A whole range of ideas, practices, and institutions intersect and reciprocally shape one another to give life to the psychological. The overarching discipline of psychology itself, with all its constituent traditions (including clinical psychology), is of course key among these. Significant too, though, are fields such as psychiatry, counselling, social work, and education. These and much more – everyday notions, actions, and relations – form what Nikolas Rose (Reference Rose1985) has called the psychological complex. Attending to how clinical psychology is configured with respect to its close neighbours within this multifaceted and dynamic matrix offers insight into how its practitioners conceive of themselves. This production of professional identities, in turn, has ramifications for the people with whom psychologists work. Disciplinary claims making and straightforward politicking contour the psychological complex, informing the kinds of knowledge and expertise through which subjects are known about, acted upon, and configured through.

As we saw in the Introduction, the role of the clinical psychologist in the United Kingdom over the last 70 years or so has shifted from that of a psychometrician embedded in psychiatric contexts to being an autonomous therapeutic practitioner and authoritative figure within the mental health ecosystem. In considering this change, it is important to underscore that – as practitioners themselves have argued – clinical psychology ‘cannot be understood in isolation’ (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004, p. 5). Accordingly, this chapter explores how the profession engages in what sociologists term ‘boundary work’ (Gieryn, Reference Gieryn1983) in relation to other psychological specialisms and psy-professions. How, for example, are boundaries drawn between the nature, remit, and function of clinical psychologists vis-à-vis these other experts (Goldie, Reference Goldie, Stacey, Reid, Heath and Dingwall1977; cf. Buchanan, Reference Buchanan2003; Schlett, Reference Schlett2022; Scull, Reference Scull2015)? Assuming this boundary drawing can be read as a form of ‘occupational identity work’ (Allen, Reference Allen2000, p. 345; Snow and Anderson, Reference Snow and Anderson1987), what kinds of claims about and understandings of clinical psychology emerge in the process?

Boundary work is a strategy for generating and controlling status and resource (Lamont and Molnár, Reference Lamont and Molnár2002), including through the modulation of relative prestige inside a broader professional milieu where this has economic connotations (Burri, Reference Burri2008; Comeau-Vallée and Langley, Reference Comeau-Vallée and Langley2020). Within healthcare, both inter- and intra-professional boundaries serve important roles in the configuration of specialities and practices (Goodwin et al., Reference Goodwin, Pope, Mort and Smith2005; Jenkins, Reference Jenkins2020; Lindberg et al., Reference Lindberg, Walter and Raviola2017; Martin et al., Reference Martin, Currie and Finn2009; Nancarrow and Borthwick, Reference Nancarrow and Borthwick2005). In what follows, my focus is, primarily, on the relationship between clinical psychology and psychiatry – one that was vital to the consolidation of clinical psychology and which remains significant (Derksen, Reference Derksen2000; Hall, Reference Hall, Hall, Pilgrim and Turpin2015). I attend especially to the discursive configuring of psychiatry by clinical psychology, and how this acts to demarcate the disciplines and to underscore the singularity of the latter. Towards the end of the chapter, I then move to reflect on how clinical psychology navigates boundaries between, and asserts its distinctiveness and autonomy in relation to, other psychological professions in the NHS – focusing on health, as well as counselling, psychology. This is in light of both long-standing and recent ‘jurisdictional disputes’ (Abbott, Reference Abbott1988, p. 74) between these psychological professions and clinical psychology, and various attempts to manage these by the British Psychological Society (BPS). By examining how clinical psychology positions itself in relation to other disciplines, a brighter light can be cast on how professional identities, discourses, and practices are reciprocally configured.

Clinical Psychology and Psychiatry

These comments were made by the influential psychologist Hans Eysenck in an article outlining ‘The Function and Training of the Clinical Psychologist’. Eysenck (Reference Eysenck1950) asserted that the Maudsley clinical psychology training course (discussed in the Introduction) sought ‘to facilitate such a rapprochement’ (p. 714) between clinical psychology and psychiatry. More than 70 years later, the kind of mutually beneficial relationship between disciplines outlined in the section-opening quote seems, more or less, to have developed. The professions work closely together within mental health services, as well as often within universities. However, there have been many bumps along the way as clinical psychology and psychiatry have sometimes moved apart yet remained connected (Burns and Hall, Reference Burns, Hall, Ikkos and Bouras2021; Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004; Samson, Reference Samson1995). Today, flare-ups between them remain not altogether uncommon, and within the literature and especially on social media those sometimes burn brightly.

Before examining some of those tensions, I want to step back for a moment to consider some of the salient (dis)similarities between clinical psychology and psychiatry. Within popular culture, distinctions between these professions can often be elided: the terms ‘psychological’ and ‘psychiatrist’ – not to mention ‘therapist’ and even ‘shrink’ – are sometimes used synonymously. Boundaries can inadvertently be further blurred by practitioners themselves: some psychiatrists are consultants in medical psychotherapy, for which they have received advanced training in psychological treatments (Royal College of Psychiatrists, 2019). Certainly, both professions are orientated towards intervening in psychological distress. The stated and enacted differences between them are important, however (Abbott, Reference Abbott1988).

In the United Kingdom, prospective clinical psychologists must study for a Doctorate in Clinical Psychology (DClinPsy). This is achieved through a combination of teaching, research, and therapeutic provision. Applicants for doctorate programmes are commonly only successful after some years working as an assistant psychologist or in a similar role, usually within the NHS (following undergraduate training in psychology and often an MSc degree as well). For their part, psychiatrists are, by definition, medically qualified. After a degree in medicine, further training is then undertaken in psychiatry. Following examination, this eventually leads to membership and then later perhaps fellowship of the Royal College of Psychiatrists. As medical practitioners, psychiatrists can legally prescribe pharmaceuticals; clinical psychologists cannot. They also tend to be more diagnostically orientated than clinical psychologists. Nevertheless, the differences between professions with respect to diagnosis can sometimes be overstated, and – as we will see – also deployed to underscore the distinctiveness of clinical psychology.

Prescribing is a useful starting point to think about the discursive boundary work that helps to configure clinical psychology. Perhaps unsurprisingly, debates about whether psychologists should have some kind of prescribing rights occasionally foment. The legal authority to prescribe would bring clinical psychology in line with other key health professions, such as nursing. However, opinion on this matter varies greatly (BPS, 2020; Cohen-Tovée, Reference Cohen-Tovée2020). Rebecca Courtney-Walker, Chair of a BPS Group charged with considering this issue, reflected during her work that the question of prescribing rights for psychologists has long ‘been a controversial topic with strong views on both sides of the debate’ (Courtney-Walker, Reference Courtney-Walker2019, p. 2). Responses to a 2019 consultation with psychologists about prescribing ‘showed’, in her view, ‘considerable passion’ (Courtney-Walker, Reference Courtney-Walker2020, p. 3). Some judged prescribing rights as representing an opportunity for ‘evolution’ – ‘especially as other professions have evolved and now routinely practice as psychological therapists, which was previously one of our unique selling points’ (Courtney-Walker, Reference Courtney-Walker2020, p. 3). Concerns were raised by other respondents, though, ‘that prescribing rights would mean psychologists may become more medicalised, posing a potential threat to their identity and practice as a profession’ (Courtney-Walker, Reference Courtney-Walker2020, p. 2).

Alison Clarke, then Chair of BPS Practice Board, noted in 2020 that the diverging views about prescribing rights suggest ‘the need for a wider debate about the future shape of our profession and what our trajectory towards that future may look like’ (Clarke, Reference Clarke2020, p. 4). As Courtney-Walker’s summary of consultation responses indicated, this is because negotiating a consensus on prescribing rights also involves negotiating what psychology is and what it should be doing. Discussions around pharmaceuticals are particularly volatile in this respect, since debates about their potential or proper roles within clinical psychology invite – and for some, even many, demand – deep reflection on what their use implies for how the profession conceptualises the ontology of psychological distress. If clinical psychologists are to prescribe the same drugs as psychiatrists, for example, does it mean that they must regard the targets of that intervention in the same way? Should clinical psychologists be urged to think more like psychiatrists?

This question speaks to a bigger concern within clinical psychology about what many practitioners see as the quintessentially biomedical epistemology shaping psychiatric thought and treatment. Unease about, critique of, and explicit opposition to this has been increasingly evident within a range of reports and commentaries over the past decade or so. This includes a high-profile BPS report produced by the Division of Clinical Psychology (DCP) and led by Anne Cook, titled Understanding Psychosis and Schizophrenia. In it the authors write that there is a ‘need to shift from seeing ourselves as treating disease to seeing ourselves as providing skilled help and support to people who are experiencing understandable distress’ (BPS DCP, 2017, p. 102). Accordingly, clinicians ‘need to move beyond the “medical model”’ (BPS DCP, 2017, p. 103). It seems likely that for the authors of this report, the answer to the question ‘Should clinical psychologists be urged to think more like psychiatrists?’ is a ‘no’ – as it is for a significant number of others as well.

We can see, then, that while clinical psychology and psychiatry can have broadly similar professional foci, the former can express considerable unease about mimesis with the latter. This is both despite and because of what Eysenck (Reference Eysenck1950, p. 714) referred to as the ‘inseparable destinies’ of these professions: what happens to one has implications for the other. Professional tensions between psychiatry and clinical psychology can at times be deeply felt. These can reflect much deeper ontological and epistemological disjunctures that through their proclamation and rehearsal come to be further enacted and more deeply entrenched.

Diagnosis and the ‘Medical Model’

Clinical psychologists critical of medical approaches to mental healthcare sometimes posit that their profession works with a fundamentally different ontology of distress compared with ostensibly diagnostically orientated psychiatry. For these psychologists – and, it should be noted, quite a few psychiatrists – the complexities of subjective experience escape straightforward categorisation through diagnostic terms such as bipolar disorder or schizophrenia. Indeed, two of the authors of the aforementioned Understanding Psychosis and Schizophrenia report have argued that ‘psychiatric diagnosis has the potential to be particularly damaging’ when deployed in relation to experiences associated with psychosis (Cooke and Kinderman, Reference Cooke and Kinderman2018, p. 47). Such comments articulate with other statements around diagnosis in outputs from the BPS, and especially the DCP, in recent years. These assertions have occasionally been to the chagrin of some clinical psychologists who judge them to be made as part of intellectual debates and professional turf wars in which they profess varying degrees of disinterest.

Clinical psychologists who position themselves against biomedical – or, more specifically, diagnostic or pharmaceutical – approaches to mental health have held powerful roles within the BPS. Although many BPS documents suggest that psychologists should not be “anti” diagnosis in any straightforward way, these figures have helped to inflect wider debate within the Society and the profession. Peter Kinderman, for instance, is a professor at the University of Liverpool who has held a range of BPS leadership roles, not least BPS President (2016–2017) and, for two terms, DCP Chair (2004–2005 and 2010–2011). He is also the author of a range of texts critical, to varying degrees, of biomedical approaches to mental health, including the books A Prescription for Psychiatry (2014) and A Manifesto for Mental Health (2019). For Kinderman, ‘diagnoses are often unreliable, invalid and separate inappropriately the person from their experiences’ (Kinderman, Reference Kinderman2015, p. 156).

Other high-profile clinical psychologists, such as Richard Bentall (Reference Bentall2009) and Mary Boyle (Reference Berrios1997), have also written critically, and sometimes for a wide audience, about psychiatry, psychiatric diagnosis, and pharmaceuticals. Probably one of the best-known critics in clinical psychology of psychiatric diagnosis is Lucy Johnstone, a senior practitioner in Bristol. She is a key contributor to, and occasionally an architect of, a variety of highly visible BPS policy statements and guidance (including some described later here). In a range of writings, such as her monograph, Users and Abusers of Psychiatry (Johnstone, Reference Johnstone2021), she has set out clearly and powerfully the harms that can result in the adoption of a disease-focussed conception of subjective distress. Johnstone has sought to actively further the separation of clinical psychology from diagnostically orientated approaches to mental health. In her view, ‘We are close to recognising the traditional psychiatric model of “mental illness” for the failed paradigm that it is’ (Johnstone, Reference Johnstone2016, p. 732).

Beyond Diagnosis

A particular focus of psychological critique has been the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (the DSM). This is widely judged to be emblematic of a diagnostic approach to psychiatry with which many in clinical psychology take issue. The fifth edition of the DSM, the DSM-5, was released in 2013. Over the course of its writing, and immediately following its release, there was a proliferation of critical discourse centred upon this text (Kinderman et al., Reference Kinderman2017). As we will see, this critique was a key feature of the boundary work that informed the positioning of clinical psychological within the psychological complex.

Prior to its release in 2013, the BPS, among others (Kamens et al., Reference Kamens, Elkins and Robbins2017), wrote to the American Psychiatric Association to express concern that by classifying ‘problems as ‘illnesses’’, the DSM-5 ‘misses the relational context of problems and the undeniable social causation of many such problems’ (BPS, 2011). Subsequently, and a matter of days before the manual was released, the DCP released a Position Statement titled ‘Classification of Behaviour and Experience in Relation to Functional Psychiatric Diagnoses: Time for a Paradigm Shift’ (BPS DCP, 2013). If the title of this document left some room for interpretation, the opening sentences made its point crystal clear:

The Position Statement garnered considerable attention – including, and in advance of its release, from the left-leaning broadsheet, The Observer. An article therein framed the BPS document as an ‘attack’ on a ‘rival profession’, noting that it ‘effectively casts doubt on psychiatry’s predominantly biomedical model of mental distress – the idea that people are suffering from illnesses that are treatable by doctors using drugs’ (Doward, Reference Doward2013).

Unsurprisingly, this coverage and framing were not well received by many in psychiatry, but also generated concern, frustration, and even anger from some BPS members. Prominent academic psychologists Essi Viding and Uta Frith, for example, rebuked the authors of the DCP Policy Statement for ‘attacking the DSM-5’ and biomedical approaches. They wrote in a letter to The Psychologist,

Viding and Frith went on to outline links between genetics, psychology, and environment – conclusions about which, apparently, ‘anyone who has done their homework in keeping up with the research in the past 20 years should be able to draw’. As far as they were concerned, ‘representatives of the DCP should know better’ (Viding and Frith, Reference Viding and Frith2013, p. 382).

Viding and Frith’s letter stimulated, in turn, its own spirited responses. Refuting claims made within Viding and Frith’s contribution, Mary Boyle, for one, found it ‘surprising’ that they ‘should use the words “attacking the DSM”’, given ‘the importance they attach to evidence’ (Boyle, Reference Boyle2013, p. 466). Other psychologists also defended the Policy Statement, including a letter by Mel Wiseman and 209 other signatories which stated their clear ‘support [for] the DCP’s call for a paradigm shift in how we think about mental distress and the need to move away from psychiatric diagnosis’ (Wiseman, Reference Wiseman2013, p. 469). As far as Wiseman and colleagues were concerned, ‘We need to step out from the shadow of biological reductionism’ (Wiseman, Reference Wiseman2013, p. 469). Richard Pemberton, Chair of the DCP, also contributed to the debate. He noted that the Statement was not seen by the DCP ‘as an “attack” but as a thoughtful critique based on a two-year process of reviewing the evidence and consulting within all the DCP Faculties, where it has widespread support’ (Pemberton, Reference Pemberton2013, p. 467). He did, however, ‘regret that some of the reporting has badged this as a psychiatry versus psychology battle’.

Pemberton’s comments reflect a wider rhetorical position in some of the critique of biomedical approaches to psychiatry emerging from the BPS and, especially, the DCP; specifically, that it is not psychiatry per se that is being criticised, but rather a particular approach within that profession. However, some psychiatrists (and clinical psychologists) see diagnosis as so quintessential to psychiatry that flare-ups can and do happen, contributing to the demarcation of boundaries between these professions.

