Health psychology – a profession misunderstood?

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'.