Health psychology – a profession misunderstood?

Claire Hamlet, Fiona Marfleet, Elaine Walklet and Joanne Webb (University of the West of England, Bristol) respond to a suggestion that health psychologists are ill-equipped to work directly with patients; and, below, Karen Rodham, Rachel Povey, Peter Oakes and David Clark-Carter outline why health and clinical psychologists should be working together.

As trainee Health Psychologists in our final year, committed to staying up to date with developments in the field, we were pleased to discover an article by Hilton and Johnston (2017) reflecting on the BPS accredited Stage 2 health psychology training in the UK – 'Health psychology: It’s not what you do, it’s the way that you do it'. However, we were concerned that the fundamental message of this article is that Health Psychologists receive inadequate training and are ill-equipped to work in applied practice.

As a consequence of this proposed 'deficit', the authors suggest registered Health Psychologists should be restricted to academic settings, unless there is significant modification to the current training programme. As an alternative 'solution', the authors suggest accreditation of yet another division within Psychology – Clinical Health Psychology.

We are unsure as to why this is being called into question at this juncture, as to the best of our knowledge, there is no evidence of endemic malpractice on the part of Health Psychologists working clinically. Whilst the authors’ make some valid and interesting points, and open an important discussion about the interface between clinical and health psychology disciplines, many of the criticisms do not align with our own experiences of training. 

The authors claim that 'the health psychology discipline may be falling short of its potential to contribute more to clinical practice and reflect the aims of the discipline better in terms of both theory and applied practice'. Firstly, it is important to consider what 'applied practice' in health psychology means. Health psychology emerged as a discipline with a broad range of theoretical and practical applications (Matarazzo, 1982). Whilst applied practice can mean working therapeutically with patients, we would argue that it also means training and supporting healthcare staff, working collaboratively with stakeholders, conducting consultancy and robust research that has the potential to impact on health and wellbeing at an individual or population level. Indeed, it is this breadth of application that motivated many of us to pursue this career and enrol on Stage 2 training.

The authors suggest that Stage 2 training focuses too heavily on models and taxonomies to the detriment of interpersonal skills, and that a lack of supervision provided to trainees results in a 'self-perpetuating cycle of clinical and interpersonal skill deficit'. This is disparate to our experiences of training, encounters with other trainees and personal reflections as evolving practitioners, for a number of reasons. Firstly, to secure a place on Stage 2 training, trainees are required to have significant work experience, have obtained an MSc in Health Psychology (Stage 1 training) and have secured a health psychology related job with workplace supervision. Trainees (often working in diverse settings) are expected to bring to the course a level of self-reflection, clinical awareness and interpersonal skills. These skills are then developed over the course of the 3-4 years of training within teaching, supervision and assessment. Whilst they are not assessed via standardised competency rating scales: by the authors’ own admission these approaches are arguably limited. Trainee Health Psychologists are encouraged to be highly critical and reflective about both the discipline and their skills profile and to view the doctorate as the foundation for their professional journey. As a result, we (and qualified Health Psychologists) are acutely aware of the need to continually develop clinical skills if we want to work therapeutically with clients following the doctorate. The notion that any training course could possibly equip a trainee with all the knowledge and skills they need is, we would argue, at odds with the requirement that practitioner psychologists 'understand both the need to keep skills and knowledge up to date and the importance of career-long learning' (HCPC, 2015, p.8). The article fails to acknowledge that many Health Psychologists have no desire to work clinically, preferring to focus on research, teaching, consultancy, or contributions to public health or policy development. Stage 2 training nurtures all these skills under close supervision and assessment.

The authors do not touch upon Health Psychologists’ competence in research and teaching and training because they believe 'these competencies are more clearly defined in the Stage 2 Handbook within the context of academic settings'. We would argue that the teaching and training competency and research competency very clearly relate to practice settings, and not merely academic contexts. One of the requirements of the teaching and training competency is to train healthcare professionals (BPS, 2015, p.42) and we consider such training an integral aspect of our health psychology practice and commitment to knowledge exchange, which our course has equipped us well to deliver. In addition, we are required to demonstrate 'competence as an independent researcher in health psychology' (BPS, 2015, p.32), which is evidenced via a systematic review and an empirical study relevant to the applied area we work in (e.g. weight management, infant feeding, visible difference and neuromuscular disease). We are taught to consider research and evaluation as integral, rather than distinct to our practice and the importance of disseminating our findings to a range of audiences, particularly when this could influence current practice. Furthermore, evidence based practice is integral to our discipline. The reliance on, evaluation and continued development of models and theories of behaviour change is fundamental to this and should not be under-valued.