Since 2018, a focal point of frictions has been the Power Threat Meaning Framework (hereafter PTMF), which itself embeds and extends critical discourse around the DSM. Led by Lucy Johnstone and Mary Boyle, the PTMF, as it is commonly known, drew from and developed a range of long-standing activities and agenda-setting texts produced by the principal and contributing authors (including Peter Kinderman). Rather than serving as another kind of handbook for clinical practice, it sought to provide ‘an over-arching structure for identifying patterns in emotional distress, unusual experiences and troubling behaviour, as an alternative to psychiatric diagnosis and classification’ (Johnstone and Boyle, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 5; see also Boyle and Johnstone, Reference Boyle and Johnstone2020; Harper and Cromby, Reference Harper and Cromby2022). Concerned with distress in its social and political contexts as well as individually experienced, and as the outcome of interactional ‘relational, social, cultural and material factors’ (Johnstone and Boyle, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 8), the authors cast the PTMF as distinct from a more DSM-orientated approach. Johnstone, Boyle, and colleagues noted, for example, that the Framework ‘allows provisional identification of general patterns and regularities in the expression and experience of distress and troubled or troubling behaviour, as opposed to specific biological or psychological causal mechanisms linked to discrete disorder categories’ (Johnstone and Boyle, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 8).

The PTMF has attracted considerable praise alongside a great deal of critique, much of which has played out across social media. The authors have reflected on concerns raised around their text (Johnstone et al., Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2019), for instance in relation to how, and the extent to which, it focuses on trauma. Some criticism has also related to an assumed orientation of the PTMF towards ‘anti-psychiatry’ – although its authors appear keen to eschew accusations that the document is part of a strategy for asserting professional dominance (Johnstone et al., Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2019). Indeed, psychology itself is taken to task by the authors, along with psychiatry, including for its ‘reluctance to acknowledge positivism as a philosophy rather than a set of self-evident rules for discovering facts about the world’ (Johnstone et al., Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2019, p. 49). Still, it is hard not to read the PTMF as a kind of strategic resource for enacting boundaries between clinical psychology and psychiatry, given the latter is so often understood to have diagnosis at its heart.

Formulating Clinical Psychology

A primary concern for many psychological critics of psychiatric diagnosis – and, it should again be noted, for some psychiatrists (Pickersgill, Reference Pickersgill2024) – is that it represents a ‘loss of meaning’ (Johnstone, Reference Johnstone2017, p. 31). As Johnstone summarises,

As a counterpoint to this, the BPS supports the practice of psychological formulation. This is a skill in which the regulatory body, the Health and Care Professions Council (HCPC), requires all varieties of practitioner psychologists to be proficient (HCPC, 2023). ‘Formulation’ has increased in prominence over the last two decades; however, it has a much longer history – as the DCP themselves point out (BPS DCP, 2011). Indeed, this history is itself deployed by proponents to emphasise its importance (Johnstone and Dallos, Reference Johnstone and Dallos2014).

The central role of formulation in clinical psychology was underscored through the 2011 DCP Good Practice Guidelines on the Uses of Psychological Formulation. The development and writing of the Guidelines were led by Johnstone herself, and they attracted considerable attention and celebration. According to Johnstone, formulation ‘is considered to be the core skill of the profession of clinical psychology’ (Johnstone, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 31). Through such statements, formulation can be leveraged as an important means of bounding and defining the profession.

What, though, is formulation? Like many questions within psychology, the answer depends in part on who one is asking, why, and in what contexts. Further, as Johnstone, writing with Rudi Dallos, has described, there are also a multitude of ways through which psychologists can produce formulations (Johnstone and Dallos, Reference Johnstone and Dallos2014). In the aforementioned DCP Guidelines, formulation was defined as ‘a hypothesis about a person’s difficulties, which links theory with practice and guides the intervention’ (BPS DCP, 2011, p. 2). In a 2019 leaflet aimed at people undergoing psychological therapy, the DCP described it as ‘a joint effort between you and the psychologist to summarise your difficulties, to explain why they may be happening and to make sense of them’. A metaphor of a jigsaw was used to further articulate this process:

Formulation was presented as providing ‘a starting point’ for psychological therapy, which ‘can be updated to respond to new information or changing circumstances’. Accordingly, ‘a formulation is never static – it will keep evolving throughout your work with a psychologist as you find out more about yourself’.

Depending on how and why it is used, the practice of formulation may or may not align with diagnostic approaches to mental health. It does, however, have a particular resonance for clinical psychologists who seek to move away from the use of diagnostic categories, and is increasingly recommended in place of diagnosis (Bowden et al., Reference Bowden, Holttum, Shankar, Cooke and Kinderman2020). Lucy Johnstone, for instance, has argued that formulation is a ‘credible alternative’ (Johnstone, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 30) to diagnosis; indeed, best-practice formulation is deemed to be ‘based on fundamentally different principles from psychiatric diagnosis’ (Johnstone, Reference Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read2018, p. 39). Peter Kinderman, too, has urged the use of a formulation-based approach rather than diagnosis (e.g. Kinderman, Reference Kinderman2015; Kinderman et al, Reference Kinderman, Read, Moncrieff and Bentall2013). In his words,

Since, for Kinderman (and others), ‘diagnostic entities lack validity, it is much easier and more appropriate to develop formulations’ (Kinderman, Reference Kinderman2015, p. 157).

An enhanced focus on formulation also aligns with wider moves on the part of some psychologists over the last decade or so – including Johnstone, Kinderman, and more activist groups like Psychologists Against Austerity – to revitalise a focus on social and economic inequality as part of psychological work (indeed, the BPS Annual Conference 2019 was specifically themed around ‘The Psychological Impact of Inequality’). McClelland (Reference McClelland, Johnstone and Dallos2013, p. 121), for instance, argued that attention to inequalities within the process of formulation ‘goes beyond the traditional boundaries of psychology in emphasising the role of social and cultural contexts in shaping problems’. This focus on inequality itself speaks to concerns within clinical psychology that mental health practice can individualise patient distress – with psychiatric diagnosis commonly seen as a key mechanism of reifying such individualisation.

Despite its historical and more recently underscored role in clinical psychology, formulation has not necessarily been a consistently significant strand of psychological discourse. As Harper and Moss reflected at the turn of the century, while ‘formulation is now considered central to the professional practice of clinical psychology’ neither recalled ‘it being mentioned in any detail during our training as clinical psychologists in the late 1980s and early 1990s’ (Harper and Moss, Reference Harper and Moss2003, p. 6). Drawing on Crellin (Reference Crellin1998), they likewise noted that formulation had been presented as rather distinct to clinical psychology and ‘this, no doubt, serves a function of promoting clinical psychology as a unique discipline’ (Harper and Moss, Reference Harper and Moss2003, p. 6). To rewrite their proposition through a more explicitly sociological idiom: presenting formulation as both central and (reasonably) distinct to clinical psychology is a form of boundary work. In particular, it acts to distinguish the profession from other forms of psychological expertise within an economically challenging context (i.e. the NHS) which drives different therapeutic practitioners to compete for status and resource.

Yet, although clinical psychology dominates much discourse in mental health in relation to formulation, many psychiatrists – as well as other mental health professions – also engage in formulation (Pickersgill, Reference Pickersgill2024). A senior psychiatrist once described to me his surprise at what he saw as some clinical psychologists presenting formulation as a radical break from diagnosis. This particular interlocutor, a clinical academic specialising in biological research, noted that he had been formulating for decades and that it had been central to his training (see also Armstrong, Reference Armstrong1980). Other psychiatrists I have spoken with have likewise invoked this term and its importance to their clinical practice, and the potential to engage in formulation alongside diagnosis (Baird et al., Reference Baird, Hyslop, Macfie, Stocks and Van der Kleij2017; Owen, Reference Owen2023). Indeed, there are those who regard claims-making about formulation as sometimes comprising a rather unhelpful form of assault on psychiatry (Mohtasshemi et al., Reference Mohtashemi, Stevens, Jackson and Weatherhead2016). These contemplations and assertations are also a kind of boundary work, however. Specifically, they act to buttress against, and to an extent dismantle, claims of clinical psychological exceptionalism, and so serve their own professional ends as well.

Clinical Psychology and Other Psychologies of the Clinic

While clinical psychology is a significant focus of the work of the BPS, the membership of the society goes far beyond this profession. Currently, the BPS recognises several branches of psychology, and the Society is structured along 11 divisions that reflect these. Alongside the Division of Clinical Psychology, which as we have seen is very active in terms of producing policy statements and practice guidelines, there are also the Divisions of Academics, Researchers and Teachers in Psychology; Coaching Psychology; Counselling Psychology; Educational and Child Psychology; Forensic Psychology; Health Psychology; Neuropsychology; Occupational Psychology; Sport and Exercise Psychology; and the Scottish Division of Educational Psychology.

The DCP is the largest of the BPS divisions. Its members include clinical psychologists both in the NHS and in private practice, alongside some whose role is primarily research. The DCP is currently subdivided into 13 ‘Faculties’, which are largely orientated to foci of particular clinical concern and expertise, such as Addictions, Eating Disorders, and Psychosis and Complex Mental Health (an outlier is the DCP Faculty of Leadership and Management). Notably, some of the Faculties overlap with the interests of other BPS Divisions: the DCP Faculty of Clinical Health Psychology and the Division of Health Psychology, for instance. Indeed, there can be some overlapping orientations at the divisional level itself, most notably between the DCP and the Division of Counselling Psychology (DCoP). These intersections can be key sites of boundary work among professional psychologists, and are a further means through which clinical psychology configures itself.

The challenge of demarcation between clinical and counselling psychology has been an issue at times for both professions. The latter has long roots in counselling in the United States and the United Kingdom; however, the BPS only approved a Division of Counselling Psychology in 1994 (Strawbridge and Woolfe, Reference Strawbridge, Woolfe, Woolfe, Dryden and Strawbridge2003). Even then, ‘fierce resistance’, as clinical psychologist Glenys Parry (Reference Parry, Hall, Pilgrim and Turpin2015, p. 190) put it, had to be overcome for this to happen. While technically a much younger profession than clinical psychology, counselling psychology nevertheless had considerable and long-standing evidence, concepts, and embodied experience from which to draw. Further, unlike clinical psychology, counselling psychology had always been configured around the therapeutic.

What is the difference between counselling and clinical psychology? As the authors of the introductory chapter of one handbook for the former remarked back in 2003, this question ‘is not easy to answer’ (Strawbridge and Woolfe, Reference Strawbridge, Woolfe, Woolfe, Dryden and Strawbridge2003, p. 4). More than a decade later, counselling psychologists Jessica Jones Nielson and Helen Nicholas argued that ‘it is becoming more difficult to differentiate counselling psychologists from clinical psychologists’ (Neilson and Nicholas, Reference Nielson and Nicholas2016, p. 211). Today, both groups deliver some kind of psychological intervention to a range of populations. Both, too, will be expected to have a (critical) understanding of psychiatric diagnosis, risk assessment, therapeutic relationship, and a range of other similarities.

Like clinical psychology (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004), counselling psychology has come to engage with a ‘scientist-practitioner’ model of practice (Corrie and Callahan, Reference Corrie and Callahan2000). This is a popular phrase, if sometimes a little ambiguous. Holding it close, though, enables fully qualified psychologists across BPS Faculties to assert a keenly honed and sophisticated ability to engage closely with – and produce – research evidence about therapeutic mechanisms and efficacy. Part of this sophistication is knowing when to creatively interpret, move beyond, or elide ‘the evidence’ when doing so is deemed to be implied by the calculus of clinical judgement. The term also helps to draw boundaries between, for instance, both clinical and counselling psychologists and other providers of psychological care, implicitly elevating their status through the cultural, professional, and epistemic legitimacy that the term ‘scientist’ bestows.

Of course, despite all this there are also a range of differences between clinical and counselling psychology. Not least of these is the requirement for trainees of the latter profession to undertake personal therapy. Despite the assertions and recommendations of key figures in the DCP, there are also some in counselling psychology who feel that clinical psychologists espouse a more ‘biomedical model’ (Neilson and Nicholas, Reference Nielson and Nicholas2016, p. 211) through their work. The articulation of this position can be regarded as, in part, a strategy for differentiating the disciplines in ways that are advantageous to counselling psychologists. Since this group ‘often compete[s] for similar jobs in the NHS’ (Neilson and Nicholas, Reference Nielson and Nicholas2016, p. 211) as clinical psychologists, it makes good sense to present counselling psychologists as already practising in the ways DCP leaders are encouraging their own members to embrace.

The phrase ‘reflective practitioner’ has also been framed as perhaps especially important within counselling psychology. For Ray Woolfe (Reference Woolfe2012, p. 72), author or editor of several textbooks in this field, the notion of the reflective practitioner has ‘offered a distinctive identity which articulated the special quality of counselling psychology’. It is one that is concerned with the thoughtful and critical analysis of clinical activities, with a view to ensuring that deep and open-minded reflection contributes to enhancing therapeutic and other kinds of practice (Carmichael et al., Reference Carmichael, Rushworth and Fisher2020). It is also a professional identity that is explicitly inculcated as part of training. For instance, the BPS Handbook for Candidates (BPS, 2022), for people seeking qualification in counselling psychology, describes how by the end of the qualification candidates are expected to ‘embody the identity of the Reflective Practitioner’ (BPS, 2022, p. 34). In contrast, while candidates are expected to be familiar with the scientist-practitioner role, no such embodiment is required. The aforementioned therapy that trainee counselling psychologists undergo is commonly framed as a key mechanism to develop and configure an identity as a reflective practitioner (Hanley and Amos, Reference Hanley, Amos and Galbraith2017).

Such an identity is not, though, one which clinical psychologists are willing to leave solely for counselling psychology. A range of writings on, training in, and encouragements towards reflective practice exist in the former field, commonly with a view that this should be imbricated with a scientist-practitioner approach (Carmicheal et al., Reference Carmichael, Rushworth and Fisher2020). Clinical psychologists have come to assert the values of reflection increasingly and publicly (Wigg, Reference Wigg2009), such as in the DCP guidelines on formulation (BPS DCP, 2011). As we can see, then, there are elements of a reciprocally iterative mimesis between clinical and counselling psychologies. This process can be regarded as powered, to a degree, by economic aims to secure posts for their members in an expanding but by no means limitless mental health workforce.

The Growth of Health Psychology

Just as the Divisions of Clinical and Counselling Psychology have their overlaps and potential for frictions, so too do the Divisions of Clinical and Health Psychology. The latter group are principally orientated to the study and mitigation of psychological issues associated with physical ill-health. Like counselling psychologists, health psychologists become chartered psychologists through a training route distinct to clinical psychology (BPS, 2021). The instantiation of health psychology within the BPS was first via the establishment of a Section in 1986, which became a Special Group in 1993, and then, ultimately, a Division in 1997- many members of which were initially trained as clinical psychologists (Bennett, Reference Bennett, Hall, Pilgrim and Turpin2015; Quinn et al., Reference Quinn, Chater and Morrison2020). This gradual formalisation and growth followed interest by a small number of UK psychologists in the 1970s in the establishment of the American Psychological Association Health Psychology Division in 1978 (Wallston, Reference Wallston and Dewsbury1997). Thereafter, a growing research and evidence base developed within universities and, more slowly, the NHS in the 1980s and beyond (Quinn et al., Reference Quinn, Chater and Morrison2020).

