Ian Fleming

University of Manchester and Rochdale NHS Trust

and

Mark Burton

Manchester Learning Disability Partnership and University of Northumbria at Newcastle

In this article the authors want to discuss their experience of teaching about links between individual and society to clinical psychology trainees. The teaching has objectives of increasing knowledge about the influence of social inequalities on psychological disorder; understanding the relationship between individuals and their social context and considering the conceptual nature of this distinction; reflecting on existing clinical practice and considering alternatives; and considering clinical practice with marginalised people

Clinical Psychology, like psychology more broadly, is often a site of tension between the recognition that people are above all social beings, and a set of concepts and methods that often seem to deny this, operating on individuals in isolation from the contexts that create and influence them. Within clinical psychology this tension is reflected, for example, in disagreement about the importance that should be attributed to social and economic causes of distress, and the appropriate methods for alleviating it. Psychology in general has often put social and economic factors beyond its disciplinary boundary, preferring instead to look to intra-psychic explanations (Danziger, 1994; Smail, 1993). A minority has always worked in other ways (e.g. Jahoda and Zeisel, 1933/1972).

It might appear paradoxical that clinical psychology has so often ignored a societal perspective, given its location in and dependence on a socialised health and welfare system. However, the National Health Service, like the welfare state has always been a contradictory institution, concerned more with treating individual pathologies than creating and nurturing a healthy population. The last (Conservative) government promoted individual responsibilities for all aspects of health and ill-health, even hiding research that revealed the link between social and economic inequality and inequalities in health (e.g. The Black Report, Townsend et al 1988). For the first time in 20 years there is a Government that explicitly links health with poverty and other social and socio-economic factors, whatever may be thought about its practice.

Clinical Psychology training.

The authors both trained some 20 years ago. Then, there was little if any content that linked individual and societal factors, despite a context that included among other things the "crisis in social psychology" (Armistead, 1974; see Parker, 1989), the then recent exposure of fraudulent research on heredity and IQ (Kamin, 1974), the beginnings of a critical psychology (Ingleby, 1970; Adlam et al.1977), and the emergence of the user/survivors movements. An exception may have been work with people who were learning disabled, where even prior to the influence of normalisation/ social role theory (see Gathercole, 2000) some elements of practice involved an explicit identification of extra-individual factors.

By November 1995, however, the British Psychological Society body that specifies the content and method of training in clinical psychology had caught up! Clinical Psychology training courses are governed by the Committee on Training in Clinical Psychology (CTCP), which is responsible to the Membership and Qualifications Board of the BPS. The CTCP issues Criteria for the Accreditation of Post Graduate Courses in Clinical Psychology, statements that specify the content and method of training. The most recent revision of these was in December 1995. One of the changes was the introduction of a new section 8.12 which stated,

Moreover, the introduction to the document stated that courses

The clear indication is that training courses should include teaching on issues, which locate individuals in a societal context. It is unclear to what extent this happens. The authors` impression is that there is a widely varying picture across training courses and that in attending to section 8.12 there may be more emphasis on gender than on the other factors. This may be an accurate reflection of current academic research concerns and (without us wanting to minimise the importance of gender as a basis for social inequality), an implicit denial of the importance of class.

The introduction of a module of teaching that aimed to explicitly cover some of the issues identified at the beginning of this paper came about through a conjunction of interested parties, and a course that was willing to make changes in order to increase the breadth and quality of its training. The Course had existing teaching on race and cultural issues, as well as gender (amounting to 25 hours over 3 years), and care was taken to minimise overlap between these different modules.

The module was first taught to the first year of the 1997 intake and has now been completed, having been introduced to successive intakes.

The course content reflects the authors interests in social and critical theory, its relation to psychology, and to a practical and action orientation. Concepts tend to be critical realist (there is a social reality, but experiencing and knowing it are socially constructed) rather than postmodernist, and social psychological rather than psychodynamic. Different teachers might handle the course differently.

The module consists of 8 hours of teaching across the 3 years of training and is composed of the following sessions:

Examples of references are included. More extensive lists of references for these sessions are available from the authors.

(1) Year 1, Term 1 Social Inequalities and their links with Health and

(2 hours) Mental Health

Teaching focuses on importance of social inequalities in any serious consideration of health and mental health. Data about social inequalities are reviewed and trainees are orientated towards the social and economic factors influencing populations in the Greater Manchester area. Consideration is given as to why social factors should be included in psychological formulation, and why this may not be considered important in the history of psychology. Questions are asked concerning whether such links remain "hidden" and if so why. The role these factors play in assessment and formulation within clinical psychology models is reflected on.

