Column
‘My Way’ written for the Newsletter of the British Association of Group
Psychotherapists
Clinical
judgment and power in psychotherapy
When are clinical issues
purely clinical? Never, of course! Obvious isn't it? Well no, not obvious actually.
I have banged my head (and risked other parts of my anatomy) against the
brick wall of clinical judgement on far too many occasions to be able to ever
again allow anybody exercise their clinical judgement in my presence with
impunity. What the hell is clinical
judgement anyhow? It has often felt to me like one of those indulgences we
allow each other as 'professionals' - the professional conceit is surely, the
worst of all - in which we avoid doubt, unknowing, rivalry and much else and
collude with each other around fantasies of ourselves as ubermensch - experts in
our fields, purveyors of remedies, the modern seers, founts of ancient wisdom,
the blessed. Paul Gordon, in his recent
clear headed critique of some of psychotherapy's worst conceits (he lead our
January Seminar this year) reminds us of the work of Ivan Illich some twenty or
so years ago in which 'clients' are needed by 'professionals', indeed it is the
client who services the professional.
The client's 'needs' are made up of a mass of assumptions made on their behalf.
My particular gripe is
fiercest in the warzone of assessment. I have worked in an organisation in
which group therapy was very much the servant of individual therapy. Clients
were fed to me under circumstances of severe rationing. Assessment was a conveyor belt into on-going
one to one - only for group were positive indicators sought. Eventually, the Governors of the
organisation listened to the clinical judgement of the Director, which was that
group therapy wasn't working. This is
an example of how power relations within institutions are played out within the
client work, as much because there is a dismal tendency within psychotherapy to
imagine we are above the mess of power and politics - we get to the real cause
of things. Taken from this perspective
the needs of the client cease to play any part, the needs of the professionals,
i.e., those earning a crust, understandably determined to defend their share of
the loaf, are paramount. The question
that my experience within a wide range of public and voluntary institutions has
always begged is: just how come is it that counselling and psychotherapy
clinics of one form or another always manage to provide just the right
proportion of clients to sustain the different treatment forms they offer. Clinical judgement is surely way down the
pecking order of explanations for this.
I currently work within
an NHS Child and Adolescent Mental Health Service in which a so-called
'multi-disciplinary' team - largely psychotherapists - has been set up to help
reduce burgeoning waiting lists. The Consultant Psychiatrist, who wields
clinical judgements with no hesitation, is keen to profess her sympathy for
psychotherapy but at the same time one is left in no doubt as to what our role
is about - to protect her. We have had
a number of bogus democratic discussions within the team on the nature of our
assessments, however at the end of the day we are reminded that 'this', i.e., a
basic psychiatric assessment, 'is minimally what we have to do' because this is
all about weeding out potential suicide risk or care cases so that nobody can
be accused of not having acted, i.e., the person with clinical responsibility
cannot be so accused. By the way these
are my inferences from our discussions.
As a result our clinical meetings are laughable, well they would be if
wasn't such a pain in the arse struggling through them, because our function as
psychotherapists on the shop floor is to service the needs of the dominant
profession - psychiatry.
In my experience this
type of power struggle is not much talked about within psychotherapy. Too many assumptions are made about our
relations as 'professionals' that disguise the underlying hostilities. Clinical judgement, particularly at the
level of assessment, is as much about power - the internal dynamics of the particular
organisation added to the hierarchical tensions that exist between schools,
models, theories, methods (etc.) of psychotherapy and counselling in
competition with each other within the market scramble place.
I hope to see colleagues
at the forthcoming BAGP Workshop "The Assessment Controversy" on
Saturday May 8th in order to take these issues further.
Readers of this column
should note that I am soon to move to Spain (hence the new title) but will
continue to pen my views for the Newsletter from afar. By the way, I would be grateful to hear from
any Spanish group psychotherapists, or anyone in the know, about opportunities
for working in Spain within the field.
Notes: 1. Face to Face:
Therapy as Ethics (Constable 1999)
Peter Zelaskowski