic minorities and bilingual origins, as well as those with special educational needs.

Moreover, the broader context of the UK government’s National Childcare Strategy, implemented
by the local Early Years Development and Childcare partnerships, the Sure Start programmes and
Early Excellence Centres for children aged 0 to 4 all indicated the demand for high levels of
co-operation between professional agencies.

In this edition there would be scope to address a broad range of medical, health-related, physical and
social welfare issues involving multiprofessional partnership with families and young children,
located in diverse contexts.

We hope that you will be interested in submitting a paper; please send a brief outline or abstract.
Completed papers (of between 3500 and 5000 words) would need to be received by 31 May 2003.

If you would like to discuss this further, please contact Peter Lloyd Bennett, Educational Psychology
Service, Bayard Place, Broadway, Peterborough PE1 1FB; e-mail: lloydbennett@freenetname.co.uk.

35
Addressing power
Jan Bostock, Newcastle, North Tyneside and Northumberland
Mental Health NHS Trust
For psychologists to make valid contributions to
the understanding, amelioration and
prevention of distress we need to take account
of social and political influences, acknowledge
the limitations of psychology and be mindful of
our relative power. These issues are discussed in
relation to clinical and community psychology,
and the contributions of David Smail.
T
here have been overall improvements in
life expectancy over the last 100 years and
these largely reflect improvements in nutri-
tion, housing conditions, hygiene, and immunisa-
tion. However, death rates have fallen more
significantly for those in social class 1 in the UK
and the chances of dying before the age of 65 are
substantially higher among people who are un-
skilled (Acheson, 1998). When life expectancy is
compared to indices of deprivation that include
measures of income, disability, employment, edu-
cation, housing and access to services, there is a
consistent correlation of longer lives and less
deprivation. In addition, there is evidence that
there is an increase in the numbers of people ex-
periencing disability and chronic illness and,
again, the socioeconomic differences are marked
(Acheson, 1998). The most potent determinants
of health are income distributions, education,
employment and housing. Despite major medical
advances, the incidence of major causes of death
such as coronary heart disease, stroke and lung
cancer are largely not addressed by medical inter-
ventions. Thus there is an overriding rationale for
public health improvements via primary preven-
tion and the addressing of structural inequalities.
Similarly, for people in distress, mental health
services do not have any impact on reducing
the rate at which people are identified as having
significant difficulties. While mental health pro-
fessionals may successfully work with some indi-
viduals, there are huge numbers of people waiting
36
to be seen, and even greater numbers of people
with disturbing struggles, needs and difficulties
whose interests are not necessarily served by
referral to mental health services. The social
determinants for physical health have a similarly
profound impact on the prevalence and distribu-
tion of psychological suffering, and the risk of
death through suicide. For those who do access
therapeutic services, these factors also affect the
scope for sustained individual and community
improvements in well-being.
Understanding and changing reality
There are important implications for psychology
from this evidence about the social influences on
health and well-being. As well as having to tolerate
greater material poverty, particular groups are also
faced with a greater likelihood of experiencing dis-
ability, ongoing health problems, and the loss or
physical vulnerability of friends and family. As well
as having limited finances to help deal with on-
going stresses, they may also have less access to
social and cultural resources to enable them to
overcome difficult circumstances and disrupted
relationships in the long term. It is important,
however, to recognise the inventiveness, courage
and resourcefulness with which people approach
painful and long-term challenges.
There is scope for psychological formulations to
encapsulate these issues, and to generate explana-
tions which illustrate how subjective experience
is embodied through the powers and resources
with which we are socially invested. These powers
and resources are indelibly linked with our social
class, physical build and race and gender (Smail
1996). In addition, our perceptions and analyses are
profoundly (and often imperceptibly) influenced
by what we experience from those who are closest
to us during our growing up. How parents and key
adults deal with the power disparities in the rela-
tionships around them, is crucial to a child’s own
learning about dealing with the world. However,

the most facilitative parenting can be under-
mined by influences such as racism or bullying.
We are all exposed to physical and social realities
which affect us via public discourses and prac-
tices which may strengthen or damage us.
Discussions that are relevant to the endeavour
of individual psychological therapies are therefore
likely to focus on the following issues. What have
been this person’s experiences to date? How has
power been exerted in his or her life within and
outside the family? What has he or she subsequently
learned about dealing with diverse demands? Is
there scope for this person to gain some power
or control in any domain of his or her life which
will significantly change current circumstances?
What potential is there for any environmental
change that would ease this person’s predicament?
David Smail’s analysis of the ‘impress of
power’ (Hagan and Smail, 1996) provides a com-
prehensive understanding of the interplay of
social and personal injustices, and the psycho-
logical consequences of these for individuals and
communities. Smail further challenges contem-
porary psychology views about the malleability
of our choices, thoughts and beliefs, and is criti-
cal of what he describes as ‘magical voluntarism’
(Smail, 2002), where it is claimed that we can
change our thoughts at will. He points out the
requirements of a global market economy which
is motivated by profit rather than social interests.
The psychological repercussions of economic in-
terests are that people’s subjective experiences
can become alienated and confused.
David Smail’s fierce critiques of grandiosity in
clinical psychology serve as good reminders of
the limits of individual therapy:
Psychology, to survive as an intellectual or practical
undertaking, needs in my view to cultivate a very
strong sense of professional modesty and to strive
continually to make clear what the limits of its pos-
sibilities are (Smail, 1996: 241).
Far from limiting psychologists’ contributions,
this position of professional honesty about our
limitations frees us to develop ambitious, innov-
ative and critical approaches to our work with
individuals, communities and organisations.
While we need to retain humility about our
powers to influence very difficult circumstances
Clinical Psychology 24 – April 2003
for individuals and communities, we also need to
be mindful about the potentially harmful aspects
of the therapeutic ideologies we inevitably per-
petuate. Too often psychologists behave as
though it is the person’s inappropriateness or
‘negative transference’ or ‘lack of motivation’ that
is the cause of unsuccessful engagement with or
use of therapy, rather than the understandable
limitations of the therapeutic approach in the
face of insuperable past or current constraints.
We need to address the paradox that while we
do not overstate our powers with individuals, we
also do not inflict further harm. We need to be
sure that we are not contributing to people feel-
ing blamed and disempowered by our meetings
with them and communications about them.
Thus we need continually to aim to demystify
our contact with the people who use psycholog-
ical services and with those who provide them.
Remembering our humanity is essential.
Using a therapeutic discourse that incorporates
notions of proximal and distal, personal and formal,
powers that shape peoples lives gives a more mean-
ingful framework for understanding and inter-
vening than the classificatory systems which dog
mental health practice and therapy. The intellectu-
ally redundant term ‘personality disorder’ is a good
example of a pathologising and limited categorisa-
tion of people which always needs elaboration and
deconstruction to be practically useful.
It’s the world that needs to change
Persisting with an environmental focus on
change inevitably means that psychologists cast
their eyes on organisational and social change
beyond individuals. In Nottingham in the early
1990s David Smail set up a community psychol-
ogy service in adult mental health which ex-
plicitly gives clinical psychologists the remit for
community-orientated work in addition to the
more usual therapeutic roles in primary care.
This provides useful opportunities for psycholo-
gists to work with others to develop initiatives
which promote well-being. The scope for learn-
ing from local residents and staff (particularly
community development workers) is huge
(Bostock & Beck, 1993). Substantial projects
were established: community action research,
“MAN’, a men’s health action project (Melluish &
Bulmer, 1999); ‘Actions’, a community counsel-
37
Bostock
ling and welfare rights service (Bostock, Noble &
Winter, 1999); and proactive needs assessment
work with primary care colleagues.
In Northumberland there have been opportu-
nities for me to continue this work. Community
psychology has recently been established as part
of the public health and health improvement
brief of the health action zone. While resources
are limited to cover the whole county and sub-
ject to short-term funding, we do have a full-time
Assistant Psychologist and two days of clinical
community psychology time with which we aim to:
■ clarify the influences on psychological func-
tioning and distress;
■ facilitate the awareness of issues common to
communities and groups, and the develop-
ment of social resources and interventions
that address these;
■ promote environmental change in order to
work towards the prevention of difficulties.
In meeting these aims we have undertaken par-
ticipative action research, for example with young
people to find out their views of their needs for
support, and facilitated discussions and action plans
about the promotion of well-being with community
groups, local council representatives, and workers
in primary care and mental health services.
An issue which profoundly affects people is
poverty and financial overcommitment. Obviously,
this occurs because of the need for money for
physical and practical survival, and also because
of the overwhelming societal and personal influ-
ences that foster competitive material acquisition.
In the context of social stratification, people des-
perately try to buy the trappings of class distinc-
tion that are so important to social identity
(Bourdieu, 1984). A major concern arising from
meeting people during my clinical work has been
the financial challenges which they negotiate more
or less successfully, and in particular the taking
out of loans which they cannot afford to repay.
In the light of these concerns, and as a result
of discussions with a voluntary group in
Northumberland, we contributed to the develop-
ment of a project called Action Against Poverty.
This aims to raise the profile of debt in the
38
county in order to prevent associated crises.
Four support workers work with the public,
mental health service users and staff to alert
people to the risk factors and practices relevant
to handling debts (e.g. their legal rights in deal-
ing with creditors), so that difficulties can be
resolved, reduced or averted. Action Against
Poverty is hosted by a voluntary agency which
gives direct telephone advice called Debt Advice
Within Northumberland (DAWN).
There is evidence that debt has a significant
impact on mental health (Grant, 1995) and many
people who use mental health services live on
low incomes and have difficulties in making their
income last the week (Morgan et al., 2001). In
spite of this, financial issues are not routinely pri-
oritised by mental health professionals.
In order to inform the work of the Action
Against Poverty staff we undertook a survey of
Northumberland psychological therapists. This
investigated their views on how health and debt
are linked, how people deal with debt, the
strengths and gaps in support and advice ser-
vices, and how services need to be developed to
meet people’s needs. Thirty three people (69 per
cent) responded. They reported that the most
common types of debt among the people who
use their services were rent, loans, credit cards
and catalogues. The most frequently cited cause
of debt was living on a low income and changes
in income due to disability, redundancy or changes
in welfare benefits that had been relied upon. The
most obvious effects of debt were related to mental
health problems, and links were made with hos-
pital admission and suicidal feelings. Debt affected
the possibility of housing transfers, and put pres-
sure on some people to work even when they were
unwell or concerned about their children’s care.
Many respondents mentioned that people in debt
with mental health difficulties neglect their needs
for food, medicine and hygiene and have reduced
options for socialising. In some instances services
had been cut off or people had become homeless.
Advice agencies such as the Citizens Advice
Bureau and DAWN were highly regarded but
not accessible enough. Psychological therapists
emphasised that there is a need to promote aware-
ness of financial matters for example, the dis-
advantages of company loans, and that repayments
of loans can be renegotiated. More than half the

