Chapter 2 explores the rise of the English Improving Access to Psychological Therapies (IAPT) programme. This flagship initiative aimed at doing exactly what its titles suggests, and has drawn international acclaim – alongside critique and concern. In attending to its underpinnings, I highlight the managerial and clinical trends IAPT drew from and extended to proliferate therapy at scale. I examine how features of IAPT understood to be novel came to be regarded as vital forms of infrastructure around which other psychological services should be built. I also illustrate how the economic logics that underpinned IAPT initially resulted in particular kinds of therapy being rolled out for certain types of conditions experienced by specific groups; most notably, CBT for anxiety and depression diagnosed in adults of working age. The chapter reflects on the ramifications of IAPT, including in relation to the understandings of the nature of ill-health that result from it.

In Chapter 1, I demonstrate how professional claims-making operates as a form of boundary work that both configures and is configured by the evolving identity of clinical psychology. The keenness of many in the field to position it as different from psychiatry is illuminated, with the ‘diagnostic’ approach deemed particularly problematic by many leading clinical psychologists. Likewise, I spotlight how some in clinical psychology also labour to differentiate it from other psychological traditions (like counselling psychology and health psychology). This includes through the development of a professional body solely for clinical psychologists: the Association of Clinical Psychologists UK (ACP-UK). Ultimately, these forms of boundary-work help to configure the nature and practices of clinical psychology. Accordingly, they also have implications for the values and perspectives of individual therapists, and the kinds of care that patients are (not) able to access.

The purpose of this chapter is to analyse bioprecarity in terms of two dimensions of Foucault’s biopolitics, categorization and subjectivization (Foucault, 1977, 1982, 2002, 2008). With examples of the precarious lives of trans people, especially those of colour, I engage with the conceptual arguments of Foucault, Judith Butler (1997, 2009) and Kimberlé Crenshaw (1991) regarding the relation between categorical framing and bioprecarity. The chapter explores how subjects as bodily selves are bound into population control and therefore normalized and regulated (Spade, 2011), how norms and regulations create bioprecarious situations for these bodily selves (Butler and Athanasiou, 2013), the role of intersectionality (Crenshaw, 1991) in creating such precarious positions and, finally, how such bioprecarity might be avoided (Lorey, 2010; Shotwell, 2016; Weheliye, 2014).

Chapter 4 analyses how clinical psychologists preface (potential) care through negotiations of referrals and acts of assessment prior to any kind of therapy. I regard these as key ‘uncertainty moments’ in which practitioners must decide whether to see a patient for therapy. This decision-making process depends on far more than an ‘objective’ evaluation of the patient in front of them. Resolution of uncertainty entails the reciprocal configuration of at least three kinds of ontologies: the ontology of a potential patient, the ontology of the service in which they work, and the ontology of their profession. These are not necessarily stable; rather, they can be remade over time and in relation to particular service users (demonstrating how visions and adjudications of therapeutic need are highly contextualised). Such ‘prefacing practices’ contribute to the denial of access for some patients, although even exclusions might themselves sometimes be accounted for by professionals as forms of care.

This chapter centres on circumcised women’s experiences of bioprecarity in the context of seeking clitoral reconstructive surgery in Sweden. Female genital cutting (FGC), significant in marking the mature, desirable and marriageable woman in some cultures (Johansen, 2017), is today a significant phenomenon in Europe due to recent migration patterns (van Baelen et al., 2016). Transcultural migration and societal changes create new perceptions of the body, self and identity. At the same time, new notions of bodily rights, what is perceived as legitimate claims and needs and advances in biotechnology have enabled circumcised women in some European countries to have their clitoris reconstructed (Foldés et al., 2012). Based on original empirical data in the form of interviews with FGC-affected women, this chapter seeks to investigate how migrant women who have undergone FGC perceive their bodies and selves, how they construct and negotiate their identity within new social structures and gender norms and how they understand clitoral reconstructive surgery after FGC, in the Swedish context.

Paediatric heart surgery missions define an emergent, high-tech form of medical humanitarianism characterized by their focus not on populations in crisis, but on broken body parts – in this case, damaged paediatric hearts. Comprised of specialists from the world’s most elite medical centres, mission teams make visits to poor countries to perform highly specialized and otherwise prohibitively expensive surgical procedures on children with few alternatives for survival. A team’s success is measured in terms of patient volume, surgical complexity and the probability of the patient being well enough to leave the hospital within thirty days. This chapter explores the forms of bioprecarity that both precede and follow mission visits and that inadvertently affect the very patients whose surgeries are publicly billed as ‘successes’. As much as surgical missions aim to repair paediatric bodies in distress, they, too, produce new anxieties, uncertainties and biological vulnerabilities for patients and their families that are often visible only long after missions depart from the host country. These findings emerged from thirteen months of ethnographic fieldwork carried out in Honduras, where I carried out observations and interviews in public hospitals before, during, and after visits by paediatric heart surgery missions and in the homes of surgical patients.

In this Introduction, I sketch out the rise of a transnational ethic of access to treatments for ill-health, and how it configures and is configured by mental healthcare in the UK. The instantiation of this ethic has resulted in policy and clinical attention to enhancing access to psychological therapy (often cognitive behavioural therapy, CBT, specifically). I introduce the importance of clinical psychology within this context and chart its consolidation as a profession, alongside a discussion of the role of CBT within the UK. I also discuss the wider entanglements of psychological praxis and societies, and the theoretical perspectives that propel the analysis presented in this book. I conclude with outlining the various chapters that follow.

This chapter elaborates the notion of bioprecarity as it is utilized in this volume by drawing on three theoretical concepts that have not been ‘thought together’ before. They are intimate labour, as discussed in Boris and Salazar Parreñas’ (2010) work; bios, as understood in Michel Foucault’s (2008) writings; and precarity, as originally developed in France in the 1970s, then taken up by Judith Butler (2004) in the context of war, terrorism, survival and ‘grievable’ lives and popularized in the relation to new forms of labour by Guy Standing (2011). The chapter develops these three concepts in the context of bodily interventions prompted by opportunities for bodily labour, meaning labour on and with the body, in order to investigate bioprecarity, a new form of vulnerability that is associated with providing and seeking intimate bodily labour in cross-cultural contexts.

This second empirical chapter describes the production of data from the wood samples generated during fieldwork, which consisted of attributing the precise calendar year of formation to each annual layer of wood grown by the tree (a ‘tree-ring’) in a process called ‘dendrochronology’. The main body of the chapter describes the work of creating an 800-year-long tree-ring chronology for Scotland. I show that the scientists studied were able to generate a tree-ring chronology that peers could accept as carefully dated by initially accepting a traditional belief and practice in dendrochronology (the so-called ‘principle of crossdating’) and then critically examining the applicability of this dogma to the Scottish context. This conclusion speaks to public discussions about the existence of ‘group-thinking’, ‘tribalism’ and dogmatism in climate science. In response to those who (mis)judge climate scientists against the ideal of science as a form of radical doubt, I argue for the positive function of trust, tradition and dogma in science.