We disagree with the authors recommendation for the BPS to formally recognise 'the discipline of clinical health psychology as formal division'. We recognise there is some overlap between clinical and health psychology, however, the creation of an entirely new division (and associated training route) to demarcate all Clinical and Health Psychologists who work within this overlap seems unnecessary, and potentially divisive. Furthermore, we would argue that using one division’s training criteria and assessment as a benchmark for another’s, neglects the fact that the two divisions have different aims, scope and training routes, which must be recognised and appreciated. Currently, Stage 2 training in Health Psychology is self-funded by trainees or subsidised by their employers, who have an invested interest in the career development of their employees. We believe creating a clinically focused health psychology course would deter those who are interested in developing a broader range of competencies. In our experience, employers are attracted to the wide-ranging skills Health Psychologists offer, including their research self-efficacy, argued to be lacking in clinically focused psychologists (Wright & Holttum, 2010). We believe it is important not to narrow the focus of health psychology, but allow individuals to decide where their own focus lies after training.

Some of the points made in the article reflect an on-going dialogue within our own discipline around Health Psychologists working in clinical settings. We hope that the new ‘Psychological Interventions’ competency within Stage 2 training – whereby trainees one-to-one work with clients is now observed by a supervisor who can attest to their ability to assess, formulate and deliver an intervention – will go some way in alleviating the authors concerns of a clinical skill deficit.

Whilst we respect the authors views, we feel their article fails to provide a balanced view of the discipline of health psychology and the current Stage 2 training. We hope this response has provided a greater insight into the current provision of training for Health Psychologists and the level of critical self-awareness trainees are required to demonstrate. The knowledge and skills that Health Psychologists possess, has much to offer the variety of settings they chose to work in, including the development and maintenance of an optimally functioning National Health Service. This is not a time to further divide or overhaul well-functioning programmes and competencies – this is a time for psychologists to work together.

References

Health and Care Professions Council (2015) Standards of proficiency – Practitioner Psychologists [online]. Available from http://www.hpc-uk.org/publications/standards/index.asp?id=198 [Accessed 08 August 2017].

Hilton, C.E. and Johnston, L.H. (2017) Health psychology: It’s not what you do, it’s the way that you do it. Health Psychology Open, 4(2), DOI: https://doi.org/10.1177/2055102917714910

Matarazzo, J.D. (1982) Behavioral health's challenge to academic, scientific, and professional psychology. American Psychologist, 37(1), p.1.

The British Psychological Society (2015) Qualification in Health Psychology (Stage 2). Candidate Handbook [online]. Available from http://www.bps.org.uk/system/files/Public%20files/qhp_stage_2_candidate_handbook_jan_2015.pdf [Accessed 08 August 2017].

Wright, A.B. and Holttum, S. (2012) Gender identity, research self‐efficacy and research intention in trainee clinical psychologists in the UK. Clinical Psychology & Psychotherapy, 19(1), pp.46-56.

 

Stand by me; he ain't heavy, he's my brother

Karen Rodham, Rachel Povey, Peter Oakes and David Clark-Carter (Staffordshire University) on why health and clinical psychologists should be working together.

We were alerted to a recent article by Hilton and Johnston (2017) when we read this response to it penned by Claire Hamlet and colleagues. Having read the article by Hilton and Johnston, we feel ‘It’s a Sin’ (Pet Shop Boys) to stay silent on such an important topic.  Indeed, we believe that the article contains serious misperceptions and inaccuracies which need to be addressed. We would go so far as to wonder if perhaps they are in ‘The Land of Make Believe’ (Bucks Fizz); and we suggest that the response by Hamlet and colleagues has done an excellent job at showing that this may indeed be the case. However, in this response, we focus on one specific issue and argue that Hilton and Johnston’s proposal to formalise a new Division of Clinical Health Psychology is not a useful solution. We would like to take this opportunity to explain why.

In the spirit of transparency,

1)     We are all involved in the provision of doctoral level training for both health (KR, RP, DCC) and clinical psychology trainees (PO & DCC).