respondents did not consider it was part of their
remit routinely to raise financial status with people
who used their services. Those who did cover
financial matters recommended the provision of
further training for themselves, improved infor-
mation, and better access to agencies.
The survey enabled recommendations to be
made to psychological therapists, Action Against
Poverty and advice providers. In addition the fol-
lowing policy changes were suggested which
would need to be implemented via legislation:
■ guarantee adequate standards of living, par-
ticularly for people with disabilities;
■ develop flexible procedures for benefit claims
given people’s complex circumstances;
■ promote socially responsible lending;
■ ensure adequate access to grants and low-
interest loans.
This survey has been widely disseminated and
the National Association of Citizens Advice
Bureaux is further publicising the results and
recommendations. As well as raising the issue of
financial stressors with psychological therapists,
it has been used for lobbying purposes by DAWN.
The work is an example of using psychologists’
evidence to clarify a particular influence on psy-
chological well-being and identify pertinent issues
with implications for environmental change. There
are significant economic interests served by fur-
nishing expensive loans to people, and individual
psychologists are not in a strong position to chal-
lenge this. However, we can illuminate the issues
and work with others to increase knowledge and
awareness among the public and service providers,
and we can suggest that the BPS takes up such issues.
While most psychologists do not have large-scale
or significant societal influence, we do have the
authority to contribute to various organisations, for
example universities, mental health services and the
wider NHS, with trainee clinical psychologists and
in occupational settings. It is therefore important
for us to debate and reflect upon the messages
that we transmit and the ideologies to which we
subscribe. In the fields of clinical and community
psychology we need to work in ways that are rel-
Clinical Psychology 24 – April 2003
evant and genuinely responsive to people, recog-
nise and attend to their interests, and ensure that
we are at least benign in our practice. In my
view, David Smail’s analyses generate an under-
standing of the significance of power in the gen-
esis of psychological distress, and challenge us to
develop innovative ideas for research and action.
Acknowledgements
I would like to thank Jane Sharpe for her com-
mitment and contributions to this work, and col-
leagues from the Action Against Poverty team
and the Northumberland Department of Psycho-
logical Services for their support.
References
Acheson, D. (1998) Report of the Independent Inquiry
into Inequalities in Health. London: HMSO
Bostock, J., Noble, V., and Winter, R. (1999)
Promoting community resources. In C. Newnes, G.
Holmes and C. Dunn (eds) This Is Madness. Ross on
Wye: PCCS Books
Bostock, J., and Beck, D. (1993) Participation in social
enquiry and action. Journal of Community and Applied
Social Psychology, 3, 213-224
Bourdieu, P. (1984) Distinction. London: Routledge &
Kegan Paul
Grant, L. (1995) Debt and disability. Social Policy
Research Report, 78. York: Joseph Rowntree Foundation
Hagan, T., and Smail, D. (1997). Power-mapping 1:
background and basic methodology. Journal of Com-
munity and Applied Social Psychology, 7, 257-268
Melluish, S., and Bulmer, D. (1999) Rebuilding solidarity:
an account of a men’s health action project. Journal of
Community and Applied Social Psychology, 9, 93-100
Morgan, E., Bird, L., Burnard, K., Clark, B., Graham, V.,
Lawton-Smith, S., and Ofari, J. (2001) ‘An uphill struggle’:
A survey of people who use mental health services and
are on a low income. London: Mental Health Foundation
Smail, D. (1996) How to Survive Without Psycho-
therapy. London: Constable
Smail, D. (2002) The Making of Subjectivity. Paper
presented to the Psychotherapy Section Conference,
London, September.
Address
Department of Psychological Services and Research,
Newcastle, North Tyneside and Northumberland
Mental Health NHS Trust, West Farm House, 1-2 West
Farm Court, Station Road, Cramlington, Northumberland
NE23 1AX; janet.bostock@nmht.nhs.uk
39
Smail’s contribution to understanding
the needs of the socially excluded:
the case of Gypsy and Traveller
women
Lucy Appleton, South East Primary Care Trust, Teresa Hagan,
Community Health Sheffield, Pete Goward, Julie Repper, University
of Sheffield, and Rachel Wilson, South East Primary Care Trust
S
ince the purchasing of mental health care
became the framework for the provision of
services, there has been an upsurge in the
measurement of ‘need’ and the development of
methods of needs assessment. The aim is to pro-
vide services, which will increase health gain.
Recent policy guidance from the Department of
Heath (1997) has prioritised the needs of those
suffering social exclusion which then targets eth-
nic minority groups. This poses a considerable
challenge to planners and policy makers who wish
to assess the needs of such groups and target
appropriate interventions. The challenge does not
only include the acknowledged deficits in the
development of culturally competent instruments
with which to assess need (see Hutchinson, Bentzen
and Konig-Zahn, 1997), but also puts centre stage
the social circumstances experienced by such
groups. Clearly poverty and deprivation are cen-
tral considerations, but traditional approaches to
the assessment of need concentrate on the mea-
surement of the individual (in relation to the
bodily, experiential and social functioning di-
mensions) and the aggregation of these measures
to estimate population and subpopulation ‘need’
(see Kat 1992). This epidemiological frame of
reference is used to estimate the needs of any
group in society and necessarily limits the field
of enquiry. When assessment of need is confined
to individuals, the only service response can be
to change, enhance or modify personal services
for the use of individuals.
Here an attempt is made to apply a different
framework based on Smail’s theoretical perspec-
40
tive which insists that to understand the causes
of distress attention should not be exclusively
maintained at the level of the individual, but en-
courages analysis at other levels (Smail, 1993).
The intention is to see what issues arise and
consider what an adequate response might in-
volve. In particular attention is given to the fields
of action which would be suggested by each
approach.
The case example of one minority group is used,
as this has been a recent focus of the authors’ work.
As part of a mental health needs assessment pro-
ject, 13 women (targeted to reflect the age and
family circumstances in the group as a whole) in
a Gypsy and Traveller group were recruited to
take part in qualitative interviews where the
focus of discussion was their relationships with
statutory mental health services. A range of pro-
fessionals were also included in the project in
focus groups where discussion centered on iden-
tifying service providers experiences of the
problems faced by this minority group in access-
ing their services.
In the qualitative interviews, a phenomenolog-
ical approach was adopted, as this was particu-
larly well suited to the exploration of the life
worlds of participants. The focus was on obtain-
ing personal accounts of individuals themselves,
being prepared for the possibility that each indi-
vidual can have an entirely different view from
the others, so that at the time of interviewing the
focus is not on looking for similarities between
interviewees and explicit attention is given to
setting aside assumptions about how interviewees