Exercises ask trainees to consider the links between socio-economic circumstances and psychological distress, and then to describe the processes that may be involved in this linkage. Emphasis is placed on a consideration of the resources available to individuals for engaging in change. Psycho-social stress is considered using historical and current examples, and consideration is given to the role of mediating factors between social inequality and psychological health. A model of psycho-social stress is examined.

Key references include: Brown and Harris (1978), Hutchings (1993), Smail (1993), Townsend, et al. (1988), and Wilkinson (1996).

(2) Year 1, Term 2 Conceptualising the individual and society. (2 hours

This draws on social theory especially Bhaskar (1979), and on Leonard s (1984) attempt to build a theory of the societal construction of the individual. The unit follows the adult mental health placement, and Leonard s approach is used to attempt a "societal case formulation" that considers the person as constructed through their social relations, past and present. Key questions developed /asked include (1) How do we define `the individual` and `society`? (2) What are some of the ways in which the relationship between the individual and society can be formulated? (3) What concepts are helpful in understanding the individual-society relationship? (4) How can scrutinising the factors that describe an individual`s relationship to society enhance our clinical practice?

Other texts include Burton and Kagan (1994), Danziger, (1994), Luria (1976) and Williams (1976).

(3) Year 2, Term 4 An alternative: Community Psychology: what it is and what it isn t (2 hours)

2. Community psychology (e.g. Sarason, 1974) that takes the community rather than the individual as its unit of analysis, is presented as a counter to individualistic models of psychological thinking and practice. The main stages in the development of Community Psychology are examined.

Descriptions and developments in the field are presented, together with British and overseas examples of theory and practice (Holland, 1992; Orford, 1992, 1998; Rappaport, 1977; Smail, 1994; Thomas and Veno, 1992; Prilleltensky and Nelson, 1997, Kagan, 2000). The origins of Community Psychology are outlined with specific reference to its distinctive features. Trainees are given an example of community psychology practice and asked (i) if the activity is legitimate for a clinical psychologist, (ii) if, and in what ways, the practice described differs from that they are familiar with, and (iii) what is the focus of the activity in the example. Another exercise uses case material and asks trainees to identify the differences between community and clinical psychology and to design an intervention within the perspective of community psychology.

(4) Year 3, Term 8 Working with marginalised people. (3 hours)

This session draws on the experience of social marginalisation, and how it can be understood both in terms of social determinants and psychological responses. The teaching considers the nature of social marginalisation in relation to Clinical Psychology practice and goes on to explore ways of engaging with social marginalisation in clinical work. Trainees explore the definition of social marginalisation and consider its influence with respect to examples of clinical practice with people from different client groups. Work by Freire (e.g. 1974, 1994) and liberation psychologists (e.g. Martín-Baró, 1983, 1989, 1994; Blanco, 1993) is used as a framework.

The teaching attempts to draw together issues explored in the previous 3 sessions of this teaching module. It is hoped that trainees will identify strategies that could be incorporated into their future professional work. The session starts by reviewing the previous teaching in the module and highlights some of the objective factors relevant to working (post qualification) in the north-west of England, before exploring the concept of marginalisation. Exercises ask trainees to explore how their practice may have increased clients` empowerment

Generally, and, using case material, participants are encouraged to identify the psychological effects of disadvantage and marginalisation.

All teaching for the Manchester Course is reviewed in two ways. First, each trainee is requested to complete a feedback form on every teaching session. These forms, currently under review, are sent to the relevant teaching module organiser who gives feedback to the teacher concerned. Second, there is a review meeting at the end of each term where all trainees in a particular year discuss the term s teaching with the Curriculum Co-ordinator and the Programme Director.

The feedback about this teaching has been variable.

Leaving aside inevitable criticisms of a new course under development, we have been struck by an apparent contradiction. Students have welcomed the existence of input on the real social issues such as poverty, powerlessness, or discrimination that they see in the lives of those they meet in practical work. Yet they often seem to want short cuts; "what techniques should we use with marginalised people?" For students studying at a doctoral level we find this surprising, as we find the question" will we get examined on these references?"! Our view is that issues such as social marginalisation have to be understood, both theoretically and through lived experience where those who are marginalised are also teachers. Interventions have to be generated through application of the craft of psychology with this understanding, in active interaction. That is not so different from some models of so-called clinical practice, yet the confidence to work in this way may be lacking.

