Forced Compliance in NHS: The dumbing down of thoughtfulness

by Bruce Scott on July 4, 2011

From job description of an NHS Trainee Child Psychotherapist post.

To take an evidence-based approach and show preparedness to collaborate with outcome measurement and generally comply with clinical and social care governance requirements.To present reports and research to a high clinical and academic standard.”

I was horrified to read the job description for the post of an NHS Trainee Child Psychotherapist quoted above. This short extract shows how certain paradigms in the NHS are being pushed in favour of others (i.e., evidence based, psycho-medico-scientific over the rest). To favour an approach is all fine and well, but the last sentence in advert

To present reports and research to a high clinical and academic standard.”

contradicts the demand in the previous sentence for having a

“…..preparedness to collaborate with outcome measurements and generally comply with clinical and social governance”…(and I take it this means NICE).

Why? Well to present reports to a high clinical and academic standard necessitates more than mere compliance and collaboration with the notions of evidence based practice and outcome measures. If the poor trainee is truly going to measure up to a high clinical and academic standard, they would have to take a very critical scientific stance to evidence based paradigms, outcome measurements and NICE clinical governance. The recent NICE guidelines on depression are a case in point where the consultation exercise that went to make up this document, clearly dismissed strong and valid critiques by Professor David Healy of the proposed NICE anti-depressant medication guidelines and dismissed others (i.e., psychologists and psychotherapists) critiquing the effectiveness of cognitive-behavioural therapy and the relative absence and appraisal of other forms of psychotherapy from the NICE guidelines; the recent closure of many counselling practices in GP surgeries in favour of IAPT is an example of this. My point is blind compliance and collaboration with a branch of thought is contra to an objective scientific stance, which surely trainee NHS therapists would learn as part of their academic training?

What would happen if the poor trainee wrote a report criticising the evidence based paradigms in psychology/psychotherapy-which is acceptable from a high academic standard? What if the trainee quoted research that showed the poor reliability/validity of outcome measures and how from certain philosophical perspectives the notion of outcome measures was a short sighted and a reductive way of thinking about human distress. What if the trainee criticised the NICE guidelines for ADHD, depression, or anxiety? Would they be disciplined by not complying and collaborating?

In short, the evidence based and outcome measurement based paradigms are not perfect, subject to much criticism and there are other ways of thinking about psychotherapy and working with people in mental distress. So why demand compliance and collaboration on the one hand and ask for a high clinical and academic standard on the other. This all just smacks of the Double-Bind that RD Laing talks about in his book the Divided Self.

To quote the mantra of the Health Professions Council (HPC) and those in favour of regulation along the lines of an HPC and/or evidence based approach, “protection of the public” is at stake here. Surly it is in the public’s interest to have practitioners that are able to be, questioning and critical of paradigms, go beyond them if necessary and not to be constrained by them? Surly, trainee child psychotherapists are members of the public who should not have certain ways of thinking outlawed by arbitrary and dogmatic ideas of how to treat patients, but then be given mystifying advice or demands to be academic and scientific? Is this not harmful?

This job advert shows quite clearly that certain ways of thinking are being cultured in to the NHS, while others are being cultured out. The subtle wording of this advert may pass many by without much thought, but in those three short lines, something terrible is occurring.

The terrible has already happened as Martin Heidegger wrote. It has, he was right. It is in this advert. It is also being played out in the Health Professions Council fitness to practice hearings. Psychologists are being named and shamed, punished and chastised for critiquing the Diagnostic and Statistical Manual of Mental Disorders (DSM). They are being taken to the gallows for using one psychometric questionnaire over another or using a part of a psychometric questionnaire while leaving the rest of it; there are grumblings of discontent within the Educational Psychologists fraternity. Psychometrics and the DSM are not an exact science. There is much leeway and disagreement about the DSM and reliability and validity of psychometric measures. There is also much disagreement and there are many flaws in the evidence based approach, but to demand compliance and collaboration and then to demand to be academic and scientific ……

I am speechless. The terrible is occurring.