2)     We are working in academia but we have practice experience (KR, PO)

3)     KR is also currently Chair of the Division of Health Psychology (DHP).

4)     We note that the authors drew inspiration from an 80s pop record for their title so we have continued this theme and used 1980s number 1 record titles in our response.

I should have known better (Jim Diamond): We were dismayed that an attack on health psychology training has been made via the publication route. To our knowledge, neither the DHP Committee nor the DHP Training Committee have been approached by Hilton and Johnston. Had they approached either Committee, their fears would have been allayed, their misperceptions addressed and their paper need not have been written. It is a shame that they felt raising the issue in this way, before speaking to the Division concerned, was an appropriate method of dealing with it.

Careless Whisper (George Michael): It seems to us that Hilton and Johnston are treating two unrelated points as though they were related: 1) the suggestion that health psychology training is inappropriate and 2) the need for formalising a new Division of Clinical Health Psychology. Furthermore, Hilton and Johnston offer a critique of the Behaviour Change Wheel and Taxonomy, but erroneously conflate the taxonomy with health psychology training. These are two separate issues. The development of a model, does not equate to practice and training.

Health Psychology Training: ‘Respectable’ (Mel and Kim): Just as with Clinical Psychology, accredited Health Psychology (Stage 2) courses offer training that equips successful graduates with all the skills necessary to practise as a competent Health Psychologist. Courses are accredited/approved by both the British Psychological Society and the Health and Care Professions Council. Neither professional body would accredit courses that were not fit for purpose.

Trainees work in practice throughout their training period. Clinical supervision is an issue highlighted by Hilton and Johnson. Of course, those providing the courses need to be able to supervise at doctoral level – the trainees must achieve a high standard in both their practice and their academic work to be deemed fit to be a practitioner. And of course, not all providers of training are equipped to provide clinical supervision. But supervision is something which trainees are expected to source in order to complete their practice-related competencies. This is no different to when we have completed our training and are working in practice – we are bound by our professional bodies to ensure we work within our competences and that we secure appropriate and regular supervision.

In short, we are saddened that Hilton and Johnston have such a low regard for the quality of health psychology training, and because of this, indirectly seem not to trust that our professional body, the British Psychological Society, nor our regulatory body the Health and Care Professions Council have established appropriate training criteria designed to produce competent scientist practitioners. In addition, we take exception to the suggestion that health psychology trainees are not properly trained or equipped to work in applied settings. Our UK trainees work in many different applied settings and bring with them an extremely high standard of skill set. We also suggest that the inaccurate assumptions Hilton and Johnston have made about the training do not logically lead to the need for a formal establishment of a Division of Clinical Health Psychology.

Clinical Health Psychology: Just Like Starting Over (John Lennon): We see no need for the establishment of a formal Division of Clinical Health Psychology, such a Division would only serve to further fracture applied psychology and add to confusion about what psychologists do. It is, in our opinion, more important to move away from using adjectival titles in the work setting and instead use the term ‘Applied Psychologist’. Psychologists should be employed based on their skill set, not on the title that they have worked towards.  After all, we are all required to engage in CPD after completing our training and in so doing, we gain extra skills that equip us to work in different settings, with different clients and different therapeutic tools. As such, the title soon ceases to convey what someone is equipped to do.

Stand By Me; He Aint Heavy He’s My Brother (Ben E King as well as The Hollies): We have a sense that all the branches of psychology struggle with the fact that we have to acknowledge the primacy of relationship (‘we know this much is true’, Spandau Ballet) but at the same time we love ‘OUR MODELS’ and techniques and secretly think ‘OUR MODEL’ is best and if everyone did ‘OUR MODEL’ right the world’s problems would be solved. And of course, careers can be made from a model. . . If we are honest, none of us spends the time we should spend on this, and the idea that clinical psychology has it sorted is patently absurd. So, let’s work on this together and not create a new division in our profession that will have exactly the same problem. The alternative of course is to carry on subdividing ad infinitum – in a truly reductionist way:

“I am a registered community clinical counselling health occupational pain management psychologist. I am proud to be a member of the profession of community clinical counselling health and occupational pain management psychology. We have our own training course, professional body and conference every year. We also have lots of important letters after our names but we pretend not to like that”.