might see their world (see Giorgi, 1975). It is im-
portant to understand in this context that the
results are constituted by the themes identified
in the analysis, which emerge as the result of an
iterative process whereby each interview is con-
sidered individually. At a later stage, commonalties
in the form of overarching themes, which can
encompass the range of views expressed, can be
identified. This approach is outlined in Hagan
(1986) and Kvale (1996). The areas of experience
which guided the interviews included social
identity, sense of agency in different arenas,
sense of own presence and voice, relations with
others, sense of self as embodied, sense of own
biography, what the world looks like from where
the participant sits, to what extent they are able
to carry out activities to which they are commit-
ted and what kind of terms are used to describe
their condition of living and relationships, if any,
with statutory service provision. Any topics which
have importance for the interviewee are discussed
at greater length and note is taken of any areas
that pose difficulty for discussion.
The focus groups (four groups with eight par-
ticipants in each) were recorded and analysed
within a framework approach (Miles & Huberman,
1994). Preliminary findings from each of these
parts of the project are used to illustrate the case
example.
Gypsies and Travellers: case example
Concern has been expressed about the high levels
of health and mental health problems among
Gypsies and Travellers (see Van Cleemputt &
Parry, 1999). There has been a paucity of research
evidence with which to address these concerns.
Recent epidemiological research using standard-
ised instruments to measure mental health status
and levels of social functioning has indicated that
the situation for women in this group is likely to
be worse than that for men and that they suffer
significantly worse levels of problems than their
counterparts in other deprived communities.
Health visitors have been at the forefront of this
awareness (Pahl & Vaile, 1986; Anderson, 1997).
Smail suggests that simply applying an individ-
ualistic psychological or psychiatric frame of un-
derstanding constitutes ‘blaming the victim’ (Ryan,
1971). This is because it is central to individualistic
models that there is something wrong with the
Clinical Psychology 24 – April 2003
person in distress, which could be put ‘right’.
Smail does not concur with the view that psy-
chological pain is a problem which is caused
and can be cured within the immediate scope of
people’s personal lives. His framework suggests
that a more adequate way forward can be achieved
through clarifying what is wrong with the social
world which gives rise to such suffering and in
this case example the disproportionate suffering
of those who are socially excluded. To under-
stand their suffering Smail insists that we explore
beyond the boundaries of personal experience
and relationships and examine the social world
they occupy. He insists that an individual’s pow-
ers are strictly limited by the social environment
in which they live. What makes it possible to live
a comfortable life, both psychologically and ma-
terially, depends heavily on the influences that
impinges upon one. Furthermore, capacity to
change will depend on the extent to which one
can modify these influences. Personal ideas,
wishes and plans have less relevance than the
pushes and pulls of the all too material forces,
which structure the social environment (see dia-
gram below, Smail 1996). Here, we can report in
a preliminary way the issues which come to the
fore when Smail’s framework is applied to the
women’s accounts. In particular we were able to
identify the personal and day to day consequences
for mental health of their social situation.
Politics
In the case of the Gypsy and Traveller group, the
impress of power over which they have no con-
trol is all too clear. Decisions affecting their entire
way of life have taken their toll. Over the past 100
years, their lifestyle has changed significantly as
a result of powerful political and economic in-
fluences reinforced by racial discrimination in
British culture.
Central government and local authority policies
introduced since the First World War have made
it increasingly difficult for this group to live a
nomadic way of life. Traditional stopping places
have been removed through the introduction of
a number of policies. Stopping on common land
became trespassing and private sites needed to
be licensed. For a time, councils had a duty to
provide sites but this was infrequently enforced
and eventually removed. The government en-
41
Appleton et al.
Figure 1. Influence of the social environment (from Smail, 1996)
couraged self-provision but in practice planning
permission was difficult to achieve. The result
has been a growth in the number of over-
crowded or unauthorised sites and difficulties for
second generation members to secure pitches.
Travelling legally is very difficult and those who
persevere with their traditional way of life are
routinely subjected to harassment and moved on.
Many have been forced to accept offers to move
into ‘settled’ accommodation (Morris & Clement,
1999). Participants in this study would not de-
scribe themselves as ‘settled’. These changes have
transformed their day to day existence without
their having had any significant power or choice
over this.
Limited travelling and over crowded sites have
posed this group with the problem of maintain-
ing privacy and appropriate boundaries for them-
selves and their families. One key way in which
many participants in this study described how
they coped with such crowding was to keep
42
themselves strictly to themselves and not mix
too much with those around them. This was
often the only means by which any sense of pri-
vacy could be attained. They would studiously
avoid knowing too much about others and guard
their own privacy by striving to avoid gossip
building up around their own circumstances.
Such self-enforced isolation was acutely felt by
the women interviewed, who said it could be
too costly to get too close to those with whom
they were forced into company. For some this
meant deliberately not having a confidante, for
others it was sometimes necessary to deliber-
ately mislead others about the identity of visitors
to their homes and there was also evidence that
for some individuals (particularly those who had
been born and spent their childhood in open
fields) the forced intimacy of the sites was an ex-
treme source of stress constituting unbearable
pressure and leading to an unwillingness to go
out at all.