While health psychology was professionalising in the 1990s, many clinical psychologists continued to consider physical health part of their territory. Some characterise themselves as ‘clinical health psychologists’ and work in services relating to, for instance, oncology, physical trauma, and pain management. The DCP supports a Faculty of Clinical Health Psychology for such practitioners, best regarded as ‘a special interest group for all clinical psychologists practising in physical health settings’ (Bennett, Reference Bennett, Hall, Pilgrim and Turpin2015, p. 304). This focus has obvious resonances with the activities of the BPS Division of Health Psychology (DHP), given its purposes to support and develop the discipline of health psychology and individual health psychologists – some of whom are indeed ‘psychologists practising in physical health settings’ (Bennett, Reference Bennett, Hall, Pilgrim and Turpin2015, p. 304), although many work in academia or public health. Given that the Faculty of Clinical Health Psychology was established in 1998 – a year after the formalisation of the DHP – it is hard not to regard its inauguration as, at least in part, a form of professional boundary work by the DCP.

When speaking informally to DHP members, I have sometimes encountered frustration about the position the larger and more established professional group of clinical psychology has held within what increasing numbers of health psychologists see today as their purview. This can centre on, for instance, the use by some DCP members of the aforementioned moniker, ‘clinical health psychologist’. Notably, this is not a ‘protected title’ – that is, one of the professional titles legally protected by the HCPC in its role as the professional regulatory body for psychology in the United Kingdom (whereas ‘clinical psychologist’ and ‘health psychologist’ are). Some health psychologists feel that they are being implicitly, and on occasion explicitly, excluded from NHS jobs that advertise health-related posts through the terms ‘clinical psychologist’ or, more rarely, ‘clinical health psychologist’ (Bull et al., Reference Bull, Newman, Cassidy, Anderson and Chater2020) (despite BPS guidance about the use of inclusive job titles; Dooley and Farndon, Reference Dooley and Farndon2021). Such advertisements can be explained, in part, by service leads who might be clinical psychologists that are perhaps unaware of the therapeutic expertise professed by some more recently trained health psychologists, or who are sceptical about the nature, extent, or potential applications of health psychology training. Regardless, health psychologists can at time feel discounted or marginalised within NHS settings where clinical psychology continues to hold considerable power and influence as compared to other psychologies (Asimakopoulou, Reference Asimakopoulou and Forshaw2022; Bull et al., Reference Bull, Newman, Cassidy, Anderson and Chater2020).

At the same time, some clinical psychologists can be disquieted by the increasing move of DHP members into what they have long seen as their domain, rather than that of health psychology: the provision of psychological therapy itself. For many years, health psychology was orientated far more towards academia than the NHS (Quinn et al., Reference Quinn, Chater and Morrison2020). The non-therapeutic emphasis of health psychology was in fact part of the repertoire of persuasion and compromise that ensured support for the establishment of the DHP in the face of DCP members uncomfortable with the notion that health psychologists might deliver therapy (Bennett, Reference Bennett, Hall, Pilgrim and Turpin2015; Quinn et al., Reference Quinn, Chater and Morrison2020). In recent years, however, ever more inroads are being made by health psychologists into the NHS and the delivery of psychological interventions (Forshaw, Reference Forshaw2022; O’Carroll, Reference O’Carroll2014; Quinn et al., Reference Quinn, Chater and Morrison2020).

Within BPS documents, the work of health psychologists is commonly carefully framed in terms of ‘behaviour change interventions’ or ‘therapeutic intervention techniques’ (e.g. BPS, 2021, pp. 5, 30), rather than more directly as ‘psychological therapy’ per se. Nevertheless, health psychologists can now be found in services orientated to, for instance, pain management and addiction, and employing psychological technologies like acceptance and commitment therapy (ACT) and CBT. Accordingly, characterising the interventions of health psychologists as lying outside of the realm of the therapeutic requires a particular framing of therapy that seems challenging to sustain. Unsurprisingly, this configuration of health psychology as a practitioner discipline can create friction with clinical psychologists.

The overlaps and tensions between clinical and health psychology, as with clinical and counselling psychology, underscore how, while psychological disciplines configure themselves through their professional self-image and foci, others in turn come to draw on similar language or practices to morph their own ontologies. A form of ratcheting is one result of this, with declarations of expertise and authority in a given field resulting in similar assertions from another, only to be met with fresh claims-making. Boundaries between psychologies are thus constantly being worked up through intra-professional praxis: they are built, partially dissolved, and redrawn. Importantly, this occurs within a notoriously competitive professional field, underscoring the need for psychologists within and beyond clinical psychology to stake claims to distinctiveness and significance.

Clinical Competition

Competition in clinical psychology starts early: training programmes are highly oversubscribed, and have been for a long time (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004). Application success rates are low, and those candidates who are not rejected are predominantly white and middle class (Palmer et al., Reference Palmer, Schlepper, Hemmings and Crellin2021). Thereafter, career progression can also be challenging, although notably easier for white men, despite their proportionally far smaller numbers within the clinical psychology workforce (Palmer et al., Reference Palmer, Schlepper, Hemmings and Crellin2021). Yet, despite many people seeking training in clinical psychology, NHS services can still sometimes struggle to recruit for a post (e.g. due to where a service is based geographically or institutionally). When this happens, these roles can be downgraded, or in some circumstances the funding for the job can be relocated or withdrawn (Dooley and Farndon, Reference Dooley and Farndon2021).

Different employment pressures thus articulate and encourage what some critics of clinical psychology see as a shielding of that profession’s interests by its more senior members, who can hold powerful roles within academia and the NHS. Some other kinds of psychologists consider that a corollary of this is the disadvantaging of their own specialisms (and perhaps, as a consequence, patients as well). Clinical psychologists are not necessarily unaware of the conversations that can circulate about them in this regard. As one noted in their reflections on working for 25 years in the NHS, clinical psychologists ‘can be perceived as being precious or protectionist’ (Fleming, Reference Fleming, Emerson, Hatton, Dickson, Gone, Caine and Bromley2012, p. 185) in relation to how they conduct their therapeutic work. This characterisation certainly aligns with some of the comments and assertions I have heard or seen made by other psychological practitioners, and even a few clinical psychologists themselves.

Over the past few years, issues around NHS employment for psychologists have come to be a focus of activity both for the BPS as a whole and for its individual members. Clinical psychologists have sometimes lamented the aforementioned downgrading of clinical psychology posts; at the same time, some other psychological practitioners have questioned why some jobs are earmarked for clinical psychologists in the first place (BPS Practice Board, 2019). The BPS Workforce Planning Advisory Standing Committee has been exploring these and related issues, which have also entered into discussions at the BPS Practice Board (one of the five activity-orientated boards of the BPS, reporting to the overarching Board of Trustees). In particular, there has been a desire expressed by some psychologists to move away from using protected titles (and unprotected titles, like clinical health psychologist) in job adverts and towards ‘more inclusive’ titles such as applied and practitioner psychologist (BPS Practice Board, 2020). This would enable a wider range of psychologists to apply for certain posts if they could evidence relevant expertise that might not be encapsulated by their route of chartership alone.

This move to ‘recruitment by competence’, as it is framed by the BPS, has generated various tensions since at least 2017 when moves began to be made towards refreshed recruitment guidance. According to some of my interlocutors, the shift has had support from some prominent members of the BPS over the years. However, while jobs advertised for ‘applied psychologist’ or ‘practitioner psychologist’ are more common, not everyone supports this move – and change has been slow. Job adverts are still not always framed inclusively, and the BPS Practice Board (2022) continue to consider how movement on this front might be encouraged. At the same time, various clinical psychologists have expressed concern about guidance around competency-based advertising which they read as potentially damaging to practitioners in their field (Kat and Yang, Reference Kat and Wang2021). Concerns are on occasion also articulated, often less publicly, that people seeking therapy might not encounter psychologists with the necessary range of expertise. As we might expect, this charge can be hotly contested by BPS members beyond the DCP.

Tensions around changing recruitment guidance relate, in part, to the place that clinical psychologists have within the mental health workforce. For many years now they have been the dominant branch of applied psychology within the NHS, and a greater proportion are employed at senior levels that other kinds of psychological practitioner (Palmer et al., Reference Palmer, Schlepper, Hemmings and Crellin2021). In Scotland, for instance, about 60% of the psychological workforce are clinical psychologists (NHS Education for Scotland, 2022). Across the United Kingdom, they also represent over half of the psychologists registered with the HCPC, whereas health psychology, for instance, comprises only around 2% (Palmer et al., Reference Palmer, Schlepper, Hemmings and Crellin2021). Still, despite this dominance, these percentages indicate that there must be plenty of other professionals competing with clinical psychologists for jobs, influence, and prestige. We can see why clinical psychologists might want to defend their position within the NHS, despite widespread respect and regard for the knowledge and skills of – and a frequent management role in relation to – other psychological practitioners.

Therapeutic techniques common to clinical psychologists, particularly CBT, are also increasingly practised by other professions, including counsellors and psychotherapists (Parry, Reference Parry, Hall, Pilgrim and Turpin2015). These groups are not necessarily BPS- and HCPC-recognised counselling psychologists, but instead tend to be members of the British Association for Counselling and Psychotherapy (BACP, founded in 1977 as the British Association for Counselling) and/or the UK Council for Psychotherapy (UKCP, founded in 1993). The additional boundary work between clinical psychologists, counselling psychologists, and counsellors (and, indeed, between the BACP and UKCP, and between both and the BPS) represents another means through which the psychological complex is further torqued (see, e.g. Hall, Reference Hall, Hall, Pilgrim and Turpin2015; Parry, Reference Parry, Hall, Pilgrim and Turpin2015).

However, the ramifications for clinical psychology of the place and role of counselling and psychotherapy within the NHS (and private sector) seem generally not to be felt so acutely as those associated with psychiatry and other BPS divisions. One possible reason for this is that clinical psychologists are often paid more than other providers of psychological therapy; for instance, within the NHS Talking Therapies initiative (although, as we will see in Chapter 3, this also has corollaries for clinical psychology). Still, the provision of CBT by people who are not clinical psychologists has occasionally raised concerns.

These tensions have collectively contributed to the launch of a professional society specifically for clinical psychologists: the Association of Clinical Psychologists UK (ACP-UK). Incorporated as a Community Interest Company in 2018 following an initial launch in the summer of 2017, in some ways the ACP-UK was a long time coming. Since at least the 1980s, some DCP members were dissatisfied with their relationships with the wider BPS, with various plans bubbling at different points to develop a professional society dedicated to the needs of clinical psychologists (Hall and Wang, Reference Hall, Wang, Hall, Pilgrim and Turpin2015). The ACP-UK has expanded rapidly in size and has various member networks within it to support practitioners. Some of these have resonances with the DCP Faculties, such as the Clinical Health and Neuropsychology Psychology Network. It has also swiftly grown in influence, undertaking meetings with stakeholder organisations like the HCPC and the Royal College of Psychiatrists and putting out joint statements with other professional societies – including the BPS.

Nonetheless, the relationship between the ACP-UK and BPS is not always easy. Peter Kinderman (Reference Kinderman2017), for instance, felt that he had to resign as a Trustee of the BPS given his support of the ACP-UK and what he described as a contrasting view on the part of other Trustees that the BPS ‘needed to press forwards with one message; that the Society (and only the Society) was the natural home for psychology and psychologists’. Later, in 2020, the BPS Practice Board declined to approve a Memorandum of Understanding to shape collaborative working between the DCP and the ACP-UK, noting among other factors in the decision that the latter was ‘a competitor organisation’ (BPS Practice Board, 2020, p. 9). Relations seem to have improved, with the websites of both organisations proudly displaying news items relating to co-working on different campaigns. However, the very existence of the ACP-UK as is a reminder that the psychological complex is a matrix of many shifting facets, and that the actions of clinical psychologists themselves are key to many of those shifts.

Persistence through Reconfiguration

As sociologist Andrew Abbott (Reference Abbott1995, p. 876) has noted, ‘no social entity ever takes shape in a vacuum’. The social entity that is clinical psychology operates within a wider complex of psy disciplines, discourses, and practices (Rose, Reference Rose1985) which inform what it has been and what it could become. In this chapter, I have reflected on how recent and ongoing shifts in clinical psychology are both powered through and have impacted claims-making and boundary work in relation to other professions, configuring the discipline in particular ways. Boundaries shift both iteratively and dynamically in response to changing contexts and professional evolution (Lindberg et al., Reference Lindberg, Walter and Raviola2017) while also helping to maintain a professional whole (Abbott, Reference Abbott1995). Practitioners labour to sketch out or even remake modalities of distinction within clinical psychology, such that the whole might retain its uniqueness and so help it to endure. Boundary work ensures that clinical psychology persists, rather than fracturing into further emergent professional realms or collapsing completely into the domain of applied psychology. At the same time, the reification of certain visions of clinical psychology provides a fleetingly stable referent in relation to which other fields might configure themselves.

Debates, discussions, and proclamations about diagnosis and the ‘medical model’ comprise one form of boundary work in which clinical psychology is presented as being distinct in orientation and approach to (a certain style of) psychiatry. This particular working of boundaries is significant by virtue of the prominence and influence of many claims-makers. When senior figures within the BPS advance assertions about what clinical psychology is like and what it should be more (or less) like, these do not float unacknowledged into the ether. While the transport of these proclamations through the circuits of discourse constituting the profession cannot necessarily be taken for granted, my encounters with clinical psychologists (and psychiatrists) working at the coalface of practice nevertheless indicate their traction. Not everyone agrees with every statement made by the DCP or senior clinical psychologists in relation to diagnosis, yet their quantity and prominence are often noted by Division members. Demarcations from psychiatry help to refine how the praxis of clinical psychology can be recognised as distinct, and so contribute to shaping practitioners’ understandings of themselves and others (Hacking, Reference Hacking1995, Reference Hacking2002).

Clinical psychology is not, however, configured solely through professional, epistemic, and ontological politics with an ‘external’ competitor for resource and prestige. It is also shaped through more ‘internal’ negotiations with other kinds of explicitly psychological practitioners. As professions like health psychology place increasing emphasis on their skills as therapists, and as lower-paid professionals such as nurses with CBT training become ever more visible within the NHS, the need for clinical psychology to assert its novelty and significance increases. Clinical psychologists are well paid compared to the average UK wage and often to others who deliver psychological care, are highly qualified by anyone’s standards, and enjoy associated social prestige. However, changes to the overall landscape of healthcare have left some within clinical psychology concerned that the value of their expertise is being diminished and the uniqueness of their training and skill-set downplayed. Organisations like the ACP-UK consequently today represent a compelling alternative to the BPS, which also continues to support professionals like counselling psychologists who can be direct competitors to clinical psychologists (e.g. for NHS jobs).

Clinical psychology, then, is at once a prestigious and influential profession while also being increasingly called upon to justify itself within a healthcare system ever more subject to an economic calculus of value. In these circumstances, the unique skillset of clinical psychologists vis-à-vis other therapeutic practitioners is not always apparent to healthcare commissioners and policymakers. This striving for singularity, and the role of boundary work within that, has a long history; as Derksen (Reference Derksen2000) has argued, the boundaries between clinical psychology and psychiatry in the 1940s and 1950s were productive for the former profession in terms of helping to configure what exactly it offered in relation to its competitor/patron – stimulating innovation as a result. We can see similar dynamics operating over the 21st century, as discursive and institutional manoeuvring help to configure clinical psychology not only with respect to psychiatry but also in relation to other psychological specialities. The tensions that result are themselves propellants for sociotechnical reconfiguration within the profession.