We believe that we should stand together as applied psychologists; not seek further division (and Divisions). Whilst we understand that ‘You Can’t Hurry Love’ (Phil Collins), in our opinion, there is no need to create a hybrid applied psychology protected title; health psychologists, clinical psychologists and other applied psychologists can all work together. Imagine if we did, in the words of Yazz and The Plastic Population, ’The Only Way is Up’.

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Comments

In the following comment Dr Charlotte Hilton, Dr Lynne Johnston, Professor Stephen Rollnick, and Professor David Marks provide further details and context to supplement the arguments outlined in Hilton and Johnston's 2017 paper "Health Psychology: It's not what you do, it's the way that you do it."


Following the publication of the peer-reviewed paper [Health psychology: It’s not what you do, it’s the way that you do it (Hilton & Johnston, 2017)], we were pleased to see that the points that were raised opened up an interesting and timely debate. What follows is additional commentary elaborate and reiterate the discussion points raised and clarify some misinterpretations that appear to have been made by the respondents thus far on the BPS Psychologist website. For completeness we have addressed each of the points raised by Rodham and colleagues. We are delighted to welcome Professor Stephen Rollnick and Professor David Marks as co-respondents and thank them for their extremely supportive comments on our original paper. We would encourage those who have contacted us privately in support of the arguments outlined to respond in an open and transparent way.

We recognise the diversity of health psychology as a profession and the range of settings in which trainee and qualified health psychologists work including teaching and research, public health and the NHS. As part of the Stage 2 training process, qualified health psychologists are required to demonstrate knowledge of a number of core competencies grouped into five broad areas (BPS, 2015) which Hilton and Johnston outline in the paper. However, the main focus of the discussion points raised centres around not whether the current requirements for Stage 2 training adequately support trainee health psychologists to work in applied practice generally but for those who wish to work clinically and therapeutically with patients specifically. We acknowledge that not all health psychologists do work clinically with patients, but this particular aspect of training is made explicit in the paper and this seems to have been misinterpreted or overlooked by the response provided thus far. For added clarity, one way of understanding what is meant by clinical therapeutic interpersonal skills development has been provided by Bennett-Levy, Thwaites Chaddock and Davis (2009).

Currently, there is little to no requirement for trainees to shift from the assessment of knowledge and knowing in Stage 1 (typically an MSc programme of study) to skills in demonstrating (implementation) in Stage 2. Related professions such as public health, are explicit about the value of both knowledge and skills (demonstrating): “this demonstration of knows and knows how provides the platform for assessment of the practice of public health” (Faculty of Public Health, 2015 p.27).  A trainee nurse would not be expected to perform a medical procedure after only being assessed on their knowledge on how to do so via a written portfolio. In the same way, a full UK driving licence would not be issued without individuals being coached through an iterative process of learning and skill development and assessed on both the theory and a practical demonstration of their driving ability against a minimum threshold level of proficiency. To that end, it is difficult to understand why the current arrangements for health psychology training do not adopt the same emphasis on both knowledge and skill development/implementation and appropriate assessment of such. As Hilton and Johnston state in the paper “the assessment of health psychology trainees further reflects the emphasis on the what (knowledge focused) at the expense of the how (skill demonstration/implementation focused) because candidates are assessed via a portfolio of competence and an oral examination” (Hilton & Johnston, 2017 p.5).  We recognise that this limitation is not exclusive to health psychology but that any practising applied psychologists who are also Health and Care Profession (HCPC) Council registered and are working directly with patients would benefit from an iterative and reflective process of clinical and therapeutic skill development that is assessed appropriately. In essence, assessing people on what they actually do rather than what they think they do is paramount in the implementation of practical clinical skills.

Indeed, the applied strengths and limitations of sport and exercise psychology vs. clinical sport and exercise psychology has been the subject of much debate for the same reasons and we invite academic and practitioner colleagues to reflect on the health psychology training requirements in a similar way. As psychologists, we know that people often present with complexity. Problems, illness, causes and symptoms rarely present in isolation and the combination of a broad range of factors can impact on our behaviour in many different ways. Clinical health psychologists tend to recognise this complexity in the form of the biopsychosocial model. If we return to the example of sport psychology, qualified sports psychologists are well-placed to support athletes through anxiety related conditions that are performance specific and validated tools such as the Competitive State Anxiety Inventory (CSAI-2; Martens, Vealy & Burton, 1990) are commonly used to assess this. Applied sports psychologists are also well-placed to deliver programmes of mental skills training to enhance performance. However, the difficulty arises when an athlete’s performance may be affected by underlying clinically defined issues (e.g., depression; substance misuse; eating disorders). Of course, recognition of professional competency boundaries and the ability to refer on is critical here. However, it is because we can recognise the complexity of factors that effect human behaviour and performance that this similar debate regarding the potential utility of clinical and therapeutic skills within sport and exercise psychology has also been opened (e.g., Hutchison & Johnston, 2013).