Economics
This group rarely have a single occupation but
practice a combination of trades, such as seasonal
work, fortune telling at fairs, and horse dealing all
of which enable mobility. However, changes to a
more modern machine-based agricultural industry
meant the end of farmers’ need to accommodate
seasonal labour and many of the traditional fairs
that members of this group visit have been closed
down and all are under threat from local councils
who dislike the influx of caravan dwellers to
their areas (Morris & Clement, 1999; Kenrick &
Clark, 1990). Working independently in temporary
jobs is becoming more and more difficult. It was
mainly the men who worked outside the home
and a key theme emerging from the focus group
data showed that the response of this group has
been to develop extreme adaptability. Profes-
sionals who have extensive experience of work-
ing with this group described how members
diversify to fit current opportunities and develop
the ability to try something and move on quickly if
it does not work out. They described rapid move-
ments from farm labouring, to scrap dealing to
tree cutting to gardening to fitting UPVC win-
dows and doors. Professionals also described
having observed an ever-reducing lack of oppor-
tunities. This has particularly impacted on women
who rarely described having any work outside the
home any more. This has meant women spend
more time on sites with family and other domes-
tic responsibilities and reduced incomes.
Many of the accounts were simply dominated
by the practical problems arising out of poverty
and lack of resources: the inability to carry out
essential repairs, to maintain standards of living
and to be hopeful about future prospects.
Opportunities for change or improvement were
strictly limited but endlessly explored.
Culture and media
History documents the hostility this minority group
has suffered. Romany Gypsies have faced perse-
cution since their arrival in Europe. They faced
racial prejudice as the only dark-skinned minority,
slavery, expulsion orders, the death penalty and
mass execution. In 1988 ‘Gypsies’ became legally
recognised in Britain as an ethnic group under
the Race Relations Act 1976. Discrimination
continues; for example, proposals for council or
Clinical Psychology 24 – April 2003
private sites are often faced with opposition
(Kenrick & Clark, 1990). They have suffered
from two contradictory stereotypes: the image of
the mysterious and attractive wanderer and the
image of the repulsive vagabond. The media reg-
ularly reinforces this and mediaeval accusations
of stealing children still surface in the popular
press (Kenrick & Clark, 1990).
There is little to be found in the dominant and
settled society which promotes or celebrates their
culture and many forces at work to denigrate
them. It was clear from their accounts that the
possibility of hostility (and for some even an ex-
pectation) was an ever-present reality in any social
encounters. Those services which were used,
were routinely described as ‘they were OK with
me’ showing that the opposite could easily have
been the case. Asking services for help was kept
to a minimum and only considered in a crisis
when all else had failed. The anticipation of hos-
tility was based on their lived reality of being re-
jected and insulted by statutory services, public
houses, and other community facilities. Notable
exceptions to this were described and were dis-
tinctive in that relationships with named individ-
ual service providers had been built up over many
years, during which trust had been established.
Modern developments in the provision of ser-
vices, such as the range of services now covering
what used to be the province of the family doctor
(NHS Direct, locum and deputising services, and
NHS Walk-In Centres), require us to become
anonymous users of impersonal services, staffed
by an ever-changing array of faces. Such services do
not depend for their staffing on named individuals
whom users would get to know over time and with
whom they would develop personal relationships.
Members of the Gypsy and Traveller group who
have had to adopt an embattled defence are faced
with great difficulties in using such provision,
where the anticipation of rejection or insulting
treatment by strangers has to be faced every time.
This could be contrasted to the few trusted ser-
vice providers known to this group who had
proven their worth and respect for this group
over many years. Again there was evidence of
conflicting views between members of this group
and the professionals in the focus groups. The
latter had already assimilated the changes in ser-
vice provision into their mind sets for their work-
43
Appleton et al.
ing lives. The providers cherished by the Gypsy
and Traveller group were considered by some of
the professionals in the focus groups to be ‘over-
used’ by this group and offering an unsustainable
and unjustifiable level of personal care.
Clashes of culture were also described. One
example was when members of this group ex-
pressed a preference and an expectation that
they would join any of their relatives who were
admitted to hospital and accompany any family
member to clinic appointments. They often de-
scribed the great efforts, which were made by the
whole extended family to stay with and be pre-
sent for their relatives. Hospital ward and clinic
staff reported feeling overwhelmed to find an
entire extended family attending upon a relative.
Modern hospital care expects relatives to ‘hand
over’ the care of their relative to the professionals
and to pick it up again when professionals think
the time is right. This is not the way in which
members of this group wished to care for each
other. In many ways this group’s approach to care
for their relatives would seem to have much to offer
the much discussed ideal of community care,
which has been so difficult to achieve in practice.
Domestic and work situation
None of the women interviewed worked outside
the home. This was now their way of life. Their
main role was the care of their children, families,
husbands and homes. The work is never ending,
requires constant vigilance and an ever-changing
capacity to respond to others’ needs and frequent
crises. Research which has looked at the nature
of domestic labour has highlighted the pressures
involved (Oakley, 1976; Graham, 1993). Partici-
pants described the sheer difficulty of coping
with this on their own and without any obvious
encouragement or recognition. It may well be
the case that where men could engage in their
trade (e.g. scrap) on site, there was more involve-
ment in the domestic arena possible on a day-to-
day basis.
Education
The English Education Act of 1902 extended
compulsory schooling to the whole population.
However, The Children’s Act 1908, reduced re-
quirements for children of nomadic parents from
380 to 200 half-day sessions. The low levels of
44
enrolment and attendance amongst Gypsy and
Traveller pupils has been highlighted in Ofsted
reports (Morris & Clement, 1999). Strictures
around the appropriate interventions which can
be funded to enhance attendance, for example the
reluctance to provide separate or on-site school-
ing, result in little being done on the ground to
ensure children receive the education required.
In addition to this, research has demonstrated high
levels of discrimination, racism and unfair treat-
ment, all of which militate against attendance at
schools. One result is low levels of literacy, which
makes negotiation through the modern world a
challenge. Whilst professionals in the focus groups
expressed their concerns about the diminishing
pool of employment possible for those with little
education, members of this group felt that first-
hand work experience for boys with their fathers
(outside the home) and girls with their mothers
(within the home) was to be preferred as the
most beneficial preparation for their envisaged
adult roles. It was anticipated that the children
would follow their parents’ example.
Personal relationships and family
Outside their family, the women did not have many
friends and none described any significant rela-
tionships with members of the wider locality. As
a group they were separate and felt separated
from others. Their accounts were dominated by
their family relationships. Children and husbands
were identified as central influences in these
women’s lives. Their family members’ moods and
personal crises impacted significantly on their
lives, which they felt, was their responsibility to
resolve. This meant that the women had to find
ways of negotiating their way through the maze
of health and social services they felt obliged to
use for their family members. Interestingly, many
women described how, for themselves, they simply
made do with either no help or easily available, off
the shelf remedies such as could be bought from a
chemist shop. They would, however, tackle even
the most daunting services when they felt their
children or other elderly family member needed
this. As is the case with any group, the proximal
events and relationships were regarded and ex-
perienced as of the greatest significance and, where
negative, were identified as contributing to often
unbearable levels of stress and unhappiness.

Issues raised by this analysis
Some of the more obvious issues raised by this
analysis can be noted. There was clearly a need
to look at the provision of adequate space and
privacy for families on sites and the development
of work opportunities for both men and women
which could fit with their skills and family re-
sponsibilities. The impact of unemployment on
mental well-being (Murphy & Athanasou, 1999)
and financial hardship is clearly established. There
was a need to consider family-oriented care in
mental health where individuals were not re-
moved from their carers to be ‘treated’. These are
only a few of the challenging issues for service
provision raised by this preliminary analysis.
For most ordinary people, what power they have
usually stems from their association with others
– being part of a relatively powerful organisation
or group. Many of the Gypsy and Traveller
women only gained support from their family of
origin, whom they often did not live near as they
had joined their husband’s family. No power or
support is drawn from being part of the wider
community and few other groups or networks
were raised in their interviews. At times of crisis,
women described travelling to their family of
origin for back up and help.
Psychological and psychiatric ‘treatments’
would appear to have a limited role in addressing
the levels and complexity of difficulties experi-
enced by this group which were contributing to
their high levels of reported mental health prob-
lems. In fact, the Gypsies and Travellers inter-
viewed would support this view. There was a
clear reluctance to engage with secondary mental
health services. When asked about their usage of
routine mental health services (e.g. counselors in
general practice or mental health professionals
in other sites), the women said they did not un-
derstand how repeating their story to a new
healthcare professional or receiving different
medication from a psychiatrist would change or
improve things in any way. Many of their prob-
lems would only be dealt with by increases in re-
sources. It is clear to them that it is the practical
difficulties in their life that are the origin of their
unhappiness and discussing these with a mental
health worker is not going to change this.
The participants in this study adopted strate-
gies to maximise the resources that they have
Clinical Psychology 24 – April 2003
access to and examples of these have been given.
It is clear than any significant improvement in
their lives will need to address the effect of distal
powers over which they have no control which
results in deprivation and thus distress in their
lives. Whilst it would be difficult to deny the
need for some personal support for members of
this community, in preference to a narrow focus
on individual problems in isolation, there is a
need for a broad effort to deal with deep rooted
and inter related social problems (Kat, 1992).
Clearly, there is potential for a community psy-
chology approach to work collaboratively to
promote preventative work, by enabling the iden-
tification of common issues, helpful strategies and
the addressing of some of the distal and proximal
sources of distress that have been described.
Acknowledgement
We would like to thank the members of the
Social Power research interest group, in particu-
lar Janet Bostock, Dave Phillips, Dave Miller,
Carol Saul, Gordon Grant, Peter Ashworth and
Mike Grimsley, the steering group for the project
– Julia Phythian Adams, Mark Knowles, Jo Zasada
and Sue Scott – and members of the community
itself who do not wish to be named.
References
Anderson, E. (1997) Health concerns and needs of
traveller families. Health Visitor, 70, 148-150
Department of Health (1997) Health Gain for Black
and Ethnic Minority Communities. London: HMSO
Giorgi, A. P. (1975) An application of phenomenologi-
cal method in psychology. In A. P. Giorgi, C. Fisher
and E. Murray (eds) Dusquesne Studies in Phenome-
nological Psychology (volume 2). Pittsburgh:
Dusquesne University Press
Graham, H. (1993) Hardship and Health in Women’s
Lives. London: Harvester Wheatsheaf
Hagan, T. (1986) Interviewing the downtrodden. In P.
Ashworth, A. Giorgi and A de Koning (eds) Qualitative
Research in Psychology. Pittsburgh PA.: Dusquesne
University Press
Hutchinson, A., Bentzen, N., & Konig Zahn, C. (1997)
Cross-Cultural Health Outcome Assessment: A user’s
guide. European Research Group on Health Outcomes.
Kat, B. J. B. (1992) On Advising Purchasers. Leicester:
British Psychological Society, Division of Clinical
Psychology
45
Appleton et al.