Other problems are that " The teaching is not psychological enough". Here we are confronted with a dominant definition of what psychology is, a definition that is highly individualistic. Students who have striven hard to be accepted and socialised as clinical psychologists may be reluctant to break out of the boundaries and roles that they have adopted. Examples of this include the difficulty students can have in relinquishing a pathological conceptualisation (cf. Goldiamond, 1974) when considering the circumstances of people who are shaped by social circumstances, and who also resist those circumstances, trying to transform them. However some of this difficulty is shared by the discipline itself.

"The teaching is too conceptual". This was a problem with session 2 in particular, and to some extent has been met through the "societal case formulation" exercise. Time is a problem, where theoretical concepts (e.g. ideological interpellation (Therborn, 1978; Leonard, 1984) have to be introduced that may not be familiar. Sometimes the gaps are more surprising, for example a lack of familiarity with concepts of action research. This can mean students have few familiar landmarks when they encounter our teaching.

Nevertheless, the sessions do seem to address a need. As we develop the teaching we are getting better at engaging with students experience of social issues, and offering some tools for understanding and acting on this neglected dimension.

From our perspective these comments have been very important. While recognising that attention needs to be paid to teaching style etc., we think that other issues may underlie some of the problematic reception of this teaching.

1. The content may not fit with some trainees experience / identity.
2. There may be a lack of fit with placement experience.
3. Are the links to practice made explicit?
4. Is there a tension within the doctoral qualification between on the one hand, gaining knowledge and practical skills and on the other, developing reflective abilities and thinking in different ways

How effective has the teaching been? This is difficult to answer. It may be even more difficult to assess directly in the short term and evidence of a broad approach to conceptualisation of human distress and resulting actions may not be visible until later as individuals develop their own theoretical and therapeutic practice.

The Manchester course requires trainees to submit 5 written reports describing clinical activity. One of the 10 assessment criteria for these is the

presence and integration into the report of social context. It is hoped that the teaching aids in the development of a social analysis of psychological distress described and helps trainees to report their activity in a way that meets this particular criterion.

We would welcome a discussion about any of the points contained in this article. The teaching described here is one possibility; we recognise there are others. In particular we note that although exercises, the use of case material, explorations and dialogue are employed, much of the teaching described, until this year has been didactic in mode, and that other methods are likely to be better.

It is immediately obvious that the teaching of these issues as a separate module may act against the integration of the content into the teaching content as a whole. This issue may also be relevant to the more extensive teaching on the Course about `Race`, Culture and Gender issues, although in this case explicit attempts have been made to develop teaching throughout the Course that includes consideration of these issues to complement the specific teaching. One consideration could be to integrate that module more with the one discussed in this paper.

Moreover, we would welcome discussion about the nature of this project of introducing societal thinking into clinical psychology training, theory, and practice: is it possible to do this, or is the discipline so irrevocably rooted in an individualistic ideology that this is a waste of time?

It has been reported elsewhere (e.g. Burton and Kagan, 2001; Kagan and Burton, 2001) that alternatives to the dominant, individualistic outlook of psychology are relatively weaker in the UK than elsewhere in the world where other influences are more rooted.

Various explanations for this have been advanced. It is noticeable that some of the current (written in March 2001) government s initiatives for health give space and legitimacy to a practice in which clinical psychology could be firmly linked to social engagement, community action and critical practice.

Clearly there is a link between the training of new psychologists and dominant professional practice. It remains to be seen whether training that includes elements of more critical alternative thinking that encourages consideration of alternative practice will contribute to the development of different practice in the future. It is also interesting to consider how such training fits into the dominant ethos ( Newnes et al, 2000).

This article cannot do more than raise these questions for further analysis and debate.

The authors can be contacted by e-mail at the following addresses:

Adlam, D., Henriques, J., Rose, N., Salfield, A., Venn, C. and Walkerdine, V.(1977) Psychology, ideology and the human subject. Ideology and Consciousness,1,5-56.

Armistead, N. (Ed.) (1974) Reconstructing Social Psychology. Harmondsworth: Penguin.

Bhaskar, R. (1979) On the possibility of social scientific knowledge and the limits of naturalism. Journal for the Theory of Social Behaviour, 8.

Blanco, A (1993) El desde dónde y el desde quién: una aproximación a la obra de Ignacio Martín Baró. Comportamiento 2, (2), 35-60.

Brecht, B. (1976) A Worker's speech to a doctor. In B. Brecht. Poems 1913-1956. London: Eyre Methuen.