In a similar way, obesity is a common condition of interest to health, exercise, and clinical psychologists working within physical health care settings. Yet, obese individuals, especially at the higher end of the BMI continuum, often present with complex underlying psychological causal and maintaining factors such as long standing depression, social phobia, low self-worth, loss, trauma, attachment issues, and increasingly, a recognised eating disorder (See Johnston, Hilton & Lane, 2017).  If we conceptualise ‘weight’ as an outcome it is necessary to work with the patient therapeutically to understand the various causal and maintaining factors that impact upon this outcome. Clinically, this requires a collaborative and therapeutic approach to developing appropriate assessment, formulation, and treatment plans linked to evidence-based treatment models. Whilst obesity therefore, is of common interest to health, clinical, and exercise psychologists, a review of the training requirements for Stage 2 makes it difficult to understand how a practising health psychologist from Stage 2 training alone would be able to undertake this collaborative and therapeutic process.

A report published by the British Psychology Society (BPS, 2014) indicated that health psychology is underutilised and that this is a key area for potential development. We would question why this is so?  Specifically, why are there so few health psychologists with a specific interest in working directly with patients currently employed in clinical practice? Clinical psychologists with an interest in physical health conditions are often favoured and employed for this purpose (BPS, 2008). Is this due to a perceived failing of the current approaches to Stage 2 health psychology clinical and therapeutic skill demonstration and assessment or are there other factors at play?  We are not sure, but we certainly feel that this is a question that warrants further investigation, debate and discussion.

Hilton and Johnston outlined some of the differences between the clinical and therapeutic skill development and assessment processes required for health psychology and clinical psychology training. This is particularly apparent with regards to the requirement to formulate treatment plans and also the behaviour change competency (BPS, 2015). We fully appreciate that approaches to behaviour change can be theoretical, epidemiological and population based but critically, approaches to behaviour change are also clinically oriented and this is a common shortfall with recent developments in health psychology (e.g., BCTs). It is unclear why health psychology trainees are required to formulate and also utilise Motivational Interviewing (MI) skills if neither of these competencies are assessed adequately and Hilton and Johnston make suggestions as to how this may be done in the paper and based upon their experiences as members of the Motivational Interviewing Network of Trainers (MINT) and previous research (Miller & Moyers, 2006).

We recognise that not every qualified health psychologist will want to work therapeutically with patients but we wonder if, with the growing recognition of the inseparable link between mental and physical health and illness [Department of Health (DH), 2011; NHS England (NHSE, 2016)] and the expansion of services such as Improving Access to Psychological Therapies (IAPT) (NHSE, 2016), there are opportunities for health psychologists to work clinically should they wish to do so?  Following the BPS (2014) Scottish survey, perhaps it would be valuable to undertake a UK-wide survey of trainee health psychologists to establish what the need/interest is? Nevertheless, we agree that the current training and assessment requirements for Stage 2 would need to be adjusted to better support trainee health psychologists to work therapeutically within clinical practice with patients. We are also agreed that with respect to clinical and therapeutic encounters ‘it’s the way that you do it - that’s what gets results’. Crucially, the notion of the therapeutic alliance has been consistently demonstrated to contribute to favourable patient outcomes (Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin et al., 2000) and we consider this alliance and the interpersonal processes that contribute to such an alliance as important to all ‘helping professionals.’

We are aware that CPD opportunities are available for all qualified applied psychologists to improve their clinical and therapeutic skills.  We are often approached for this reason to provide training and supervision. CPD is an important part of any practicing psychologist’s profession although we wonder why clinical and therapeutic skill development is not considered as a standard and integral part of the Stage 2 assessment process within health psychology to allow those who wish to practice clinically to do so? 