Kenrick, D., & Clark, C. (1990) Moving On: The
Gypsies and Travellers of Britain. Hatfield: University
of Hertfordshire Press.
Kvale, S. (1996) Inter Views: An introduction to quali-
tative research interviewing. Thosuand Oaks, CA.: Sage
Miles, M. B., & Huberman, A. M. (1994.) Qualitative
Data Analysis: An expanded sourcebook (second edi-
tion). London: Sage
Morris R., & Clements, L. (1999) Gaining Ground –
Law reform for Gypsies and Travellers. Hatfield:
University of Hertfordshire Press.
Murphy, G., & Athanasou, J. (1999) The effect of
unemployment on mental health. Journal of
Occupational and Organisational Psychology, 72,
83-99
Oakley, A. (1976) Housewife. Harmondsworth: Penguin
Pahl, J., & Vaile, M. (1986) Health and Health Care
among Travellers. Canerbury: University of Kent at
Canterbury, Health Service Research
Ryan, S. (1971) Blaming the Victim. New York:
Random House
Smail, D. (1993) The Origins of Unhappiness: A new
understanding of personal distress. London: Harper
Collins Publishers.
Smail D (1996) How to Survive Without Psycho-
therapy. London: Constable
Address
St George’s Community Health Centre, Winter Street,
Sheffield S3 7ND

New ethics advice

surgery
The Society’s regulatory affairs team deals with enquiries about
ethical and professional matters raised by members. Traditionally
the team has dealt with these enquiries ad hoc. Last year the team
dealt with nearly 350 enquiries.

In an effort to provide a more effective and consistent service the

team has now set up an ‘advice surgery’ for members to call for
advice (use the main Leicester office number:
0116 254 9568). The service operates from 1 p.m.
to 4 p.m. every Thursday, when a member of the
team will always be available to answer queries.

Members can also make enquiries by e-mail

(conduct@bps.org.uk) or letter.

46
An audit: do the people I see ‘get
better’?
Guy Holmes, Shropshire County PCT
There’s all these audits and measures and graphs of
numbers of people using the services, but what we
really need to know is do people get better.
Simon Richards, Health Authority Purchaser, 2001
T
his statement, made during a conference
called to review community mental health
services in Shropshire, made me think about
my own work and whether people who see me
‘get better’. Of course, a concept like ‘better’ (or
the in vogue ‘recovery’) is troublesome to define,
has medical connotations and may vary in mean-
ing from person to person. On the other hand I
imagine most people who have become clinical
psychologists have had a general hope that the
people they see would get better. As a conse-
quence, I set out to try and audit my clinical work
over the past six years in terms of this concept.
The people
I see people who have been referred to a com-
munity mental health team that concentrates on
trying to help people deemed to have ‘severe
and enduring mental health problems’ (the defi-
nitions and realities of what this means vary – see
Holmes, 2001). The estates on which many of
these people live are some of the most socially
deprived in Britain. The majority of people I see
are (or have been) suicidal. Their past and cur-
rent lives are characterised by appalling trauma.
The resilience they reveal often astonishes me.
I decided to audit people who had entered into
a therapeutic contract with me and who had come
for at least five sessions. That is, they had identi-
fied a number of difficulties that they wanted help
with and a number of hopes for the therapy, and
had (according to my assessment) some degree
of psychological mindedness and motivation to
come. In short, I believed they might benefit
from regularly meeting with me. All received in-
dividually tailored therapy, which was unimodal
or multimodal, often open-ended or for at least six
months’ duration, and which generally focused
on exploring the roots of the person’s difficulties
and alternative ways for them to live a more
meaningful and less painful life. The website
www.shropsych.org and Holmes (2001) give
more detail about the kind of person and psychol-
ogist I am and the conditions within which I work.
The audit did not include people who came
for less than five sessions: some of these people
dropped out; with some, both of us felt I could
be of little more help over and above the initial
sessions we had had; some were referred else-
where or encouraged to find help outside psy-
chological services. Some people appeared to
significantly improve during this consultation
process where as others appeared to get worse;
for many I have no idea what ultimately hap-
pened to them.
The audit covered a six-year period and included
55 people in total who were seen for therapy.
The measures
Dependent variable: getting better
This was based on my subjective judgement of
whether there had been:
1. no change or a worsening of the problems
that initially led the person to seek help – the
person had got worse or made no improvement
2. some improvement – the person had got a bit
better;
3. great improvement – the person had got a lot
better, or recovered.
Where records of evaluation had been kept,
this judgement was based on (a) people’s own
evaluation of the extent to which their hopes for
therapy (listed at the onset of therapy) had been
47
Holmes
fulfilled (a three-point scale – ‘not achieved’,
‘achieved to some extent’, ‘fully achieved’) and
(b) the extent to which their problems had im-
proved (listed at the onset and rated on a 0-10
scale, then given to them at the end of therapy
and rated again).
Independent variables
In order to explore the factors that might relate
to whether people get better, nominal data on a
number of factors was gathered:
Gender.
Relationship status: single or in a couple.
Age: young = under 30; not so young = over 30.
Psychiatric medication: people were desig-
nated to the no medication category if at the end
of our contact they had either come off their
medication completely or had never taken psy-
chiatric medication. People were deemed to be
on medication even if they had substantially re-
duced their medication.
Experienced therapist: people were designated
as seeing me as an inexperienced therapist if
they saw me in the first three years after qualify-
ing, and as an experienced therapist if they saw me
four to six years after I qualified.
Toxic environment: to some extent virtually
every person I see has been living in what I
would describe (and experience) as a toxic en-
vironment – environments that are often com-
pletely devoid of care or love, where there is a
continual and real threat of violence in the com-
munity in which they live, there being little or no
support or people they can trust, coupled to a
lack of money, financial resources and decent
housing. However, people were categorised as
experiencing a toxic environment if they had not
been able to escape from: (i) severely abusive
family members, (ii) severe abuse in their neigh-
bourhood or (iii) severe abuse in their work or
daytime environment. Otherwise they were cat-
egorised as living in a not so toxic environment.
An analysis
Chi-square analysis was conducted on the above
variables.
Some results
Gender: 11 men got worse or made no improve-
ment, 11 got a bit better, and 3 got a lot better or
48
recovered. Three women got worse or made no
improvement, 14 got a bit better, and 13 got a lot
better or recovered. This difference was signifi-
cant (Chi=10.7, N=55, df=2, p<.01).
Relationship status: 10 single people got worse
or made no improvement, 7 got a bit better, and
5 got a lot better or recovered. Four people in a
couple got worse or made no improvement, 18
got a bit better, and 11 got a lot better or recov-
ered. This difference was significant (Chi=7.9,
N=55, df=2, p<.05).
Psychiatric medication: 13 people on medica-
tion got worse or made no improvement, 11 got a
bit better, and 2 got a lot better or recovered.
One person on no medication got worse or made
no improvement, 14 got a bit better, and 14 got
a lot better or recovered. This difference was sig-
nificant (Chi=19.6, N=55, df=2, p<.001).
Toxicity of environment. Ten people in toxic
environments got worse or made no improvement,
six got a bit better, and one got a lot better or re-
covered. Four people in not so toxic environ-
ments got worse or made no improvement, 19
got a bit better, and 15 got a lot better or recov-
ered. This difference was significant (Chi=16.1,
N=55, df=2, p<.001)
Non-significant differences in the cell distribu-
tions were found for Age (chi= 1.3, N=55, df=2)
and Experienced therapist (chi=1.0, N=55, df=2).
Notably, of the 14 people who got worse or
made no improvement, 13 stayed on their medica-
tion, 11 were male, 10 were single and 10 were
suffering in toxic environments, and 8 had all
four of these factors.
A discussion
One aim of the audit was to put some figures on
my paradoxical beliefs. On the one hand, espe-
cially when with them, I genuinely feel that the
people with whom I engage in therapy are likely
to get better soon. On the other hand, when
more distant from them, I am sceptical about the
power of therapy to lead to significant changes
in people’s lives and well-being, and generally
wary of the claims of various schools of therapy.
To some extent the results support this apparent
paradox. Sixty-five per cent of the people who
engaged in therapy got a bit better, a lot better,
or recovered. However, given that only a small
percentage of people referred to the CMHT, or