Given what we know about the interpellations between psychology, society, and the self, we can reasonably assume that the ontological and epistemic machinations of clinical psychology have material and subjective effects. The ways in which this field seeks to (re)position itself and is positioned by – and positions – other fields have professional and economic ramifications in terms of what clinical psychologists are enjoined or permitted to do within the NHS, and (relatedly) how many are employed. These outcomes in turn affect investments in staffing and the nature of job roles for other experts in the psychological. Ultimately, the “success” (or lack thereof) of clinical psychology undergirds what kinds of professionals and forms of care people seeking support are able to access, and how they are configured through these (e.g. truncated forms of CBT as opposed to longer-term integrative therapies, or diagnostic versus formulation-based ontologies of distress). As wide-ranging psychological expertise continues to flourish and proliferate, the meaning and nature of therapy – and its subjects – likewise continue to change.

At the turn of the century, an adult in England who felt very down, lacking in hope, and unable to enjoy everyday pleasures, might have made an appointment with their primary care General (Medical) Practitioner (GP). The GP would then, perhaps, have concluded that their patient should receive a diagnosis of depression, with that in turn resulting in a prescription for a pharmaceutical such as a selective serotonin reuptake inhibitor (SSRI). Today, there is a good chance that some kind of psychological therapy would be recommended. In fact, a GP appointment is not always necessary at all: often people can call a local NHS therapy service and refer themselves directly. Such services are likely to have developed from something called the Improving Access to Psychological Therapies (IAPT) initiative – rebadged in 2023 as NHS Talking Therapies (Clark and Whittington, Reference Clark and Whittington2023). This much-lauded public health programme has had many millions of pounds invested in it, with the objective of making treatment for mental ill-health more accessible (Department of Health, 2012).

The advent of IAPT is largely associated with the campaigning of (among others) London-based academic and clinical psychologist David Clark alongside health economist and member of the House of Lords, Richard Layard. Through the English IAPT initiative, the number of clinicians delivering therapy has proliferated, and ideas about the salience of the psychological within the NHS across the United Kingdom have been reshaped. During the early days of IAPT, its therapists targeted men and women of working age and focused on depression and anxiety, employing psychological interventions to treat those conditions. IAPT later began to include older adults (Ghosh, Reference Ghosh2009), and since 2011 children and adolescents have been the focus of a linked initiative (Fonagy and Clark, Reference Fonagy and Clark2015). Some services further extended into the terrain of ‘severe and enduring mental illness’ (Jolley et al., Reference Jolley, Garety, Peters, Fornells-Ambrojo, Onwumere, Harris, Brabban and Johns2015) – although IAPT, and now NHS Talking Therapies, continued to emphasise depression and anxiety. IAPT gained substantial media coverage in the United Kingdom and subsequently abroad, with one New York Times article describing it as ‘the world’s most ambitious effort to treat depression, anxiety and other common mental illnesses’ (Carey, Reference Carey2017). An editorial in the journal Nature (2012, p. 473) asserted that IAPT ‘represents a world-beating standard thanks to the scale of its implementation and the validation of its treatments’. Such comments have acted to stimulate, and have been stimulated by, significant international clinical and policy attention to and mimesis of the initiative.

In this chapter, I examine the instantiation, operations, and ramifications of IAPT – perhaps the most striking and significant materialisation of an ethic of access in the United Kingdom, and a singular example internationally. I draw on interviews with professional and policy actors working in organisations that shape the wider field of psychological care, alongside interviews and conversations with dozens of NHS practitioners (especially clinical psychologists, from whom we will hear much more in the second part of this book). My sources also include an array of English, UK, and international policy papers, journal articles, clinical guidelines, and charity campaign materials (from 2005 onwards). Through these I sought to better understand the development and reception of IAPT, and the repertories of accountability through which it has been both celebrated and critiqued.

I focus on some of the movements in healthcare the IAPT initiative reflected, helped to stabilise, and further propelled. IAPT was a specifically English initiative, given the devolution of healthcare provision to the constituent nations constituting the United Kingdom of Great Britain and Northern Ireland. Yet, its logics and effects are readily apparent beyond England, with IAPT contributing to revivifying psychological framings of pathology and therapy across the United Kingdom. However, it has achieved this in ways that are more familiar within biomedical contexts, for example through recourse to randomised controlled trials (RCTs) studies (cf. Healy, Reference Healy2004; Horwitz and Wakefield, Reference Horwitz and Wakefield2007; Kitanaka, Reference Kitanaka2012; Lee, Reference Lee1999; Luhrmann, Reference Luhrmann2000; Rose, Reference Rose2007; Rosenberg, Reference Rosenberg2006).

Following its success, IAPT was held up as a model for other psychological services and augmented the legitimacy of public bodies that have the capacity to shape healthcare (most notably the National Institute for Health and Care Excellence (NICE)). Lessons from it have been widely deemed valuable to learn, and clinical psychologists sometimes speak – often critically – of the influence of IAPT on their profession and the services they provide (e.g. its focus on patient throughput). Consequently, IAPT has enjoined wider shifts in the landscape of UK – and international – mental healthcare. I suggest that IAPT morphed from being one ostensibly novel component of this terrain into an element around which other services are constituted (cf. MacKenzie and Pardo-Guerra, Reference MacKenzie and Pardo-Guerra2014). In effect, it has moved from being content to context (MacKenzie, Reference MacKenzie2015), with its renaming as NHS Talking Therapies signalling its expansive remit and effects. IAPT has played a significant role within mental healthcare, producing standards against which other ventures have been held to account.

Problematising Access

As noted earlier, IAPT per se can be largely – though clearly not wholly – traced to the actions of two key individuals: David Clark and Richard Layard. Currently a professor at the University of Oxford (previously King’s College, London), Clark is also National Clinical and Informatics Advisor for NHS Talking Therapies. He is prominent for his research around anxiety disorders and as a major innovator of CBT. Layard is an emeritus professor at the London School of Economics and Political Science (LSE) and a very influential economist. He has played a number of major policy roles relating to mental health and well-being. In 2000, Layard was made a life peer by Prime Minister Tony Blair and remains a member of the Labour Party in the elite UK House of Lords. Both Clark and Layard were elected Fellows of the British Academy in 2003, and it was at the Academy that they first met (Evans, Reference Evans2013a, Reference Evans2013b; Layard and Clark, Reference Layard and Clark2014). Subsequently, they came to work together closely to try and move access to therapy further up the policy agenda. To do so, they actively sought to expand their own influence regarding how issues of access and therapy should be understood and addressed. Their research and campaigning found favour within the Department of Health and at Downing Street, helping to impel reconfigurations of the matrix of clinicians, services, guidelines, treatment sites, and more that comprise mental healthcare. Ultimately, they played vital roles in orchestrating the development and rollout of IAPT.

However, the campaigning of Layard and Clark did not emerge de novo. In the 1990s and during the early 2000s, many patients and clinicians were troubled by ever more testimonies that people experiencing mental ill-health were not receiving the care they needed, including because of shockingly long waiting times. As a result of considerable charitable and clinical advocacy work, policymakers became more sensitised to these issues, with admission to services noted in (for instance) the major NHS policy document, A National Service Framework for Mental Health (Department of Health, 1999a). This Framework also stated a requirement to expand the numbers of professionals deemed competent to deliver mental health interventions. Wider concerns were furthermore emerging about the economic ‘costs of mental illness’ (Sainsbury Centre for Mental Health, 2003, p. 1), which likewise attracted attention.

Layard proved adept at steadily entwining these discourses of access and economy, focusing on depression specifically, and ultimately delimiting a straightforward framing of the (economic) problem(s) of access. In the early 2000s, he was an active publisher across a range of discursive spheres, and his widely reviewed trade book, Happiness: Lessons from a New Science (Layard, Reference Layard2005b), argued that depression was a social problem that could be addressed through psychological therapy at scale. Following the publication of Happiness, Layard also authored various clinically oriented writings (e.g. Layard, Reference Layard2006a) and was a regular discussant on related issues with journalists and policymakers. Through such activities, he worked to at once characterise the nature of the problem of access and to articulate its solution (cf. Callon, Reference Callon and Law1986).

Layard’s messaging generated policy traction. For example, in January 2005, he was invited to present a report to the Prime Minister’s Strategy Unit, in a seminar at which Clark was also present (Evans, Reference Evans2013b). Titled ‘Mental Health: Britain’s Biggest Social Problem?’ (Layard, Reference Layard2005a), this document claimed that mental illness ‘imposes heavy costs on the economy’. It asserted – in bold typeface: ‘There are now more mentally ill people drawing incapacity benefits than there are unemployed people on Jobseeker’s Allowance’ (Layard, Reference Layard2005a, p. 1). An apt response, Layard argued (like the Department of Health before him), was a massive expansion of the mental health workforce.

Senior Labour figures seemed to have been receptive to Layard’s arguments: following his presentation, The 2005 Labour Party Manifesto committed to improving mental health through ‘behavioural as well as drug therapies’ (p. 65). The phrasing of the manifesto promise presented psychological services as a kind of addition to the (pharmaco)therapeutic status quo. It thus underscored neurobiology as a key aspect of the UK mental health landscape (see Pilgrim and Rogers, Reference Pilgrim and Rogers2005; Rose, Reference Rose2007). Yet, the commitment also reflected increasingly outspoken voices (such as Layard’s) in support of proliferating specifically psychological therapy. As we will see, the Labour Party pledge ultimately materialised as the IAPT initiative.

Layard’s Reference Layard2005 paper was subsequently expanded into The Depression Report (Centre for Economic Performance, 2006). Released on 19 June 2006, this was also widely termed the ‘Layard Report’, indicating the importance ascribed to Layard in developing IAPT. Though principally associated with him, the report advertised its authority through a list of impressive signatories from mental health research and practice, including David Clark. It further demonstrated epistemic accountability through its digestible number of endnotes linking the claims it made to relevant academic literature. Immediately prior to publication, Layard promoted The Depression Report in the UK left-leaning broadsheet The Guardian (Layard, Reference Layard2006b), with the online edition linking to the LSE website where the report could be downloaded. It was also heralded on its release date in The Observer (the Sunday counterpart of The Guardian), which later, in September 2006, circulated a hardcopy (with support to do so from the mental health charity, the Charlie Waller Memorial Trust). Such widespread dissemination enabled The Depression Report to act as a rhetorical and collectivising device for articulating a particular problematisation of access to therapy, and expanding discussion on depression more generally (cf. Callon, Reference Callon and Law1986).

The overall message of The Depression Report was straightforward: depression negatively impacts the economy, it should be treated, and treatment was affordable. Economics was a key apparatus through which the normative and clinical claims contained with the Report were assembled. Readers were, for instance, told that ‘the total loss of output due to depression and chronic anxiety is some £12 billion a year – one per cent of our total national income’ (Centre for Economic Performance, 2006, p. 5; in bold type for emphasis in the original). The word ‘cost’ appeared 24 times in the main text of the 14-page report, including in a section subtitle that added the prefix ‘cost-effective’ to the word ‘therapies’. Pound signs were scattered throughout, and – like in Layard’s Reference Layard2005 paper – the number of people diagnosed with mental illness receiving state benefits appeared on the first page. Even the subtitle of the report – ‘A New Deal for Depression and Anxiety Disorders’ – gestured towards the economy, reminding some readers of the culturally resonant 1930s US New Deal economic development programme. Altogether, it constructed a vision of a society full of despondent individuals whose despair impacted not only themselves but also (the wallets of) the wider citizenry.

More than any other text of the time, The Depression Report braided mental health and the economy within public discourse, relating expertise associated with the latter as an essential feature of (evaluating) attempts to understand and manage the former. Such an economistic framing attracted criticism from many mental health professionals, not least clinical psychologists (articulated across a wide range of blogs, newsletters, and journals). Nevertheless, it also garnered support for the therapeutic options it outlined, specifically psychological therapy. As noted, drug treatments for and a neurobiological understanding of depression were prominent within broader popular discourse at the time (Rose, Reference Rose2007), even if these were never hegemonic (Pickersgill, Reference Pickersgill2014). The Depression Report instead urged the NHS to adopt psychological therapies for redressing the economic, social, and personal costs of depression. It stated that ‘hundreds of clinical trials’ had helped to show that ‘therapy is as effective as drugs in the short-run’, and that psychological treatment ‘has more long-lasting effects than drugs’ (Centre for Economic Performance, 2006, p. 6). This promotion was seemingly a consequence of economic calculation rather than overt ontological partisanship over what depression ‘really’ was and hence how it should be treated. Overall, psychological therapy was presented as the most (cost-)effective solution to a pressing social problem.

Clinical psychologists and other health professionals I have spoken with often mention Layard as significant in helping to shift the mental healthcare landscape, with IAPT itself referred to as, for instance, the ‘Layard initiative’. Nevertheless, important as he was, Layard by no means acted alone. As illustrated earlier, his arguments took considerable cues from policy reports and charitable briefings. Aside from David Clark, Layard also worked with colleagues at the LSE (e.g. Layard et al., Reference Layard, Clark, Knapp and Mayraz2007), and the underscoring of psychological therapy within his campaign put him in dialogue with wider advocacy that operated to direct change in policy.

In this regard, a range of largely London-based actors and networks were producing documents and statements about access to psychological therapies. For instance, one third-sector report, We Need to Talk (Mental Health Foundation et al., 2006), was published one month after The Depression Report and served as a de facto companion text to it. Commissioned by five major mental health charities (The Mental Health Foundation, Mind, Rethink, The Sainsbury Centre for Mental Health, and Young Minds), the report emphasised the effectiveness of psychological treatment, the long waiting times for accessing it, and the economic costs of lost work (for coverage, see Frauenfelder, Reference Frauenfelder2006). A loose association of major figures in UK mental health research, policy, and practice also formed under the banner of the ‘New Savoy Partnership’. This included social psychologist Pam Maras (then President of the British Psychological Society), clinical psychologist Peter Fonagy (Chief Executive of the prestigious Anna Freud Centre), and campaigner Paul Farmer (Chief Executive of the leading mental health charity Mind). In 2007, they released the ‘New Savoy Declaration’; this called ‘on the NHS to offer appropriate psychological therapies free at the point of delivery to all people who need them’ (New Savoy Partnership, 2007). Hence, the widely circulated Depression Report served to publicise the goals and further the momentum of a diffuse and diverse undertaking that was already beginning to gain interest and investment within Westminster.

In sum, from 2003 to 2006, an intense campaign from elite metropolitan academics and clinicians and well-known organisations and charities sought to move mental health higher up the policy agenda. This also related to, and was reciprocally informed by, wider governmental strategy and commitments to work and (psychological) well-being (Edwards and Imrie, Reference Edwards and Imrie2008; HM Government, 2005; Rick et al., Reference Rick, Hutten, Chambers, Connell, Hardy and Parry2010). These stakeholders – among whom Layard and Clark were significant – helped to set and propel a programme for expanding access to psychological care. In doing so, they contributed, via a particularly economic problematisation, to the reconfiguration of the mental health landscape from which IAPT emerged. At an early point in the campaigning, this landscape – configured through extant policy and clinical praxis – was one within which a thing called ‘depression’ could be straightforwardly delineated and operated upon by certain techniques, with those suffering from it understood to be disadvantaged by public health infrastructures that limited access to care. The activities of Layard and others helped to reshape it such that both economic and psychological rationalities became vital features. Depression itself was configured as something that should be treated primarily through psychological therapy, and which could be accounted for in terms of its economic costs (with calculations of cost also justifying psychological rather than pharmaceutical interventions). Accordingly, depression came to be increasingly understood as an object of concern not only to individuals categorised as living with the disorder but also to the State and the body politic more broadly.