We welcome the proposal of a ‘psychological interventions competency’ within Stage 2 training that is referred to in the trainee health psychologist’s response to Hilton and Johnston’s paper. From the detail provided, it appears that ‘trainees one-to-one work with clients is now observed by a supervisor who can attest to their ability to assess, formulate and deliver an intervention’ may respond to the challenges that were presented. However, how often this is observed, in what way, how this is assessed and the experience of the assessor will all be important factors. We are agreed that a written portfolio and oral examination is not sufficient. The current Stage 2 requirements state that ‘more than a single session of observation may be required’ (BPS, 2015 p.30).  This seems extremely limited with respect to what is required to support the development of clinical and interpersonal process skills. Arguably, the proposed amendment itself is testimony to the recognition that there is a need for adjustments to these skill requirements and the approaches employed to assess these for trainee practicing health psychologists, and we welcome this.

It is often difficult to communicate the broader intentions of an academic paper and we appreciate that for some, especially those very much invested in the receipt and delivery of health psychology training, Hilton and Johnston’s arguments may have been uncomfortable to read. However, rather than questioning the credibility of the health psychology discipline, we hope that the considerations presented in the paper raise the profile of the health psychology discipline and prompt further interesting and transparent dialogue regarding not only the training requirements of health psychologists, but perhaps how we may better support the clinical, interpersonal and therapeutic skill development of all practicing psychologists and allied health and social care professionals across the disciplines. We are genuinely saddened that Rodham and colleagues considered Hilton and Johnston’s paper as an ‘attack on health psychology training’ and instead did not consider the points raised as a valued opportunity to share learning and embrace the opportunity for a close working relationship between health, clinical and counselling psychology. There are many purposes of a peer-reviewed paper but one of them is to ensure that the arguments presented within are credible. Rodham et al. question the appropriateness of the arguments presented within a peer-reviewed publication. However, the discussion that has been generated here is testimony to the value of utilising the publication route as a valuable opportunity to generate important and timely discussion.

Rodham and colleagues have unfortunately misunderstood some critical points raised in the paper when they advise that the paper reported that a) health psychology training is inappropriate and the need for formulising a new Clinical Health Psychology Division are unrelated. Hilton and Johnston clearly demonstrate, and we have reiterated here, how the clinical, therapeutic, and interpersonal skills of health psychologists are not adequately supported or assessed by Stage 2 training and to that end, offered three solutions: “enhance clinical and interpersonal skills through adequate training in formulation and MI, assess these skills appropriately or formulise a new clinical health psychology discipline: “If health psychologists are required to work directly with patients and individuals with complex physical illness that often present with mental ill-health co-morbidities (Qin et al., 2014) and also support individuals through the behaviour change process, then one of  the following changes to the QHP training requirements must be implemented: (a) that health psychology trainees intending to practice, and become HCPC registered as a practitioner psychologist, are required to demonstrate clinical interpersonal skills (e.g. collaborative case formulation/CBT and MI) and are assessed through appropriate qualitative (i.e. coaching, clinical supervision & clinical process assessment) and quantitative (i.e. established coding tools, for example, MITI and CTS-R) methods, or (b) that the discipline of clinical health psychology is officially recognised by a formal division of the BPS and that the necessity to demonstrate clinical interpersonal skills becomes the requirement of this discipline and not that of health psychology.” (Hilton & Johnston, 2017 p.8). It is interesting to note that the responses thus far have all focused upon the later suggestion. We wonder whether there may be practical and exciting opportunities to explore the former suggestion?

A further misunderstanding reported by Rodham and colleagues is that Hilton & Johnston conflate the Behaviour Change Wheel and Taxonomy with health psychology training. The context of critiquing the wheel and taxonomy was to demonstrate the disproportionate emphasis upon model development (particularly within behaviour change) rather than skill development and this is referred to as an emphasis on the what rather than the how. This example is used to provide adequate context for the reader such that they understand the critique of Stage 2 training and the lack of emphasis on the ‘how to’ of behaviour change. If anything, the paper clearly demonstrates concerns regarding theoretical understandings and model developments within health psychology without equal and adequate attention to the implementation processes required to deliver theoretical approaches/models in practice. To this end, we agree that ‘the development of a model does not equate to practice and training’ and indeed, this is somewhat demonstrative of the crux of the challenges raised in the paper.