indeed actually seen by me, ask for and experience
therapy (i.e. meet me on a regular basis with a
therapeutic contract of at least five sessions
duration) it is clear that a far wider range of things
than psychological therapy are needed for many
people’s well-being to significantly improve.
What my supervisor Joe Kiff has termed ‘mid-
career blues’ is also reflected in the audit: if you
stay in the same place long enough you get to see
your ex-clients come back into the service, and
you become acutely aware of the lack of change,
or slow change, that occurs for many people, and
the gulf between this fact and the case studies re-
ferred to in many psychology and psychotherapy
texts, the positive spin put on therapy at training
courses and conferences, and the rhetoric (rather
than evidence) in which well-marketed interven-
tions are shrouded. Such ‘failure’ needs to be
openly accepted and spoken about (Harper &
Spellman, 1996).
Women benefited more from therapy with me
than men. Before doing the audit I was not aware
of this. It has made me think about the male-
female and male-male dynamics in my therapeu-
tic work, as well as whether therapy is the best
option for many of the men that are referred for
psychological help (see below).
My suspicion that many of the people who met
with me regularly but did not get better were
those who stayed on their medication was born
out. As virtually 100 per cent of the people re-
ferred to me are on medication, it has been hard
for me to say to referrers that I will only engage in
therapy with people who are not on medication,
despite believing that such people are the ones
most likely to get most benefit from psychologi-
cal therapy. My thoughts return to the words of an
eminent psychologist who said to me, one month
after I qualified, that he had given up working in
adult mental health as he had come to realise that
over the previous 10 years he had been having
too many conversations with haloperidol. I am
proud that, with the co-operation and help of the
team’s psychiatrist, I have been able to help many
people reduce and rationalise their medication
intake, but what stands out is that people who
chose and are able to come off their medication
are the ones who benefit from therapy.
Of course there may be overlaps between
whether someone stays on medication and many
Clinical Psychology 24 – April 2003
other factors. The weakness of the chi-square
analysis, unlike multiple regression analysis, is that
it does not reveal the nature of such overlaps.
Nevertheless, it seems likely that people unable
to escape from toxic environments are less likely
to give up something that they feel helps modify
their inner pain or makes them feel indifferent to
things, which David Healy (e.g. 1997) has said is
the main effect of most psychotropic medications.
One question the audit raises is whether such
people (often single men in toxic environments
in this audit) are best served by (what often turns
out to be long-term) therapy. Rather than readily,
or even cautiously, entering into therapy con-
tracts I have begun utilising some of the ideas of
David Smail with this group of people. Clarifica-
tion, solidarity and encouragement (Smail, 1999)
can be provided in much more flexible ways than
through psychotherapy. Power-mapping (Hagan
& Smail, 1999), and connecting people with com-
munity groups, education, training and work
opportunities are likely to be more helpful than
the comfort but lack of change that I have begun
to associate with long-term therapy. The vast
majority of people who seek help from me have
a lack of long-term, respectful, kind, thoughtful
relationships in their lives, but group work and
community group involvement perhaps offer more
appropriate and useful ways of people attaining
these, as well as offering (even if it is only slightly)
more opportunities than therapy for people to
access more power over their social conditions.
Partly as a result of the audit, I have begun to run
courses at community centres which help people
find fresh ways of understanding themselves and
others, including thinking about the effects of
‘the impress of power’ (Smail, 1999), as well as
doing more group and less individual work.
The people deemed most suitable for psycho-
therapy (e.g., Holmes, 1994; Malan, 1979) do not
often come to the CMHT. In contrast to the YAVIS
concept, my audit indicated that age was not a
predictor of outcome, and the people who tended
to get better were those in couples rather than
those who were single. Of course, the measures
used were fairly crude, subjective and open to
bias, and many other factors might relate to out-
come. In addition, different measures would have
lent a different slant to my work. For example, a
simple measure of how many of these people
49
Holmes

were admitted to the psychiatric hospital (1 i.e.
<2%), given the fact that the majority had a
history of previous admissions or were on the
borderline of being admitted on referral, would
put psychological therapy in a more positive
light, particularly as one of the principle aims of
the CMHT is to prevent admission to hospital.
Nevertheless, this audit has helped me think
about my work in a way that reading and apply-
ing the outcome research, doing service-user sat-
isfaction surveys, and consulting the results of
evaluations based on standardised tests never
has. What is the best way of helping the actual
References
Hagan, T., & Smail, D. (1999) Power mapping 1:
Background and basic methodology. Journal of
Community and Applied Social Psychology, 7, 257-267
Harper, D., & Spellman, D. (1996) Talking about failure.
Clinical Psychology Forum, 98, 16-18
Healy, D. (1997) Psychiatric Drugs Explained (second
edition). London: Mosby
Holmes, G. (2001) So farewell then CMHTs. Clinical
Psychology, 6, 7-10
Holmes, J. (1994) Brief dynamic psychotherapy.
Advances in Psychiatric Treatment, 1, 9-15
Malan, D. (1979) Individual Psychotherapy and
the Science of Psychodynamics. Oxford:
Butterworth
Smail, D. (1999) The Origins of Unhappiness. London:
Constable
Address
Upper House, Church Street, Madeley, Telford,
Shropshire TF7 5BW

Vacancies on the DCP Conference

Subcommittee
Are you in touch with the latest developments in clinical psychology?
Do you have the confidence to referee other psychologists’ papers?
Would you like to attend the Division’s Annual Conference for free?

If so, why not consider serving on the Division’s Conference Subcommittee? The
committee meets three times a year to plan the programme for the Division's major
annual event. In particular, it commissions and referees papers, posters and symposia.

There are currently two places vacant.

If you would like to help plan the DCP Annual conference, please request a Statement
of Interest form from Jonathan Calder at the British Psychological Society:
joncal@bps.org.uk or 0116 252 9502.

For more information about the work of the committee please contact Liz Campbell:
eac7q@clinmed.gla.ac.uk or 0141 211 3920.