Brown, G. and Harris, T. (1978) Social origins of Depression. London: Tavistock

Burton, M. and Kagan, C. (1994) The verbal community and the societal construction of consciousness. Behaviour and Social Issues, 4, 87-96.

Burton, M. and Kagan, C. (2001) Community Psychology: Why this gap in Britain. Paper presented to British Psychological Society Conference: Glasgow, March, 2001 (available at http://homepages.poptel.org.uk/mark.burton/index.htm).

Danziger, K. (1994) Constructing the Subject: Historical origins of psychological research. Cambridge: Cambridge University Press.

Freire, P (1974) Pedagogy of the oppressed. Harmondsworth: Penguin.

Freire, P. (1994). Pedagogy of Hope: Reliving Pedagogy of the Oppressed. New York: Continuum

Gathercole, C. E. (2000) Learning Disability Services in the North-West of England, 1978-1998. Clinical Psychology Forum, 146, 11-17.

Goldiamond, I. (1974) Toward a constructional approach to social problems: Ethical and constitutional issues raised by applied behavior analysis. Behaviorism 2, 1-84.

Goldstein, A. P. (1973) Structured learning: towards a psychotherapy for the poor. New York: Academic Press.

Holland, S. (1992) From social abuse to social action: a neighbourhood psychotherapy and social action project for women. In J. M. Ussher and P. Nicholson (eds.) Gender issues in Clinical Psychology. London: Routledge.

Hutchings, J. (1993) Unemployment, mental health, and clinical psychology. Clinical Psychology Forum, 52, 4-8.

Ingleby, D. (1981) Critical Psychology: the politics of mental health. Harmondsworth: Penguin.

Jahoda, M. and Zeisel, H (1933/1972) Die Arbeitslosen von Marienthal (The Unemployed in Marienthal). Leipzig. Translation published as: The Sociography of an Unemployed Community. London: Tavistock Publications, 1972

Kagan, C. (Ed.) (2000) Collective Action and Social Change Manchester, IOD Research Group

Kamin, L. J. (1977) The science and Politics of IQ. Harmondsworth: Penguin.

Leonard, P. (1984) Personality and Ideology: Towards a materialist understanding of the individual. London: Macmillan.

Llewelyn, S. and Kelly, J. (1980) Individualism in psychology: A case for a new paradigm? Bulletin of the British Psychological Society, 33, 407-411.

Luria, A. R. (1976) Cognitive development: its cultural and social foundations. Cambridge, Massachusetts; Harvard University Press.

Martín-Baró, I. (1983): Acción e Ideología: Psicología social desde Centroamérica I San Salvador, UCA Editores.

Martín-Baró, I. (1989) Sistema, Grupo y Poder: Psicología social desde Centroamérica II. San Salvador, UCA Editores.

Martín-Baró, I. (1996) Readings for a Liberation Psychology. New York: Harvard University Press.

Newnes, C., Hagan, T. and Cox, R. (2000) Fostering critical reflection in psychological practice. Clinical Psychology Forum, 139, 21-24.

Orford, J. (1992) Community Psychology: Theory and Practice. Chichester: Wiley.

Orford, J. (1998) Have we a theory of Community Psychology? Clinical Psychology Forum, 122, 6-10

Parker, I. (1989) The Crisis in Modern Social Psychology and how to end it. London: Routledge.

Prilleltensky, I. and Nelson, G. (1997) Community Psychology: Reclaiming social justice. in D. Fox, and I. Prilleltensky (eds.) Critical Psychology: An introduction. London: Sage.

Rappaport, J. (1977) Community Psychology. New York: Holt, Rinehart and Winston.

Sarason, S.B. (1974) The Psychological Sense of Community: Perspectives for Community Psychology. San Francisco: Jossey-Bass.

Smail, D. (1994) Community politics and psychology. Journal of Community and Applied Social Psychology, 4, 11-14.

Smail, D. (1993) The origins of unhappiness. London: Harper.

Therborn, G. (1978 ) What Does the Ruling Class Do When It Rules? State apparatuses and state power under feudalism, capitalism and socialism. London: NLB.

Thomas, D. R. and Veno, A. (eds.) (1992) Psychology and social change: creating an International agenda. Palmerston North, New Zealand: Dunmore Press.

Townsend, P. et al (eds.) (1988) Inequalities in health: the Black Report and The Health Divide. Harmondsworth, Penguin.

Wilkinson, R.G. (1996) Unhealthy societies. The afflictions of inequality. London: Routledge.

Williams, R. (1976) Keywords: A vocabulary of culture and society. Glasgow: Fontana.