What is perhaps most confusing is Rodham and colleagues assertion that because trainees work in practice throughout their training period this is sufficient to meet the Stage 2 competencies. Again, we ask, with specific respect to the clinical skills competencies component (e.g. formulation & MI) how is this assessed and supervised and are the current arrangements the most optimum or appropriate approach? Perhaps the current arrangements are suitable for health psychologists who are not working clinically and in direct therapeutic contact with patients with complex needs. As we and others have already acknowledged, health psychologists work in a variety of applied settings and these do not always involve direct clinical work with patients. However, for those that do, we ask again, how well do the Stage 2 training and assessment requirements prepare them? Understandably, if few health psychologists are working within this context then this may help us to understand why for some our urge to enhance the clinical and therapeutic skills of trainees is not of interest or appears irrelevant or even threatening. However, if this is the case it is difficult to understand why the specific requirement to formulate (a highly complex clinical skill) and to utilise MI (a complex counselling method) are referred to within the Stage 2 competencies. If these are a requirement, why not support the development of proficiency in them and assess appropriately in the ways that are suggested? We are not proposing that clinical or counselling psychology training routes or practices are the panacea for healthcare practice but as practitioners and researchers we engage with the spirit of sharing good practice and working from a cross-disciplinary perspective. Hilton and Johnston’s paper demonstrates opportunities to help support those health psychologists who wish to work clinically and potentially expand the utility of health psychologists and the profession.

It was particularly disappointing to read that Rodham and colleagues interpreted the arguments in the paper to be a demonstration of ‘low regard of the quality of health psychology training and distrust of the BPS’. This is highly personalised and potentially damaging and not congruent to facilitating the potential for better collaborative working across the disciplines to help support the development and increased utility of health psychologists. We recognize that this is potentially an emotive subject and Hilton and Johnston have tried to present practical suggestions to support the utility of health psychologists working in clinical practice based upon our experience as clinicians, academics and supervisors. We have presented a detailed response to reiterate the arguments and opportunities raised in the paper and to avoid any further misinterpretation. Below is a summary of the key points:

  • The concerns raised refer ONLY to health psychologists working clinically with patients although we do not know currently how many there are. The BPS (2014) survey would suggest that few health psychologists are working in clinical practice with patients and deem this as underutilisation.
  • If formulation and MI remains a competency requirement, it must be supported and assessed adequately and Hilton and Johnston make suggestions as to how this may be done
  • Three solutions were offered to the challenges raised, although the responses thus far only address one of them.

Reflections and Questions

  • If health psychologists are not keen to enhance the integration of clinical/interpersonal/therapeutic skills into routine consultations with patients then why are they referred to in the Stage 2 competencies?
  • Given that formulation and MI are a health psychology competency, why are they not supported and assessed adequately?
  • If health psychologists consider that their training supports them adequately to work clinically and therapeutically with patients in practice, why are allied practicing psychologists (e.g. clinical & counselling psychologists) not trained in the same way?
  • Why is there a dearth of clinical examples or ‘how to do’ videos and practical clinical coaching manuals specifically for health psychology?

 

Professor David F Marks: Important Historical Considerations

 It is timely and appropriate that Hilton and Johnston address these important and enduring considerations for health psychology training. As Chair of the BPS Section and subsequently the Special Group in Health Psychology in the early nineties, I was involved in establishing and obtaining BPS approval for the training programmes for Stage 1 and Stage 2 Qualifications in health psychology.  This piece of history is pertinent to the issue of misunderstanding vs. underutilization of UK health psychologists in clinical work with patients.  One highly relevant and crucial fact must not be overlooked: when health psychology training in this country was established, any actual or perceived overlap between health psychology training and clinical psychology training was absolutely off-limits. It was an accepted part of the process within the BPS Professional Affairs Board that approval for the 'upstart' health psychology training definitely could not and would not include face-to-face, one-on-one clinical work as this was recognised as the exclusive province of the Clinical Psychology profession.

I hosted at least one meeting in my home with the then Chair of the Clinical Psychology Division, the late Malcolm Adams, where it was necessary to explain over tea and biscuits that there would be no attempt by health psychologists to ape the competences of clinical psychologists. This was a view that I personally felt would be unsustainable over the longer term for a variety of reasons but any attempt to include clinical work in health psychology training competences would have been vetoed by the all-powerful Division of Clinical Psychology. It was a bit like China vetoing a proposal about human rights at the UN Security Council: there was not a chance it would get through, however desirable for those directly concerned (in our case, health psychology services for NHS patients).