50
Building bridges and community
empowerment
Iyabo A. Fatimilehin and Linda Dye, Health Action Zone and
Royal Liverpool Children’s (NHS) Trust
P
roviding services that meet the needs of
black and minority ethnic communities is a
challenge to most psychological and men-
tal health services. It is important that such de-
velopments take on board the social, economic
and political realities of the communities and
provide services that are racially and culturally
appropriate. In addition, services must be pre-
pared to meet the needs identified by the com-
munities themselves and to be accountable to
them.
Building Bridges is a three-year Health Action
Zone project funded to improve psychological and
mental health services for black and minority
ethnic communities in Liverpool. The thinking
and philosophies underlying the project were in-
cubated in David Smail’s psychology department
in Nottingham during the time that the principal
author (IF) worked there as a newly qualified child
and adolescent clinical psychologist. Many of the
psychologists in the department were develop-
ing ways of working closely with communities,
regardless of the speciality that they worked in. It
was very much a department in which issues of
the nature of human and psychological distress
were hotly debated and a critical stance (no-
where more sustained than in the Friday after-
noon meetings) taken towards the practice of the
profession. These discussions and skirmishes,
often provoked by David, ensured a re-evaluation
of one’s personal beliefs about the causes of psy-
chological distress and, therefore, how such dis-
tress should be addressed. In particular, these
experiences in the context of clinical practice led
to a keen awareness of the way in which people’s
psychological well-being is affected by the circum-
stances in which they find themselves. Further-
more, David encouraged us to view ourselves as
applied psychologists rather than psychothera-
pists, thus underscoring the fact that the body of
knowledge that is available to us is that which
pertains to normal behaviour and is derived from
both undergraduate and postgraduate (clinical)
learning. This paper is a tribute to David Smail’s
role and contribution to laying a solid foundation
for the development of clinical psychology prac-
tice that acknowledges the social (and economic)
origins of psychological distress.
Background
The Building Bridges project developed out of an
assessment of the needs of black and minority
ethnic communities in Liverpool. This assessment
identified a number of key local issues that also
reflected national trends. In particular, the indices
of social and economic deprivation, and the ex-
periences of black and minority ethnic people
within the criminal justice, mental health and ed-
ucation systems pointed to a corrosive and harm-
ful context for the psychological health of black
and minority ethnic people. This evidence of dis-
crimination and disadvantage was perceived as a
range of risk factors for the mental and psycho-
logical health of families from black and minority
ethnic groups. In addition, enough is known about
the barriers to the use of preventative and early
intervention services to suggest that services
needed to be delivered differently (McMiller &
Weisz, 1996; Fatimilehin & Coleman, 1999;
Beliappa, 1991; Littlewood & Lipsedge, 1997;
Ahmed, 1995). The research literature suggests
that black and minority ethnic people have often
had negative experiences with statutory services
in the past, have little confidence in the ability
of services to understand and meet their needs,
experience a lack of appropriate and accessible
information about existing services, experience
language and communication barriers in terms of
using services, and can experience different, more
coercive treatment as a result of the racial stereo-
51
Fatimilehin and Dye
types held by professionals. In addition, people
from black and minority ethnic communities are
often concerned about issues of confidentiality
and stigma associated with the use of mental
health services. However, it was also seen as im-
portant to identify and respond to the strengths
and resiliences of the local Liverpool 8 commu-
nities, such as the establishment of local networks
and community organisations and the mainte-
nance of strong racial and ethnic identities. The
project aimed to build on and work with these
strengths, and avoid undermining them.
Key philosophies and the work of
Building Bridges
The work of the Building Bridges project is founded
on a number of key principles and philosophies.
Identifying these from the beginning has been in-
strumental in the success of the project and clar-
ified the value of the project for both workers
within it and those in other services. These
philosophies are not mutually exclusive, but the
rest of this article outlines the way in which some
of them influenced the way in which we have
conceptualised and carried out our work.
Prevention is better than cure
It has long been accepted that preventing prob-
lems from developing in the first place is far better
than trying to resolve them once they have be-
come entrenched (Blair, 1992; Baker et al., 1997).
Prevention is superior in terms of both the cost-
effectiveness of the service and the experiences
of individuals or families (Baker et al, 1997).
Within Building Bridges, we have a commitment
to working preventatively to address the needs
of black and minority ethnic people in Liverpool.
One example of this way of working was our
involvement in the concern that was expressed
locally about the number of suicides of young
Somali men. This concern was expressed by
members of the Somali community to the Toxteth
Health and Community Care Forum who asked
us if we could help to address the issue. What fol-
lowed was a series of meetings with key people
from the Somali community that culminated in
Somali Young Men’s Day. This event provided an
opportunity to hear the experiences and views
of young men as well as to place these within a
context of discrimination and disadvantage. The
52
young men who attended the day identified issues
such as harassment by the police and security
guards or bus drivers, racism in school, and limited
opportunities for employment and leisure as some
of the major causes of distress. As a result of this day,
a number of initiatives with the police, education
and mental health services have been instigated.
Mental and psychological health is impacted
by a range of social and economic factors.
Although there are many psychological and men-
tal health services that would acknowledge that
social and economic factors play a part in the ae-
tiology of distress (HAS, 1995), there are few that
would see these issues as a fundamental part of
the formulation of the difficulties of individual
service users, and fewer still who would feel that
this was a legitimate part of the work of a psy-
chological or mental health service. In Building
Bridges, we set out to make this understanding an
essential part of our work. We address social and
economic issues in all our work with families and
individuals, and we see it as a core part of our
philosophy on prevention. People do not need to
have a mental health problem in order to access
the project, and we see helping people access
services such as child care, immigration, housing,
education and employment, as part of our pre-
ventative ethos. It is not that we see ourselves as
experts on these issues, but rather that we ac-
cept that that these issues impact negatively on
people’s psychological health and therefore it is
part of our work. We do not offer advice on these
issues but we support people in getting them
resolved. This is often by advocating on their be-
half, as described below. Accepting self-referrals
and community referrals is a key part of this
work as it enables us to keep in direct contact
with the issues that impact on people’s lives in
black and minority ethnic communities, rather than
this being filtered through a referral system. These
elements of the project both increase accessibil-
ity and reduce stigma for people requesting psy-
chological help.
Listening to local communities
In Building Bridges we are keen to ensure true
community participation in the planning and
development of services to black and minority
ethnic people. Through community centres and

relevant workers in statutory and voluntary
agencies, we obtain information about the
strengths and needs of specific communities,
and base the specific services and interventions
that we develop on this information. One exam-
ple of this is health promotion sessions that have
been run with women from the Somali commu-
nity. These sessions aimed to address some of the
psychological and emotional distress reported by
women within the community. The issue of stigma
was tackled by labelling these group meetings as
health promotion and using local community cen-
tres as venues, providing food, and not operating
exclusion criteria.
We have endeavoured to work within the guide-
lines proposed by Save the Children (1997) to
enable real participation to take place. We have
a Community Participation Group that meets on
a regular basis and sends representatives to our
steering group meetings. The concerns of local
people are discussed in the Community Partici-
pation Group meetings, and feedback is provided
about satisfaction with local services. This group
has also helped us make important decisions about
the way the project has developed in terms of
record keeping, confidentiality and ethnic moni-
toring. It has also been an important forum in
which to discuss the structure of services for
black and minority ethnic people generally. The
group has met with the Commission for Health
Improvement as part of the review of the Royal
Liverpool Children’s (NHS) Trust, and has helped
with the planning of our stakeholder meetings.
The meetings have been attended by people from
Somali, Arabic/Yemeni, Black British, Sudanese,
Pakistani, Chinese, Bengali and Nigerian commu-
nities. We see the Community Participation Group
as an important part of our commitment to em-
powering communities through consultation
and accountability. Accordingly, we have taken
account of their preferences in terms of venues
and timings of meetings, and we provide food,
interpreters and pay expenses for childcare and
travel. We have also changed times of important
multi-agency meetings about the future of the
project to enable the attendance of the Commu-
nity Participation Group.
The Building Bridges project is mainly staffed
by people from psychology or counselling back-
grounds. However, our capacity to work with
Clinical Psychology 24 – April 2003
local communities has been greatly improved by
the recruitment of a community worker. This is
an acknowledgement of the time and energy that
is needed to connect with and develop the trust
of local communities, and underscores our com-
mitment to responding to needs that do not fit
into traditional mental health service frameworks.
As part of building a picture of the needs of
local communities, we are also undertaking a
series of consultations with young people who
live in the area. This has mainly entailed group
discussions with young people in school and
community settings about their service needs.
However, we have also included discussions with
young people who are excluded from school or
are looked after by the local authority.
Long term therapeutic relationships are not
the only (or necessarily the best) ways of
helping people cope with social and
psychological difficulties
We do not view counselling or therapy as the only
way in which people can be helped to overcome
or cope with their psychological difficulties. In
essence, this is obvious if one subscribes to the
notion that some of the causes of these difficulties
are social or economic. Therefore within Building
Bridges we see advocacy as major part of our work.
We have commissioned training on advocacy for
all project staff, and we define advocacy as the
act of speaking up for or working on behalf of
another person. Underlying principles and values
of advocacy include empowerment, confidentiality,
and independence. Advocacy must also be client-
led and voluntary. One example of advocacy oc-
curred when a local women’s refuge contacted
us about a Bangladeshi Muslim resident who was
causing difficulties and whom they were consid-
ering asking to leave. Apparently, she had also
asked to see someone who could help her with
her concerns. We met with her and found that
she was distressed about some of the restrictions
placed on her in the refuge. She was unhappy
about only being allowed to have visitors at spe-
cific times, and having to share saucepans with
other residents. In addition, she had had some
disagreements with other residents about her
children’s bedtimes, and staff in the refuge were
not happy with the fact that one of her children
shared a bed with her. With the woman’s permis-
53
Fatimilehin and Dye
sion, Building Bridges staff met the refuge staff and
residents to discuss cultural differences in child
rearing, social contacts and food preparation. As
a result of this meeting, changes were made in
arrangements that were to the satisfaction of the
other residents and to the woman concerned.
Helping people access or re-access existing or
mainstream services is an important aspect of our
work. For some people who have had negative
experiences with particular services, we have
advocated on their behalf and arranged meetings
with the client and service provider in order to
talk through the client’s concerns and arrive at
some solutions.
One of our concerns is that long-term therapeutic
relationships may be disempowering for families
and communities as they foster the notion that the
experts are a fount of all knowledge and skill in
resolving problems. Although we offer counsel-
ling or therapeutic work where the individual or
family feels that it would be helpful, we have taken
a largely solution-focused approached to this work.
We chose this approach because it moves away
from an expert position by maximising the ability
of the client to identify and carry out their own
solutions to their problems. Other advantages of
the solution-focused approach include the fact
that it does not assume that there is pathology or
dysfunction, and there are no pre-conceptions
about the ways in which change can be brought
about (George, Iveson & Ratner, 1999). Every
session is approached as if it could be the last,
and this is very useful when working with com-
munities of people who do not have white, middle-
class understandings of appointment systems
and therapeutic approaches. However, it is im-
portant to note that this approach is adapted
within the project to some extent because of our
focus on advocacy and the fact that people some-
times want to tell their stories in their own way.
An example of using a solution-focused approach
was with a Chinese woman in her fifties who had
an adult son with mental health problems. She
contacted the project for help because relation-
ships within the family had broken down; her
son had hit his father who had then banished him
from the family home. She was having difficulty
coping with the situation and with the stigma of
mental illness within the Chinese community.
She spoke of how her life had now stopped, and
54
described her life before her son’s illness as com-
pletely different and much happier. She said that
nothing was going well for the family anymore. A
member of Building Bridges staff used a solution-
focused approach to help her identify her strengths,
coping strategies and resources outside of herself.
She became more positive about her abilities and
aware of continuing good relationships with her
other children and between herself and her hus-
band. She also began to discuss mental illness and
the issues surrounding this with other people in
her community. Her relationship with her son im-
proved. He began to visit and stay with the family
regularly, and the shame that they felt about his
problems was significantly reduced.
Using a solution-focused approach has been
helpful to us in working with people from dif-
ferent cultures without having to collect a great
deal of information about the family or individual’s
background, and without having to construct
pathology-based explanations of their distress.
This has been an issue when other professionals
are also involved with the family and have found
it difficult to understand that the problems we
work with are those defined by the family rather
than those identified by professionals. Another
observation has been that there are aspects of the
approach (such as constructing scales) that are
more commensurate with Western logical thought.
As mentioned earlier, we feel it is important to
take referrals for individual or family work because
of the necessity of remaining grounded in the
needs and experiences of individuals rather than
maintaining a strategic focus. It is also a means
by which we become aware of the way in which
common issues (for example, for working class
black families with teenage boys) and commonly
acknowledged issues (for example, the stigma of
mental illness in Chinese and Somali communities)
are played out in the privacy of home and family.
Critical issues
A difficulty for the project has been the recruit-
ment of appropriate staff. We have searched for
people from psychology or counselling back-
grounds who are bilingual and have an under-
standing of working with communities rather than
just using face-to-face therapeutic approaches. We
have had some success with this but have also
found ourselves with vacancies or unsatisfied