Remaking Infrastructures and Expertise

Following their commitment to improve mental health services (The Labour Party, 2005), in 2006 the re-elected Labour government granted over £2 million for trialling a programme for enhancing access to therapy within primary care: IAPT (Department of Health, 2012). A few weeks prior to the dissemination of The Depression Report through The Observer, two IAPT pilots were launched, in the city of Doncaster and in Newham, East London. The Doncaster site focused on depression, with Newham dealing with depression and anxiety disorders. Newham was part of the geographic area covered by the East London and City Mental Health Trust, chaired by Baroness Molly Meacher, Layard’s wife and a co-signatory of The Depression Report. The IAPT pilots were rapidly subject to various kinds of elaboration and attention, and in November 2006 a business case was advanced to expand IAPT nationally (Rick et al., Reference Rick, Hutten, Chambers, Connell, Hardy and Parry2010). Funding was then confirmed in 2007. By 2008, the vision of enhancing access to therapy outlined in The Depression Report (and elsewhere) was made manifest.

Though ostensibly a bounded initiative dedicated to improving primary mental health care in England, IAPT became, in the words of one Scottish mental health policy actor I spoke with, a ‘hugely influential’ programme. This has been partly in light of what they termed the ‘fundamental economic argument’ that ‘Richard Layard and Dave Clark put forward’, and ‘the way it’s [IAPT] been done’. In this section and the next, I will sketch out the contours of IAPT and examine how its novelty and legitimacy were configured and accounted for to maximise the material and symbolic investment that generated such influence. In setting out ‘the way it’s been done’, I demonstrate how the ‘economic argument’ justifying the initiative became tightly imbricated with the practices of care and accountability performed through the programme.

In my interviews, informal conversations, and documents I inspected, five key features of IAPT were regularly foregrounded: the introduction of ‘self-referral’, the multiplication of therapists, the development of ‘stepped care’, a focus on evidence-based therapies, and the measurement of outcomes. To begin with, I attend to the first three of these significant characteristics of IAPT; these comprise the infrastructural innovations of the initiative most directly geared towards its stated aims of making psychological therapy ‘accessible’. After that, the chapter turns to the design and nature of the therapeutic provision of IAPT, and how this was rendered (ac)countable. The use of evidence-based therapies and outcome measures were central to the construction, management, and maintenance of (what has been often regarded as) the success of IAPT. Hence, these features played a somewhat different, though seemingly vital, role in configuring and proliferating psychological care. As we will see, they also responded to – and had ramifications for – the broader psychological complex (Rose, Reference Rose1985) within which it was situated.

In IAPT, and now NHS Talking Therapies, people can generally contact services directly to request an appointment. This process of ‘self-referral’ was regarded as significant by many of the policy and clinical actors I spoke with. Deemed to avoid the ‘barriers’ to accessing therapy that GPs were often (and still sometimes are) seen to impose, self-referral was widely perceived as a ‘radical shift’ (Brown et al., Reference Brown, Boardman, Whittinger and Ashworth2010, p. 365). The hope was that it would help many more individuals who understood themselves to be depressed and in need of treatment. So important was self-referral to the leaders of IAPT that the number of people self-referring served as a key performance indicator for services within the initiative (Department of Health, 2011). Hence, self-referral represented a means by which IAPT could simultaneously contribute to addressing its core problematic (i.e. enhancing access) and account for the extent to which this was achieved. In problematising referral and offering a targeted solution, the architects of IAPT were further able to present their initiative to policy and clinical communities as a logical, rational endeavour with respect to the managerial and therapeutic mores of UK healthcare. Subsequently, the apparent success of the self-referral processes of IAPT was argued to support the need for this mechanism in other UK mental health services (e.g. Brown et al., Reference Brown, Boardman, Whittinger and Ashworth2010). This is despite some evidence suggesting that self-referral can itself act as a barrier for potential service users (Thomas et al., Reference Thomas, Hansford, Ford, Wyatt, McCabe and Byng2019).

Alongside such efforts to make care more directly accessible, the IAPT initiative greatly increased the number of health professionals able to deliver treatment by positioning large numbers of clinicians within specially commissioned services. A considerable proportion of the IAPT investment was spent on training several thousand cognitive behaviour therapists and new ‘psychological wellbeing practitioners’ (PWPs) (Clark, Reference Clark2011, p. 318). Today, they work across more than 100 NHS Talking Therapies services. As part of the increasingly complicated interplay between the public and private sectors within England, these are provided by a range of charitable and private healthcare organisations (including Mind) partnering with the NHS. Practitioners commonly deliver highly prescriptive forms of CBT, which can sometimes be referred to as ‘manualised’ therapy. Clinicians were initially tasked with treating individuals diagnosed with ‘mild to moderate’ anxiety and/or depression for a discrete (6–10) number of therapeutic encounters. Therapy was not regarded as requiring the expertise of doctorate-holding clinical psychologists, who were also more highly paid and demanded more autonomy. Hence, the training and employment of less expensive cognitive behaviour therapists and PWPs, who worked within closely defined clinical parameters, further optimised IAPTs economic outcomes.

The clinical foci and professional makeup of the IAPT/NHS Talking Therapies workforce are indicative of how the economic rationalities inherent in the conception of the initiative continued to be emphasised within programme delivery. IAPT – along with other NHS policy that enjoined so-called New Ways of Working (e.g. CSIP/NIMHE, 2007) – also affected how therapeutic expertise and therapy configured more widely. In IAPT and elsewhere, psychologists came to be decreasingly viewed as the primary professionals who should deliver psychological therapy. Rather, other psychologically trained clinicians were able to claim sufficient expertise, assuming therapeutic protocols were closely followed. This shift helped to shape the meanings of therapy beyond that delivered through IAPT per se. Gradually, therapy has become progressively characterised in a range of settings as a kind of pre-packaged tool that professionals, sometimes with relatively limited credentialed psychological expertise, can be trained to use in specific, predetermined ways.

Unsurprisingly, many working in clinical psychology have lamented this widespread recasting of expertise and therapy, resulting in various performances of professional boundary work. One senior psychologist told me how IAPT had ‘caused a lot of disquiet’ – something evident during my conversations with various mental health professionals – with, for instance, the ‘deskilling’ (in the words of another) of psychological services registering as a concern. In terms of the therapeutic orientation of IAPT, a policy advisor to the initiative described how he had been ‘besieged’ by criticisms about its focus on CBT. With the rising prominence of IAPT and restrictions in wider healthcare funding, clinical psychologists increasingly displayed their clinical and economic worth (as compared to PWPs, for example) by underscoring their skill in disassembling manualised therapies and recombining them on a patient-by-patient basis. This is in relation to a specific clinical formulation of a presenting problem and the psychosocial milieu inhabited by the person seeking therapy. Such reconfigurations of psychological knowledge and action are not reducible to IAPT; nevertheless, they have been propelled and authorised through the initiative, given its scale and the attention its architects have attracted and demanded.

Connected to shifts in therapists and therapy were reconfigured institutional logics regarding the subjectification (Rose, Reference Rose1996) of populations suitable for therapy. Since the inception of IAPT, the care apportioned through its services has been undertaken in a self-consciously ration(alis)ed fashion that is ubiquitously described as ‘stepped’. For example, a ‘low-intensity’ CBT intervention (such as guided self-help, including computerised CBT) can be initially provided to patients, who might then be ‘stepped up’ to a more ‘high intensity’ treatment in the absence of recovery. Levels of care relate to different kinds of intervention administered by professionals with differing (kinds and degrees of) expertise. Seen as sitting ‘at the heart of the IAPT clinical model’ (Gyani et al., Reference Gyani, Shafron, Layard and Clark2013, p. 605), stepped care was constituted through a conception of what we might term therapeutic wastage. It is deployed to prevent the loss of expertise, time, and, consequently, money to the treatment of mild depression, when these could be more swiftly applied and purportedly better spent (and accounted for) to and on other individuals understood to be experiencing more severe forms of distress.

IAPT did not, in fact, introduce the notion of stepped-care (e.g. Bower and Gilbody, Reference Bower and Gilbody2005). However, its use was significantly extended through the salience of this model in what has been a very well-resourced and highly promoted programme. Many of my interlocutors were employed by psychological services structured through a kind of stepped-care approach, with implications for managing waiting lists. This form of care generally relates closely to values of cost effectiveness. While these have long been part of British clinical life (e.g. Department of Health, 1999a), their presence has been particularly apparent since the austerity policies enacted by the Conservative Government in the wake of the 2008 financial crisis, and almost every psychologist with whom I spoke expressed anxiety regarding service capacity vis-à-vis post-2008 budget restrictions. It was around this time that the infrastructures of IAPT were being touted as therapeutically and economically effective by key clinical proponents, such as Clark (e.g. Clark et al., Reference Clark, Layard, Smithies, Richards, Suckling and Wright2009).

Stepped care, then, represented an answer to more than one problem. Through it, economic practices of accounting and clinical practices of accountability could entwine to synthesise the same ends: in principle, more people could be seen for therapy at ostensibly lower costs. Stepped-care systems also resonate with a certain notion of mental ill-health, one in which severity is not an abstract dimension of distress but is quantifiable through diagnostic language (e.g. ‘mild to moderate’ and ‘severe and enduring’ depression). Hence, stepped care represents a further example of how, through IAPT, economic understandings of care provision became increasingly enmeshed within clinical considerations.

Knowing What Works

In my interviews and conversations with policy actors, IAPT was commonly presented as a rational approach for intervening in a concrete economic, social, and clinical problem. Increasing access to psychological therapies was ‘the sensible thing to do’, as one policy advisor put it, not least because it would generate ‘a cross-ministry saving’. Relating to such economic rationalism, the stated goal of IAPT was ‘to greatly increase the availability of NICE recommended psychological treatment’ (Clark, Reference Clark2011, p. 318; emphasis added) – not therapy in general. A public body, NICE was originally the National Institute for Clinical Excellence before becoming the National Institute for Health and Clinical Excellence and, from 2013, the National Institute for Health and Care Excellence. It has a significant role within England (with implications for the wider United Kingdom) as a producer of NHS clinical guidelines. These are authored by expert Guideline Development Groups, and within them RCT evidence and assessments of cost effectiveness are salient (Moreira, Reference Moreira2011). Key to how the organisation presents and performs accountable action are the visibility of its processes of knowledge production and the managerial and clinical applicability, scientific veracity, and public and political palatability of its recommendations.

By framing the operations of IAPT as mandated by NICE, its advocates were enabled and emboldened to make claims about the clinical and epistemic legitimacy of the initiative. In doing so, the programme could be constructed as economically and politically durable. As the policy adviser above put it, NICE had ‘an authority that goes beyond the authority of any particular professional group’. Another interviewee described how, by following NICE, IAPT could deliver ‘treatments that we know work’. A further senior policy actor told me that although ‘not everyone welcomes or accepts’ NICE, it ‘is the only show in town, at least at this stage, to keep the investment flowing’. Indeed, Layard and Clark (Reference Layard and Clark2014, p. 206) have asserted that ‘the expansion of psychological therapy would never have happened at all without NICE’. CBT was prominent within the 2004 NICE guidelines for depression (and the subsequent 2009 and 2022 guidelines), and the architects of IAPT elected to emphasise this modality in their initiative. By ascribing dominance and import to NICE, this decision-making can be reframed as no choice at all: as the previously quoted interviewee asserted, ‘in terms of a largescale programme we are almost obliged to go from where the evidence sits’.

Nevertheless, NICE is not an uncontested organisation. Over the last decade or so I have encountered wide-ranging dissatisfaction about it from clinical psychologists and others working in mental health. One senior figure associated with NICE noted, for instance, that ‘a number of people’ have regarded it as being ‘too focused on CBT, to the exclusion of other psychological therapies’. Concerns have been, and continue to be, advanced within peer-reviewed and more informal literatures, with frustration about the calculative style of NICE commonly articulated. One critical journal article nicely summarises some of the concerns in its title: ‘The NICE guidelines are misleading, unscientific, and potentially impede good psychological care and help’ (Mollon, Reference Mollon2009). Part of a wider critique of NICE (Moreira, Reference Moreira2011; Syrett, Reference Syrett2003), these debates have developed a certain character through their refraction across the mental health professions. This relates especially to the occlusion of non-RCT treatment studies by the Guideline Development Groups, long-standing debates about the role diagnostic constructs (e.g. ‘major depression’) should play within clinical psychology, and the related use of manualised therapeutic approaches to CBT targeting categorical pathologies (Pilgrim, Reference Pilgrim2011). Despite these critiques, logics of quantification of the kind NICE is underpinned by and contributes to reifying are increasingly configuring UK psychological and wider mental health praxis.

The framework of evidence-based medicine (EBM) has long had traction within the United Kingdom (Armstrong, Reference Armstrong2007); likewise, health economics has shaped healthcare delivery for many years (Mulkay et al., Reference Mulkay, Ashmore and Pinch1987). Still, these trends towards EBM and the deployment of economic expertise have intensified. Early in the 21st century, NICE – then a young organisation – operated at some distance from the everyday concerns of clinicians at the coalface of practice (cf. Hedgecoe, Reference Hedgecoe2004). The first depression guidelines were only produced in 2004; prior to this, just three guidelines in mental health were available: on schizophrenia, eating disorders, and self-harm. In 2004, key players within NICE felt the need to write an article for the Royal College of Psychiatrist’s Psychiatric Bulletin introducing their organisation and its activities (Kendall et al., Reference Kendall, Pilling, Pettinari and Whittington2004). Suffice it to say, these days NICE requires no introduction to UK-based clinicians whose practice is marked deeply by its recommendations.

The import of NICE in mental health has thus grown alongside the expansion of IAPT itself, with both increasingly interacting with one another. For example, Clark chaired the Guideline Development Group for the 2013 NICE social anxiety disorder guidance, which also emphasised the cognitive model of this construct (and subsequent treatment regimens) that Clark developed with Adrien Wells (Clark and Wells, Reference Clark, Wells, Heimberg, Liebowitz, Hope and Scheier1995; NICE, Reference Pennington and Hodgson2013). Further, the perceived successes and practices of IAPT informed the evidence examined and generated by subsequent NICE Guideline Development Groups (e.g. BPS/RCPsych, 2011; NICE, 2011). More than two decades since Kendall and colleagues sought to raise awareness of NICE, its dominance can still inspire voluble criticism. Through this, health professionals reassert their authority to define subjective distress and therapeutic expertise in the face of the organisation doing so on their behalf, and following the expansion IAPT and the trumpeting of the styles of practice associated with it.

With the endorsement and encouragement of NICE, CBT has come to be widely promoted and operationalised within clinical psychology and mental health services across the United Kingdom. Over the years I have asked dozens of clinical psychologists about their therapeutic practice; they almost always reply that, at minimum, they draw on CBT, even as they generally integrate these with other approaches. IAPT itself has regularly been taken to task for its perceived (over-)reliance on this modality. One frequent criticism I encountered related to the notion that CBT has a good evidence base (which was seen to explain its promotion through NICE guidelines). Critics argue that trials for therapies that already indicate effectiveness in some populations are more likely to be sponsored for further research than untested modalities are. Accordingly, further evidence is generated, with which NICE’s Guideline Development Groups might engage. In effect, knowledge about the effectiveness of CBT is presented as partly an artefact of a positive feedback loop. This is further accelerated by the readiness to which manualised forms of CBT could be subjected to evaluation through RCTs. Again, such critiques illustrate a shifting landscape in which ‘evidence’ (of a particular sort) has come to be central to the configuration of practice; hence, the nature of that evidence is reflexively subject to uncertainty and debate.