Another relevant historical point is that influential people within the Health Psychology Special Group were themselves divided over the desired objectives of health psychology training. Many of these people were themselves previously trained as clinical psychologists and they could see no purpose in replicating clinical training under the health psychology umbrella.  They were content to make a PhD in health psychology the only necessary and sufficient training requirement for full membership of the Health Psychology Division. It is noteworthy that at the 2016 AGM in Aberdeen there was a unanimous decision to amend the criteria for Full DHP membership to enable academics with no training in health psychology beyond research to become full members. In my view this will be the final backward step towards branding UK Health Psychology a profession designed principally for researchers without the clinical skills that are necessary for clinical health psychology practice. With these proposed changes it will become increasingly difficult for trainees to become qualified in clinical health psychology when the very people they are being trained by are academics without clinical interests, knowledge or experience.

A third relevant factor is the general lack of health psychology placements and positions in the NHS. This is no accident. It is by design. The Clinical Psychology profession has squeezed health psychology out of the door for the simple reason that it's bad for their own employment opportunities. Counselling Psychology and Psychotherapy have already made inroads into NHS work and there isn't really much wiggle room left for yet another psychology profession within the NHS. That's the elephant in the room, jobs in the NHS, the country's largest employer.

 

References

Bennett-Levy, J., Thwaites, R., Chaddock, A., & Davis, M. (2009). Reflective practice in cognitive behavioural therapy: The engine of lifelong learning. In J. Stedmon, & R. Dallos (Eds.), Reflective practice in psychotherapy and counselling (pp. 115–35). Milton Keynes: Open University Press.

British Psychological Society (2008). Clinical health psychologists in the NHS. Retrieved from: http://www.bps.org.uk/system/files/Public%20files/DCP/cat-442.pdf.

British Psychological Society (2014). Health psychology and public health in Scotland; exploring current roles and future direction. Retrieved from: https://www.bps.org.uk/system/files/user-files/Division%20of%20Health%20....

British Psychological Society (BPS) (2015) Qualification in health psychology stage 2: Candidate handbook. Retrieved from: http://www.bps.org.uk/system/files/Public%20files/qhp_ stage_2_candidate_handbook_jan_2015.pdf (accessed 14 February 2017).

Department of Health (2011c). No health without mental health a cross-government mental health outcomes strategy for people of all ages. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf.   

Faculty of Public Health (2015). Public health speciality training curriculum. Retrieved from: http://www.gmc-uk.org/PH_Curriculum_2015_Final_CleanVersion_GMCapproved.pdf_62060013.pdf.

Horvath, A. O. & Bedi, R. P. (2002). The alliance. In Norcross, J. C. (Ed.), Psychotherapy relationships that work: therapist contributions and responsiveness to patients (pp. 37–69).  New York: Oxford University Press,

Horvath, A. O & Symonds, B. D (1991) Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology 38, 139–149.

Hutchison, A.J., & Johnston, L. H. (2013). Exploring the potential of clinical formulation within Exercise Psychology.  The Journal of Clinical Sport Psychology, 7, 60-76

Johnston, L. H., Hilton, C. E., & Lane, C. (In Press for 2017).  Motivational interviewing and mindfulness in weight management. In J. Weaver (Ed.), (pp. X-X).  Practical guide to obesity medicine. Philadelphia: Elsevier.

Johnston, L. H., Hilton, C. E., & Lane, C. (In Press for 2017). Psychological management before and after bariatric surgery. In J. Weaver (Ed.), (pp. X-X).  Practical guide to obesity medicine. Philadelphia: Elsevier.

Martens, R., Vealey, R. S., & Burton, D. (1990). Competitive anxiety in sport. Champaign, IL: Human Kinetics.

Martin D. J, Garske J. P & Davis, K. M (2000) Relation of the therapeutic alliance with outcome and other variables. A meta analytic review. Journal of Consulting and Clinical Psychology 68, 438–450.

Miller W.R. & Moyers, T.B. (2006) Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions 5(1), 3–17.

National Health Service England (2016). The five year forward view for mental health. Retrieved from: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf.

Qin, P. Horton, K. Mortensen, P. B. & Webb, R. (2014). Combined effects of physical illness and comorbid psychiatric disorder on risk of suicide in a national population study. The British Journal of Psychiatry 204(6), 430-435.

Wardle, J. & Steptoe, A. (2005). Psychologists making a difference, public health psychology. The Psychologist, 18, 672-675.