staff. The situation has been compounded by the
fact that we can only offer fixed term or tempo-
rary contracts due to the short-term nature of the
funding of the project. We have overcome some
of these difficulties by advertising nationally and
by offering sessional work with training oppor-
tunities attached. However, it is clear that when
we have staff within the project from particular
minority ethnic groups, then our engagement
with those communities is much improved. This
observation is one that is very difficult for main-
stream services to grapple with but it does under-
score the fact that people from minority ethnic
groups will feel more confident about engaging
with a service that reflects their own community.
We would argue that this is true for all service
users regardless of their race, ethnicity, gender,
religion, sexuality and so on. In fact, many of the
lessons that can be learnt from the work of the
Building Bridges project are not specific to black
and minority ethnic people. The principles of
community engagement, prevention of psycho-
logical distress, providing accessible and appro-
priate services and advocacy (amongst others)
should be fundamental to all services. Whilst
government initiatives such as Sure Start are
addressing the needs of some hard-to-reach and
impoverished communities, it is clear that tradi-
tional mental health services with long waiting
lists and DNA rates approaching 40 per cent are
no longer tenable and new ways of working are
essential if we are to provide services that people
both want and need.
Acknowledgements
We wish to acknowledge the hard work and
commitment of all the staff of Building Bridges,
and the Community Participation Group.
References
Ahmed, T. (1995) How to Provide Support Services to
Asian Communities: Not just black and white. London:
Good Practices in Mental Health.
Baker, S., Gilbody, S., Glanville, J., Press, P., et al. (1997)
Effective Health Care: Mental Health Promotion in
High Risk Groups. York: NHS Centre for Reviews and
Dissemination
Beliappa, J. (1991) Illness or Distress? Alternative
models of mental health. London: Confederation of
Indian Organisation
Clinical Psychology 24 – April 2003
Blair, A. (1992) The role of primary prevention in mental
health services: a review and critique. Journal of Com-
munity and Applied Social Psychology 2, 77-94
Fatimilehin, I. A., & Coleman, P.G. (1999) ‘You’ve Got
to Have a Chinese Chef to Cook Chinese Food!’ Issues
of power and control in the provision of mental health
services. Journal of Community and Applied Social
Psychology. 9, 101-117
George, E., Iveson, C., and Ratner, H. (1999) Problem to
Solution: Brief therapy with individuals and families
(second edition). London: BT Press
Health Advisory Service (1995) Child and Adolescent
Mental Health Services. London: NHS
Littlewood, R., & Lipsedge, M. (1997) Aliens and
Alienists: Ethnic minorities and psychiatry. London:
Routledge
McMiller, W. P., & Weisz, J. R. (1996) Help-seeking
preceding mental health clinic uptake among African
American, Latino and Caucasian youths. Journal of the
American Academy of Child and Adolescent
Psychiatry, 35, 8, 1086-1094
Save the Children (1997) Empowering Children and
Young People. London: Save the Children
Address
Building Bridges, 13 Croxteth Road, Liverpool L8 3SE
Clinical psychology
with asylum seeker
clients
Have you received a questionnaire about
this issue? If so, you are one of 500 DCP
members randomly chosen.
Please return the questionnaire as I hope
to make training and support
recommendations for working with this
client group.
Jenny Maslin
Clinical Psychologist in Training
jenny@maslinj.freeserve.co.uk
55

Self-help
February 24
Alison reading The Grand Complication by
Allen Kurzweill. Left open @ p 95. Hero goes to
shrink who proposes a list of ‘self help drivel’.
Charming.
February 27
Brought drivel charge up with Nigel over pie and
pint. N said I should confront Alison with list of
successful folk who use self help books.
Wondered if Napoleon had tried Russia on Ten
Francs a Day or if Idi Amin ever read How to
Win Friends and Influence People. Asked about
appt with clinical psychologist. Due tomorrow.
February 28
Clin psych didn’t turn up. Phoned to say sorry
and she had double booked with a psychiatrist.
Past position papers produced by the
Faculty are available from Jean
Isherwood. These are free to members
and £6.50 to others.
Please contact:
Jean.Isherwood@Communicare.nhs.uk
56
Asked how I was getting on with thought
diary. Lied – told her it was going well. Alison
said the t.d. should go down on a long list of all
the things I procrastinate about. Indignant –
asked for examples.
Later. A should write an encyclopaedia. Have
completely forgotten most things I promised to
do in house: washer on bath tap, paint kitchen
door frame, get ‘bloody’ CD-Rom fixed, on and
on. Must get Overcoming Procrastination from
library tomorrow.
March 5
Still not gone to library. Wading thru backlog of
self help books. Have read at best first 10 pages
of most of them, including How To Finish What
You Start. Seem to have all of Gail Lindenfield’s,
even Self Esteem. A said buying the book in the
first place said it all. Underlined bit in Louise Hay
on curing migraine by masturbating.
March 10
Pub with Nigel. Says he never finishes books either,
especially any on self-improvement. His problem
is finishing novels that he doesn’t want to end –
like House of the Spirits and Love in the Time of
Cholera.
March 15
Out with June and Graham. June says her book
club had a whole term on books u don’t want
to end. The Cornish Trilogy by Robertson
Davies and Jane Urquhart’s Away were the top
two with loads of Zola next. Graham said he
knew some books that never seem to begin:
Woolf’s To the Lighthouse, Martin Chuzzlewit
and ‘as for Proust’. Quite like Proust. Read
that Sartre’s Nausea was inspired by it so gave
it a go. Found it comforting. All that detail, no
hurry, going nowhere fast. Alison gave me one
of those looks and said she could see I might
be sympathetic to obsessive inward contem-
plation.
March 18
Bought Make Your Own Voodoo Doll. Appt
with clin psych came thru for next week. Not
sure it’s wise to record too many thoughts this
week.
Felix Q.
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