In interviews with policymakers, policy advisers, and key clinicians, I sometimes invited reflections on the criticisms that IAPT, CBT, and NICE had attracted. These interlocutors largely responded by presenting the widespread instantiation of CBT, the import of NICE, and the necessity of IAPT operationalising NICE guidelines as rational and reasoned. One asserted: ‘if you think you should be trying to invest in evidence-based things then you need to be pushing the things that have evidence’. A senior member of the British Psychological Society asked, rhetorically: ‘If one draws on the evidence base … what else could you do?’ Concerns about CBT were sometimes reframed as an indication that those working in other therapeutic traditions needed to generate evidence for their preferred interventions in ways that NICE would recognise as legitimate. A more diverse array of therapies might then be included in future recommendations, and thus within IAPT. One interviewee argued that this perspective was ‘not unreasonable, particularly in these straitened circumstances’. Even as evidence around CBT is decoupled from the social, technical, and economic contexts of its generation to justify its deployment, the reality that evidence must be actively made is therefore used as a means to critique the critics. This kind of shifting register was, I found, common in defences of IAPT: criticised on epistemic, economic, or humanitarian grounds, responses could readily be assembled from one of the other dimensions of the programme that reconstructed challenges as unreasonable or ill-informed.

Quantifying Success

Clark and Layard, as well as other IAPT leaders, have articulated the import and originality of their initiative through health economic forecasts, the synthesis of clinical guidelines, invocations of human need, and evaluation via the monitoring of clinical and socio-economic outcomes. Healthcare evaluation represents a key means of establishing intervention efficacy and demonstrating political and economic accountability (Broer et al., Reference Broer, Bal and Pickersgill2017), and was leveraged extensively within IAPT. During the programme rollout, for instance, various projects were developed to adjudicate its success, including an evaluation led by Clark et al. (2008) (see also Clark et al., Reference Clark, Layard, Smithies, Richards, Suckling and Wright2009). Information collection was codified within the IAPT Data Standard (i.e. the list of data each IAPT service must collect), and voluminous monthly data collection continues to enable the comparison and evaluation of individual NHS Talking Therapy services. This has long been publicly available, and currently so through the NHS Digital webpages (NHS Digital, 2024). Data include referral dates for calculating waiting times, the number of referrals who have completed a course of treatment, and the average number of treatment sessions (Clark et al., Reference Clark, Layard, Smithies, Richards, Suckling and Wright2009; Department of Health, 2011). Submitting data is itself a complicated process which involves considerable work in terms of the collection, anonymisation, and authorisation of the data and decision-making with regards to who monitors and controls this. Though this mass collection of data, the effectiveness of IAPT was made quantifiable.

Quantification can represent a solution to enduring issues of legitimacy and accountability in healthcare (Hogle, Reference Hogle2019) and beyond (Porter, Reference Porter1995), and patients within mental health settings have long been subject to diverse forms of calculation (Grob, Reference Grob2009; Hirshbein, Reference Hirshbein2009). Within IAPT, though, the variety and consistency of data collected on the characteristics of individuals engaged in therapy and their ‘outcomes’ from this was commonly argued to be unprecedented. Initially communicated to practitioners through the IAPT Data Handbook, the rationales for data collection indicated the range of intertwining clinical, economic, and political uses to which metrics are put (Department of Health, 2011, p. 10):

1. 1. Ensure equitable use of IAPT … by people experiencing depression and anxiety disorders from all communities within the local population, actively advancing equality […]

2. 2. Actively use data collection as part of the clinical process … to enhance patients’ and IAPT workers’ engagement in collaborative decision making and treatment plan reviews […]

3. 3. Provide objective case-load and outcomes data for supervisors to enable them to review the clinical work of IAPT workers […]

4. 4. Provide IAPT workers with information that will help identify appropriate targets for intervention in the next therapy session […]

5. 5. Monitor the extent to which IAPT workers and services are providing evidence-based treatments which are consistently applied in the manner recommended by NICE

6. 6. Measure people’s experience and benefits from IAPT services

7. 7. Assist commissioners and service providers in monitoring and improving the quality and cost effectiveness of their services for all communities

8. 8. Build a robust data archive to inform evolving service improvement strategies […]

The production and harnessing of data for different but connected ends also served to represent IAPT as a departure from more traditional means of undertaking and evaluating psychological therapy. One senior psychologist involved in the programme, for instance, told me how therapy delivered outside of IAPT could be ‘very ineffective and very poorly monitored’. He claimed that this ‘shouldn’t really be allowed to carry on’, given the risk of ‘adverse effects’ from poor practice. Such morally laden talk about the potential negative effects of therapy – and hence the need to scrutinise the expertise and performance of professionals – was also articulated in formal IAPT policy (e.g. Department of Health, 2011). Indeed, the very fact that measures were taken at all, notwithstanding the nature of the data itself or the uses to which it is put, helped to perform the novelty and legitimacy of IAPT.

One means through which different forms of accountability came to be enmeshed in IAPT was through the ongoing employment of a tool called the Patient Health Questionnaire (PHQ-9). Designed in the United States in the late 1990s to screen for and assess depression (Kroenke et al., Reference Kroenke, Spitzer and Williams2001), it asks a series of questions about aspects and occurrences of depressed mood. Possible responses are ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’. These correspond to a number, with responses summed to produce an overall severity score: 0–5 is taken to indicate mild depression, 6–10 is moderate, 11–15 is moderately severe, and 16–20 is severe. Following their (self-)referral to IAPT/NHS Talking Therapies, an individual hoping to access therapy will often be sent the PHQ-9 to complete. The score produced confirms suitability for the service, provides the therapist a starting point for the first appointment, and acts as a benchmark for therapeutic progress. By rendering depression quantifiable, the PHQ-9 enables judgements of severity to be deemed reasonable and therapeutic gains to be recordable, rendering clinical action accountable (to patients and service leads). Accordingly, the PHQ-9 acts as a significant apparatus for consolidating understandings of ‘depression’ as a bounded and discrete disorder, and hence has subjectivising effects on individuals completing it (Hacking, Reference Hacking1995, Reference Hacking2002). It aligns well with CBT, which as Stark (Reference Stark2017, p. 70) has observed, itself intertwines ‘an emphasis on numerical quantification with an ordinal schema of rationality, clarity and self-fashioning’. By configuring patent subjectivities as calculable and surveillable, the PHQ-9 also enabled the evaluation of the therapist, the service, and ultimately IAPT (and now NHS Talking Therapies) itself.

Layard and Clark (Reference Layard and Clark2014, p. 205) stated that ‘outcome measurement is probably the most important single feature of IAPT’, arguing that it ‘is really the only ultimate guarantee of quality’. Presented as descriptive statements, such comments are normative proclamations. An interviewee closely involved with the initiative told me that one reason why IAPT was ‘successful’ was ‘because from the start’ it was decided ‘you have to actually demonstrate that what you do is worthwhile’. This meant ‘that we just had to be able to have outcome data on more or less everyone who was treated’. Outcomes measures continue to be framed as providing epistemic and procedural credibility, which translates into political legitimacy. Without them, I was told, ‘I don’t think [IAPT] would have continued political support’. Despite clinical and normative claims about the import of outcome measures in IAPT, it is the economic and (consequently) political accountabilities relating to these that leaders of the initiative have often portrayed as particularly significant.

Given the salience of outcomes monitoring to IAPT – and their subsequent promotion by initiative leaders and other key healthcare figures and institutions – it is worth noting that this practice was not introduced by the programme. Rather, monitoring and evaluation have been advocated since at least the 1990s (e.g. Department of Health, 1999a; see also Roth and Fonagy, Reference Roth and Fonagy1996). This has often been on the grounds of (political pushes towards) clinical accountability (e.g. Margison et al., Reference Margison, Barkham, Evans, McGrath, Clark, Audin and Connell2000; NIMHE, 2008), generating tension and conflict within therapy communities (Power, Reference Power1999). IAPT was thus constituted within a landscape where measurement was already encouraged.

The calculation of outcomes has come to be even more forcefully mandated by policymakers, including as a key element to service commissioning and provider reimbursement (so-called payment by results) in an increasingly privatised English NHS (Department of Health, 2013). My interviews and conversation with clinical psychologists outside of IAPT/NHS Talking Therapies indicated that routine, systematic, and standardised outcomes measurements have become common following the advent of the initiative (such as the Clinical Outcomes in Routine Evaluation (CORE) framework; Evans et al,, Reference Evans, Mellor-Clark, Margison, Barkham, Audin, Connell and McGrath2000, Reference Fujimura2002). I was even sometimes told (e.g. by one key civil servant associated with IAPT, as well as by various clinicians) that people engaged in psychological therapy ‘like’ outcome measures. Hence, outcome measures do not just ensure that the direction of accountability travels “up” to service and initiative leaders, and ultimately policymakers and politicians, but also “down” to patients themselves. Given policy emphases on patient choice (Greener, Reference Greener2009), augmenting accountability to service users also enhances its political legitimacy.

The implications of IAPT for mental healthcare do not, then, lie in the introduction of outcomes monitoring per se. Rather, the ramifications of the English IAPT initiative can be seen in how it has contributed to establishing data collection in a range of mental health services across the United Kingdom as a necessary and ever more routine practical task for psychological practitioners and services to build and demonstrate clinical and economic legitimacy. Consequently, though generally presented by IAPT leaders as appropriately responsive to the demands of technocratic governance (Porter, Reference Porter1995), claims about the collection and evaluation of therapeutic outcomes have also contributed to the consolidation of this authority.

Contextification

Almost two decades after its emergence, the reach of IAPT continues to be extensive, not least through its 2023 renaming as NHS Taking Therapies and subsequent promises of further expansion (HM Treasury, 2023). Its operations have been held up as examples from which other psychological services might learn, and policymakers and clinicians beyond the United Kingdom have expressed considerable interest in embedding similar models within their own health systems (not least Australia and Norway; Cromarty et al., Reference Cromarty, Drummond, Francis, Watson and Battersby2016; Knapstad et al., Reference Knapstad, Nordgreen and Smith2018). In England and the wider United Kingdom, many researchers, clinicians, and patients have praised IAPT for attending to both scientific evidence and human need. Layard and Clark (Reference Layard and Clark2014) followed up the 2006 Depression Report with a book for a general readership, Thrive, in which IAPT was presented as a ‘great humanitarian project’ (p. 207) and ‘has shown that it is possible in a short time to make big improvements in the lives of hundreds of thousands of people’ (p. 201). Perhaps unsurprisingly given their earlier messaging, Layard and Clark described prompt access to therapy as simultaneously ‘morally right’ and ‘vital for our economy’ (p. ix).

Nevertheless, criticisms of IAPT have been plentiful. Many clinical psychologists and other mental health professionals – including IAPT therapists and managers – have expressed concerns about the programme: to me directly in interviews and casual conversations, and across the academic and professional literature, blogs, and social media (see also Bruun, Reference Bruun2023; Marks, Reference Marks and Dryden2012). Their disquiet relates to the widespread use of CBT (and sometimes to its elite advocates), challenges to therapeutic quality that might result from prioritising particular kinds of outcomes measures, and how economic rationales impinge upon – and reconfigure – clinical care. Even some of the key health economic claims made about psychological therapy have been contested (McCrone, Reference McCrone2013), and antidepressant prescriptions continue to rise (Health and Social Care Information Centre, 2016; NHS Business Services Authority, 2022).

When IAPT was criticised, its advocates framed the various choices made during the development of the initiative as almost inevitable. Justifications related to the accountabilities that Clark, Layard, and colleagues emphasised through the initiative, and the measures and means chosen to demonstrate them. The accountabilities constitutive of IAPT were, chiefly, economic, epistemic, and clinical. They were built into the operations of the programme in ways that enabled its advocates to present it as reasonable and rational, and hence any naysayers as uninformed, misguided, or even self-interested (e.g. Fonagy and Clark, Reference Fonagy and Clark2015). Their integration with the programme has served as a robust shield with which to deflect critique.

The decisions made by IAPT leaders when responding to the broader healthcare landscape during the development phase of the initiative have come, to a significant extent, to be reified as not merely a way of developing public mental health, but as the way to proliferate therapy. Elegantly advanced justifications for and defences of IAPT align closely and resonate with a seemingly ever more economistic framing of the public good by successive UK governments, further closing down spaces within which the problematisations that might propel alternative therapeutic futures can be developed. This discourse of inevitability (Leonardi, Reference Leonardi2008; Pickersgill, Reference Pickersgill2024) has helped to authorise and legitimate the decisions of the early IAPT proponents and leaders, and consequently the situation of the initiative has itself morphed. From being but one feature of a wider public health ecosystem with roots in some existing practices, IAPT reshaped its environment and emerged as a principal entity to which other services must respond. It is in this sense that the imitative moved from ‘content to context’ (MacKenzie, Reference MacKenzie2015; MacKenzie and Pardo-Guerra, Reference MacKenzie and Pardo-Guerra2014).

Such “contextification” has been highly reliant on an economic problematisation of ill-health. This underscores: (1) a certain kind of psychological ontology for subjective distress, (2) the operationalising of this in categorical terms (e.g. depression, anxiety) that are off-putting to traditions like clinical psychology, (3) the possibility of swiftly quantifying such constructs in terms of severity, (4) the necessity of standardised and readily applicable forms of therapy, and (5) the significance of therapists of varying kinds with assorted psychological credentials. This economic problematisation also foregrounds the vital role of measurement in simultaneously evidencing clinical need, therapeutic efficacy, and prudent expenditure. These features are exemplified by IAPT and, while not wholly reducible to the initiative, have become ever more characteristic of other mental healthcare settings. This is in part due to the lauding that IAPT has widely received and its casting as an exemplar programme by bodies such as NICE (the influence of which itself has grown with and through the initiative). As psychological expertise helped to configure IAPT, so too has IAPT reconfigured the psychological complex.

Within initiatives to enhance access to therapy, psychological care is generally presented as something that many people want and who are too often denied access to it (e.g. due to long waiting lists). Yet, there can also be other governmental considerations for enhancing the accessibility of psychological care. In this chapter, I focus on something that the psychological complex (Rose, Reference Rose1985) itself often configures as a ‘matter of concern’ (Latour, Reference Latour2004), namely the diagnostic category ‘personality disorder’. The diagnosis is commonly subject to reflexive consideration about its ontological coherence, its legitimacy as a clinical target, and the affective and practical responses of healthcare professionals to people living with it (Bendelow, Reference Bendelow2010; Eastman Starling, Reference Eastman and Starling2006). Individuals diagnosed with variants of personality disorder associated with antisocial actions have often been involuntarily detained within the NHS and the criminal justice system. There, the disciplinary logics that always infuse psychological care are particularly visible and impactful, with therapy framed partly as a mechanism for addressing antisociality. In the case of personality disorder and its treatment, then, the affordances of an ethic of access can be rather different to those enjoined by initiatives like IAPT.

Ruminations on personality disorder – or personality disorders, given the various subcategories that exist – date back to at least the 19th century (Berrios, Reference Berrios1993; Werlinder, Reference Werlinder1978). They are commonly framed as global personality dysfunctions rather than discrete forms of mental illness (such as schizophrenia or depression). Accordingly, personality disorders have long attracted much interest from psychologists as well as psychiatrists. In the United Kingdom, the constructs of antisocial personality disorder (ASPD) and psychopathic personality disorder (psychopathy) have been particularly important within debates about the intersections between criminal justice and mental health (Manning, Reference Manning2000, Reference Manning2002, Reference Manning2006; Pickersgill, Reference Pickersgill2009a, Reference Pickersgill2009b; Pilgrim, Reference Pilgrim2007). Individuals regarded as ‘personality disordered’ who have committed criminal offences transgress a range of boundaries: between normality and pathology, victim and perpetrator, and patient and criminal. There are enduring concerns about the medicalising circularity of associating violence or ‘criminality’ more generally with personality disorders (Wootton, Reference Wootton1959). Still, legal and policy innovations have often underscored rather than dissolved that association.

In the early 21st century, the revision of mental health legislation for England and Wales focused significant attention on personality disorders (Pilgrim, Reference Pilgrim2007). In 1999, the UK government began to formulate plans for rewriting the 1983 Mental Health Act (MHA) of England and Wales (with Northern Ireland and Scotland having separate legislation). These plans captured the attention of psychiatrists and psychologists, who were keenly aware of the potential for revised policy to reshape practice. However, the possible effects of such governance on framings of pathology per se were less widely appreciated. For decades, ASPD and psychopathy had been widely thought to be resistant to clinical intervention. Yet, as increasingly fractious discussions about the MHA played out, personality disorders came gradually but profoundly to be positioned as plastic rather than more obdurate constructs. In other words, they became treatable.

This chapter tells the story of how that happened. First, I introduce some of the legal and clinical context from which debates about a refreshed MHA emerged. I move then to reflect on key mental health policy developments over the late 1990s and early 2000s, and discuss the associated perspectives of clinicians. I then describe how the policy machinery itself shifted gear to accommodate some professional concerns. The rapprochement between political/policy and clinical goals came to be materially visible in four ‘Dangerous and Severe Personality Disorder (DSPD) Units’ at existing NHS hospitals and prisons. These sought to treat individuals meeting the criteria for DSPD while at the same time managing the risks they were understood to present to others. Finally, I analyse the culmination of these interconnected debates: a 2007 revision to the MHA, and the growing (though still not universal) belief that personality disorders are indeed treatable. The result was a reconfiguration of the role and accessibility of (predominantly psychological) care for people previously deemed ‘untreatable’, perhaps most notably within forensic settings. In sum, I demonstrate how the intensions underlying initiatives to enhance access to therapy are not always benign and can transform ideas about the subjects upon which they seek to intervene.

The 1983 MHA and Therapeutic Pessimism

In 1983, the first major revision to the MHA of England and Wales in more than 20 years was unveiled. Refining and extending much of the content of a 1959 predecessor, the Act was largely steered by the recommendations of an expert committee chaired by Lord Butler of Saffron Walden. Seen by many to be liberal and forward-thinking, the Act they helped to constitute was in turn largely well received (Moncrieff, Reference Moncrieff2003; Simpson, Reference Simpson1976; Wootton, Reference Wooton1980). This is not to say, though, that the 1983 MHA was appreciated by all and in full. Importantly, it continued a long tradition of allowing courts to order the compulsory detention of offenders with ‘mental impairment’ or ‘psychopathic disorder’. This was to the frustration of some clinicians given their acute awareness of the potential for the punitive practice arising from the ability to detain people in this way. As clinical psychologist Steve Pilling (who went on to become a major figure in UK mental health) reflected, given its ‘tautological definition […] it seems quite possible that patients classified as psychopathic could continue to be detained under the terms of the new act as they were under the old’ (Pilling, Reference Pilling1983, p. 93).

Nevertheless, the 1983 MHA did technically increase restrictions on the involuntary hospitalisation of convicted criminals (as well as non-offenders). This was well received by many, and Pilling himself noted that that the legislations would reduce ‘some of the potential for abuse of powers to compulsorily admit people’ (Pilling, Reference Pilling1983, p. 95). Specifically, it introduced what came to be known as the ‘treatability test’. This mandated that an offender could only be held in NHS settings subject to the availability of treatment that was ‘likely to alleviate or prevent a deterioration of his [sic] condition’. The ‘test’ thus sought to ensure that a diagnosis of psychopathy was not by itself sufficient for involuntary hospital detention: the disorder also had to be regarded as treatable. Accordingly, the treatability test came to direct the gaze of mental health professionals working with criminal offenders to the ontology of psychopathy, inviting the question: Could ‘psychopaths’ be treated?

In the United Kingdom, as in many other national contexts, the treatability of psychopathy had been a matter of enduring contention. A minority position, which maintained that therapy was both possible and potentially efficacious, was an established element of clinical discourse. Still, most clinicians seemed pessimistic. Following the 1983 MHA, forensic psychiatrist Adrian T. Grounds succinctly expressed such pessimism:

The treatability test in the Act invited reflection on these issues, as did the influential third edition of the US nosology, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), published in 1980. DSM-III devoted a major section to personality disorders, and the significance this accorded to them was not lost on UK-based health professionals. Its introduction of the category of antisocial personality disorder (ASPD) was particularly interesting to forensic practitioners due to its apparent overlap with the older category of psychopathy. Furthermore, it had a more specific definition than the opaque construct of psychopathic disorder in the 1983 MHA (and of previous DSM articulations of disorders of sociality; Pickersgill, Reference Pickersgill2012a). Over time, ASPD came to have increasing traction within the United Kingdom.

Previously, many mental health professionals appeared to have regarded individuals configured as personality disordered as a nuisance – people who were far from being proper subjects of the clinical gaze, even as they remained at its margins. Rather, people with personality disorder were often framed as an impediment to the ‘real work’ of treating people with discrete mental illnesses (as discussed by Cavadino, Reference Cavadino1989). Individuals living under the label of personality disorder were frequently excluded from health services and were often explicitly disliked by practitioners. Such disdain was exemplified in an influential 1988 paper, ‘Personality disorder: The patients psychiatrists dislike’ (Lewis and Appleby, Reference Lewis and Appleby1988). This was a particular issue for people characterised with ASPD or psychopathy, given the overarching significance of perceived social deviancy in making such a diagnosis. For clinical psychologist Ronald Blackburn (Reference Blackburn1988), characterising someone with one of those personality disorders was ‘little more than a moral judgement masquerading as a clinical diagnosis’ (Blackburn, Reference Blackburn1988, p. 511).

Still, as noted, personality disorders remained articulable as conditions that could and should be treated. An influential proponent of this view was community psychiatrist Peter Tyrer, a frequent writer on personality disorders. In 1991, Tyrer and colleagues argued:

The preceding quote emphasises both the subjective distress suffered by people diagnosed with a personality disorder and the extent to which this could be ameliorated through psychological therapy. These assertions can be read as simultaneously seeking to de-stigmatise personality disorders and advocate for their treatment. Nevertheless, therapy could be ‘long, arduous and difficult to complete’ (Tyrer et al., p. 468; see also Stein, Reference Stein1992; Stone, Reference Stone1993; Yorston, Reference Yorston1999).

As inspiring as Tyrer’s comments might have been to some, other mental health professionals were concerned about the evidence for such claims. In the 1990s, the concept of evidence-based medicine was making its presence felt within clinical communities, and the production of ‘hard data’ to substantiate claims of treatability was enjoined. As a 1998 editorial in the British Journal of Psychiatry asserted, ‘There is a need for claims of therapeutic success within the field of personality disorder to be rigorously appraised’ (Cawthra and Gibb, Reference Cawthra and Gibb1998, p. 8). These comments echoed psychologist Bridget Dolan and psychiatrist Jeremy Coid in their influential 1993 review of treatments for personality disorders commissioned by the UK Department of Health and the Home Office. While Dolan and Coid (Reference Dolan and Coid1993) expressed cautious optimism about treatability, they also underscored a need for statistically robust trials to provide firm evidence for the effects of interventions. These long-standing, if relatively subdued, tensions regarding the treatability of personality disorders were revitalised at the close of the 20th century as the UK government moved to reconfigure its mental health policy.

The Advent of Dangerous and Severe Personality Disorder

On 15 February 1999, Home Secretary Jack Straw asserted in the House of Commons (1999) that there was

Soon after, the concept of ‘Dangerous and Severe Personality Disorder’ (DSPD) began to circulate widely, leading to a wholesale DSPD Programme imbricating mental health and criminal justice.

Emerging from Whitehall, DSPD was, to be clear, not a formal diagnosis. Rather, it was an emergent administrative category for risky individuals. It was widely regarded as having been animated, at least in part, by the July 1996 murder of Lin and Megan Russell by Michael Stone. A prior offender diagnosed with a personality disorder, Stone was involuntarily admitted into De La Pole Hospital, Hull, in November 1994. He was subsequently discharged in January 1995, following a decision that he was no longer eligible for compulsory detention under the MHA (South East Coast Strategic Health Authority, 2006). Media constructions of a dangerous individual abandoned by mental health professionals as a consequence of legal constraints sat alongside broader public fears about violent crime (Freestone, Reference Freestone2005; Manning, Reference Manning2002; Prins, Reference Prins2007; White, Reference White2002). Politicians appeared keen to respond to these concerns.

Sitting under the umbrella of DSPD were people regarded as psychopaths and others meeting criteria for ASPD who were also believed to present a clear and long-term danger to the wider public. Some mental health professionals were highly sceptical about the introduction of this category; clinical psychologist Ronald Blackburn, for instance, argued that the ‘idea of a clearly demarcated category of ‘dangerous psychopaths’ or ‘severe personality disorders’ represents a disease entity approach which is at best a gross oversimplication and at worst a demonic stereotype’ (Blackburn, Reference Blackburn2000, p. 2). The political aspect to DSPD was signalled by psychiatrist Peter Tyrer (Reference Tyrer2001) in his renaming of the category as Jack Straw Syndrome.

Of course, the law has long sought to configure and govern ‘risky’ or ‘dangerous’ individuals (Bartlett, Reference Bartlett2003). What is pertinent here is that the already broad mandate of the State for defining and managing dangerousness was nevertheless considered too narrow by Straw. He argued that powers for indeterminate detention should be extended, regardless of whether the individual to be detained was currently before the courts. The DSPD proposals therefore represented a radical and controversial step by the UK government in the administration of offenders understood to be living with a personality disorder. As such, it also represented a reconfiguration of the activities of mental health professionals themselves.

In July 1999, a consultation paper was released that advanced the possibility of a legislative change that would enable individuals categorised with DSPD to be subject to indeterminate confinement in a special unit within a prison or NHS hospital (Home Office and the Department of Health, Reference Houghton, Saxon and Smallwood1999). As sociologist Mark Freestone put it, these ‘DSPD Units’ were intended to be ‘a ‘third way’ between the prison service and the special hospital and as such a unique environment’ (Freestone, Reference Freestone2005, p. 450). The Units were to be a place to detain individuals considered to be threats to the wider public while at the same time providing therapy to reduce the risk they purportedly presented.

As an instrument of governance, the DSPD proposals were closely related to the Dutch Ter Beschikking Stelling system (de Boer et al., Reference De Boer, Whyte and Maden2008). This was (and remains) an institutional arrangement aimed at managing criminal offenders deemed to be living with particular kinds of mental ill-health, with the aim of decreasing the risk associated with them. The proposed DSPD Units also echoed earlier suggestions made in 1975 by the Butler Committee (McCallum, Reference McCallum2001), and bore a striking resemblance to a recommendation advanced in the so-called Fallon Report (Fallon et al., Reference Fallon, Bluglass, Edwards and Daniels1999). Released in January 1999, this detailed the results of an inquiry into drug use, pornography, and possible paedophile activity at Ashworth Hospital (a high-security mental health facility near Liverpool). The report proposed the establishment of special units for individuals with severe personality disorder within prisons and NHS facilities – similar, therefore, to Straw’s DSPD Units, and perhaps an inspiration for them (Bartlett, Reference Bartlett2003).

Straw’s plans were unveiled at a time when significant doubts remained about the treatability of personality disorders. In light of these and with the Stone case in mind, the DSPD Programme was an attempt to remedy the social and clinical problems surrounding individuals configured as severely personality disordered. However, as indicated earlier, the DSPD proposals were widely resented and resisted by mental health professionals (Chiswick, Reference Chiswick1999; Eastman, Reference Eastman1999; Haddock et al., Reference Haddock, Snowden, Dolan, Parker and Rees2001; Mullen, Reference Mullen1999; White Reference White2002). Serious concerns were raised by clinicians who were keenly aware of and anxious about their role as agents of social control about a profound shift in professional focus toward public protection. The DSPD Programme was not, however, the only change to mental health policy and practice the government sought to introduce. As the century closed, plans were put in place to create what was initially presented as an entirely new MHA for England and Wales – and clinical contestation grew with these.

Changing the Terrain of Mental Health

Toward the end of the 1990s, it was increasingly felt by the UK government that the 1983 MHA needed ‘updating’. Accordingly, in September 1998 they charged an expert committee to review the Act. Chaired by lawyer Genevra Richardson, the Committee’s proposals – published as the Richardson Report in July 1999 – were widely considered humane and progressive and received favourably by clinicians (Department of Health, 1999b). For instance, the Report enjoined the further enhancement of what was commonly understood to be the ‘clear therapeutic ethos’ of the 1983 MHA by extending the conditions of the treatability test (Glover-Thomas, Reference Glover-Thomas2006; Grounds, Reference Grounds2001).

In November 1999, four months after the release of the Richardson Report, the government published a Green Paper: ‘Reform of the Mental Health Act 1983: Proposals for consultation’ (Secretary of State for Health, 1999). A key point of agreement between it, the Richardson Report, the DSPD consultation paper, and the Fallon Report was that psychopathy should be removed from the MHA and replaced with the more general category of personality disorder. This was deemed by many to be ‘long overdue’ (Laing, Reference Laing2000, p. 223), given that the legal definition of psychopathic disorder was in practice applied to a range of subcategories of personality disorder (like ASPD).

Unlike the Richardson Report, however, the emphasis of the Green Paper was on compulsion: compulsory treatment and compulsory detention. It also rejected many of the Richardson Committee proposals (Bartlett, Reference Bartlett2003). For example, in marked contrast to the extension of the treatability test recommended by Richardson, the Green Paper advocated the removal of that test altogether. Furthermore, under its terms, individuals characterised as personality disordered could be detained involuntarily based on risk, irrespective of whether the specific DSPD proposals came to fruition.

Unsurprisingly, then, the Green Paper was heavily criticised by clinicians, as well as by members of the Richardson Committee (Peay, Reference Peay2000; Szmukler and Holloway, Reference Szmukler and Holloway2000; Zigmond, Reference Zigmond2001). As lawyer Nicola Glover-Thomas (Reference Glover-Thomas2006, p. 32) put it, within the Green Paper, ‘risk management has trumped therapeutic endeavour’. Though the 1983 MHA certainly referred to the risk presented by a patient, the Green Paper placed this theme front and centre (Laing, Reference Laing2000). The foregrounding of risk – and the controversy it attracted – characterised the debate on the rewriting of the 1983 MHA over subsequent years.

The Danger of Dangerousness

Notwithstanding the negative reaction to the 1999 Green Paper, the UK government continued with its plans to revise the 1983 MHA and implement the DSPD Programme. In 2001, £126 million had been committed to DSPD service development, and the Programme was being piloted at specialised Units at Rampton Hospital (Nottinghamshire) and HM Prison Whitemoor Prison (Cambridgeshire). The DSPD Programme as enacted was a somewhat diluted version of what had originally been proposed and worked within the ambit of existing legislation. The individual DSPD Units were extremely well resourced, with little expense spared in terms of both their construction and function. High costs were justified in the context of the government’s longer-term and imbricated plans for mental health and crime control.

DSPD also formed the explicit focus of a 2000 mental health White Paper, which underscored concerns with personality disorders and dangerousness (Department of Health, 2000a, 2000b). Yet again, the UK government found that its plans were very poorly received. One editorial in the British Journal of Psychiatry, for instance, argued that the White Paper was a ‘profoundly illiberal document’ (Grounds, Reference Grounds2001, p. 387), drawing attention to its inclusion of potentially broader criteria under which offenders could be indeterminately detained via mental health law. A BMJ editorial expressed the continuing concerns of clinicians with the government’s proposals and highlighted the difficult balance between care provision and risk control (Szmukler, Reference Szmukler2001; see also Chiswick, Reference Chiswick2001; Gunn and Felthous, Reference Gunn and Felthous2000). Writing in The Psychologist, the ‘coercive’ dimension to therapeutic work in relation to personality disorders was highlighted by clinical psychologist David Pilgrim and solicitor David Hewitt (Reference Pilgrim and Hewitt2001, p. 527). Readers were reminded that DSPD itself was as a ‘politically invented notion’ (Pilgrim and Hewitt, Reference Pilgrim and Hewitt2001, p. 527).

The White Paper was thus criticised across the United Kingdom and in a variety of outlets – and by mental health lawyers as well as clinicians (Peay, Reference Peay2003). Critique focused on the preoccupation with risk and ‘dangerousness’ that characterised the document (Buchanan and Leese, Reference Buchanan and Leese2001) and questioned the meanings of these terms: How would dangerousness be measured? How dangerous would an individual have to be to qualify for the DSPD Programme? How did dangerousness relate to treatability and to risk? Representatives from mental health organisations such as the British Psychological Society directly lobbied the government to consider such matters far more carefully (Harper, Reference Harper2005). However, when in 2002 the government followed up the White Paper with a Draft Mental Health Bill, these persistent (Pfohl, Reference Pfohl1978; Wootton, Reference Wootton1959) questions remained largely unanswered.

Curiously, given the government’s previous focus on DSPD, the 2002 Draft Bill did not specifically address this category. Still, mental health stakeholders found the Bill to be troubling for a range of other reasons. Not least of these was wording which raised concern that highly antisocial individuals (i.e. individuals who might come under the rubric of DSPD) could more easily be detained involuntarily within mental health services. Significant debate reigned over this point (Pilgrim, Reference Pilgrim2007). Still, as lawyer Peter Bartlett pointed out, the concept of dangerousness was hardly unprecedented within English and Welsh mental health legislation (or, indeed, to that of many other nations). As such, concerns about social control elided the uncomfortable fact that clinicians had always played a prominent role in configuring and governing deviance. Furthermore, it was ‘not obvious’ how far the Bill extended existing powers for the detention of individuals who were perceived to be a threat to others (Bartlett, Reference Bartlett2003, p. 328). Despite these caveats, Bartlett nevertheless considered the Bill ‘badly flawed’ (Bartlett, Reference Bartlett2003, p. 327) and observed that with it, ‘the government managed to achieve a consensus rarely seen in mental health politics. Sadly, the consensus was negative: virtually no one supported the draft bill’ (Bartlett, Reference Bartlett2003, p. 326; see also Moncrieff, Reference Moncrieff2003).

Towards Treatability

As debate about the MHA reigned, deliberations regarding the treatability of personality disorders became increasingly apparent. Promissory discourse regarding more efficient and efficacious therapies was instantiated within recently established academic units, such as the Nottingham Personality Disorder Institute, and informal networks and formal associations, such as the British and Irish Group for the Study of Personality Disorder (BIGSPD, formed in 2000). These centres and forums arose from and further animated clinical interest in the aetiology, development, and treatment of personality disorders.

At the same time, public spending on personality disorder services and research significantly increased, supported by bodies such as the UK Medical Research Council, the Department of Health, and the DSPD Programme. One emergent sponsor was the National Forensic Mental Health R&D Programme, established in April 1999 (three months before the release of the initial joint Home Office/Department of Health proposals for DSPD). The Programme commissioned literature reviews into the aetiology and management of personality disorders, as well as research on behalf of the Department of Health. In so doing, it became a key funder of personality disorder research.

Still, the proliferation of research and the promise of new treatments for personality disorders did not readily foster a unified front of clinical enthusiasm: views remained mixed (e.g. Chiesa et al., Reference Chiesa, Drahorad and Longo2000; Haddock et al., Reference Haddock, Snowden, Dolan, Parker and Rees2001; Kendell, Reference Kendell2002). Nonetheless, while some expressed doubts about treatability, an increasing number of clinicians wrote articles and produced commentaries that pointed towards effective interventions. The London-based ‘therapeutic communities’ at Cassel and Henderson hospitals were, for instance, highly regarded for their effective work with individuals diagnosed with a personality disorder (Manning, Reference Manning2002). In particular, psychological strategies more broadly were viewed with optimism – partly as a consequence of a growing evidence base (e.g. Bateman Fonagy, Reference Bateman and Fonagy1999; Chiesa Fonagy, Reference Chiesa and Fonagy2000; Mullen, Reference Mullen1999). Influential Broadmoor-based psychotherapist Gwen Adshead summed up the view of many when she wrote in 2001 that there could be ‘no justification for global assertions that personality disorder is untreatable’ (Adshead, Reference Adshead2001, p. 412).

Particular faith was placed in the psychological techniques of cognitive analytic therapy (CAT) and dialectical behaviour therapy (DBT, an approach based on CBT). Hopes for these interventions increased during the first few years of the 21st century, even as the number of RCTs remained low. Pharmaceuticals, such as antipsychotics and antidepressants, were also being used as ‘adjuncts’ to the psychological treatment of personality disorders (Sushovan Tyrer, Reference Sushovan and Tyrer2001; Triebwasser Siever, Reference Triebwasser and Siever2007). This mixing of modalities brought into sharp relief the ontological plurality so often evident within mental health (Helén, Reference Helén, Pickersgill and van Keulen2011; Pickersgill, Reference Pickersgill2010).

Clinicians were urged to forego the notion of a ‘fix all’ for personality disorder and to concentrate instead on the ‘functional assessment’ of the condition (Davidson, Reference Davidson2002). The functional approach produced an increasingly modularised view of personality, first by cataloguing an individual’s particular ‘abnormal’ personality features and exploring the distress experienced as consequence of them, second by using those catalogued features as the basis for a complex management plan. This would be ‘bespoke’ rather than ‘off the peg’; individualised but nevertheless drawing on an eclectic array of existing interventions (Hogue et al., Reference Hogue, Jones, Talkes and Tennant2007; Livesley, Reference Livesley2007).

At the turn of the century, then, a variety of key actors were beginning to configure personality disorders as potentially plastic – capable of responding to the appropriate and skilled application of therapeutic knowledge. This positivity, though, was not without nuance or caveat. For example, Rampton Hospital psychologist Kevin Howells and his colleagues suggested that different models of disorder lay beneath the assorted treatment strategies, raising questions about appropriateness and efficacy (Howells et al., Reference Howells, Krishnan and Daffern2007). Concerns also circulated that many of the treatments touted for a broad spectrum of personality disorder had shown evidence of effects only for the category of borderline personality disorder (Crawford, Reference Crawford2007). Furthermore, as Bartlett (Reference Bartlett2003) wryly observed, predictions about treatability seemed to relate more to the person doing the predicting than the person about whom predictions were made.

While the mental health professions undoubtedly were moving toward an understanding of personality disorders as treatable, there was by no means a consensus. Conflicting feelings and perspectives continued to circulate, even – as noted by psychologist Tony Lavender (Reference Lavender2002) – within DSPD services themselves. Indeed, as a British Psychological Society (2006) report reflected, some doubted whether the concept of personality disorder was useful within clinical practice at all. Yet, it was precisely because the tide of opinion on personality disorders was so clearly turning that some commentators felt compelled to advance concerns and to demarcate limits to therapeutic knowledge and the potential for change.

A Policy Push

While clinicians at the coalface of practice were starting to write positively, albeit cautiously, about the treatability of personality disorders, there was markedly less subtlety in some of the proclamations made by the UK Department of Health and associated bodies. For instance, its National Institute for Mental Health in England (NIMHE) published a report, Personality Disorder: No Longer a Diagnosis of Exclusion (NIMHE, 2003a), arguing that personality disorders were treatable. Any remaining doubt about this was regarded as lamentable, and something that a future MHA might address. The controversial proposed removal of the 1983 treatability test was characterised as ‘highlight[ing] the need for new community and in-patient services for people with personality disorder’ (NIMHE, 2003a, p. 28). Mental health professionals were encouraged to be more open-minded to the potential of treatment in light of this.

Ten months later, the NIMHE released the provocatively titled Breaking the Cycle of Rejection: The Personality Disorder Capabilities Framework (NIMHE, 2003b). This aimed ‘to challenge the discriminatory association between personality disorder and dangerousness by putting in place services aimed at reducing vulnerability and promoting more effective coping by individuals’ (NIMHE, 2003b, p. 10). It further promoted a vision of treatability by painting a more sympathetic picture of people with personality disorder than many others – not least the UK government itself – had in the past:

While the NIMHE document alluded to the MHA in its section on ‘The broader policy context’, it refrained from more explicit articulation of the interconnections between the assumed clinical antipathy towards personality disorders and the proposed MHA (specifically, the provision that would remove the treatability test). The controversial category of DSPD was not even mentioned. Nevertheless, the influence of both DSPD and the 2002 Draft Mental Health Bill was evident in the list of competencies deemed necessary for clinicians working with individuals diagnosed with personality disorder, particularly skills in ‘assessing and managing risk to self and others’. Risk – the leitmotif of the proposed reforms to the 1983 MHA – thus structured the NIMHE clinical guidelines, even as the same document made gestures towards destigmatisation.

The year 2003 also saw the publication of a treatment review commissioned by the Home Office and Department of Health through the DSPD Programme (Warren et al., Reference Warren, Preedy-Fayers, McGauley, Pickering, Norton, Geddes and Dolan2003). The review, conducted by a team of psychologists (including Bridget Dolan) and psychiatrists, aimed to provide an evidence base for ‘informing the decisions about the development of services for DSPD’ (Warren et al., Reference Warren, Preedy-Fayers, McGauley, Pickering, Norton, Geddes and Dolan2003, p. 8). Building on the prior treatment review by Dolan and Coid (Reference Dolan and Coid1993), the 2003 ‘update’ came to similar conclusions; namely, that personality disorders were (potentially) treatable, especially through the application of therapies such as DBT and therapeutic community models. Among their five recommendations, Warren and colleagues asserted that ‘Greater priority should be given to research into the treatment of personality disorder, given the paucity of the evidence currently available’ (Warren et al., Reference Warren, Preedy-Fayers, McGauley, Pickering, Norton, Geddes and Dolan2003, p. 7). The review thus contained a message to which both policymakers and many clinicians were receptive: therapy was possible, but more research was needed.

In sum, through 2002 and 2003, the development of policy and clinical discourse on personality disorders brought the treatability of these conditions into sharp focus. Seemingly in recognition of the controversy it had generated, and mindful of its aims to successfully implement DSPD policy, the Department of Health sought to ally itself with practising clinicians. It did this by evoking tropes similar to those that had become increasingly evident within mental health discourse – chiefly those seeking to destigmatise personality disorders and to configure them as treatable – and articulating these within the pages of key policy documents. These texts were aimed, in part, at fostering a more favourable outlook towards the proposed mental health legislation. In the process, the hopes of clinicians were brought more closely into alignment with the aims of policymakers.

How to Treat Dangerousness

The alignment of policy and clinical goals was most markedly apparent in the DSPD Units. By the autumn of 2005, four high-security pilot DSPD Units were running, which contained ‘some of the most difficult and challenging individuals in society’ (DSPD Programme, 2005, p. 27). Two Units were inside prisons (HMP Frankland and HMP Whitemoor) and two were within NHS hospitals (Broadmoor and Rampton). Generally speaking, the prison Units stressed the correctional aspects of the DSPD Programme, whereas the hospitals focused more on its therapeutic dimensions. However, even within DSPD Units, tensions existed between carceral and clinical approaches (Freestone, Reference Freestone2005; Maltman et al., Reference Maltman, Stacey and Hamilton2008).

In Broadmoor and Rampton hospitals, treatment was administered by multidisciplinary teams consisting of clinical and forensic psychologists, psychiatrists, nurses (who comprised the bulk of the workforce), and a range of other staff (Ministry of Justice, 2011). At Rampton, a psychologist undertook an initial treatment needs assessment (TNA), which preceded a detailed, multidisciplinary formulation and thereafter an ‘agreed set of prioritizations of treatment needs’ (Hogue et al., Reference Hogue, Jones, Talkes and Tennant2007, p. 65). Therapies offered included the aforementioned DBT and CAT, with CBT initially particularly emphasised by Broadmoor (Perkins et al., Reference Perkins, Farr, Romero and Ebrahimjee2015), alongside therapeutic group work and a range of structured skills programmes.

Multiple professionals worked together to simultaneously implement DSPD policy and treat what was seen as the psychological and social deviancy of people categorised with personality disorder. While treatment was aimed at reducing offending behaviour, many clinicians were concerned to treat ‘the person in personality disorder’. In practice, this meant a more expansive therapeutic vision than a clinical focus restricted only to managing those aspects of an individual that were (in the modularised vision of personality) assumed to be associated with criminal antisociality. It also implied everyday patient life as itself having the potential to generate therapeutic effects. As Broadmoor-based clinical and forensic psychologist David Perkins asserted with colleagues in a paper reflecting back on the DSPD Unit there:

While, as we have seen, medication might be used as an adjunct, psychological therapies were salient for the treatment of personality disorders. These were later also emphasised in UK clinical practice guidelines as treatments for both ASPD (NICE, 2009) and borderline personality disorder (National Collaborating Centre for Mental Health, 2009). Several years later, guidance to practitioners working with criminal offenders regarded as personality disordered continued to emphasise psychological approaches to treatment and management (National Offender Management Service/NHS England, 2015). Alongside DBT, CBT – which was commonly employed in the probation service and, as noted, used within Broadmoor – also came to be more widely considered as a noteworthy intervention (de Boer et al., Reference De Boer, Whyte and Maden2008; Maden, Reference Maden2007). As Armstrong (Reference Armstrong2002) has argued, CBT can readily be made to serve both punitive/carceral and therapeutic/clinical ends: it is retributive (individuals are held accountable for their antisocial behaviour) while also being rehabilitative (antisocial actions decrease following therapy). It is thus particularly well-suited to forensic mental healthcare.

The nature and role of treatment in DSPD Units underline three central issues. First, these were sites where the goals of policymakers and clinicians were closely aligned: policymakers could be satisfied that the risk dangerous offenders represented was being reduced, while psychologists, psychiatrists, and others were given the time and resources to follow a therapeutic imperative to treat individuals diagnosed with a personality disorder. Second, the autonomy of clinicians within DSPD Units complicates the presumption of the unilateral political capture of clinical goals that might be inferred from the previous section. That some psychiatrists and psychologists framed their work as treating personality disorders rather than solely managing risk reveals a more dynamic, though still asymmetric, relationship between the aspirations of policymakers and those of healthcare professionals. Third, the activities of the DSPD Units had subtle yet important implications for wider configurations of personality disorder. With few established conventions regarding the ‘correct’ way to treat these conditions but with a remit to do so regardless, clinicians in the DSPD Units employed different forms of therapy. The various treatments relied on diverse underlying models of personality disorder, and their juxtaposition thus (re)assembled heterogeneous models of the conditions. In essence, the DSPD Units acted as laboratories within which the ontology of personality disorder could be experimented with, and they played a salient role in configuring the category as treatable.

The Arrival of an Act

Despite these developments, many professionals continued to contest the UK government’s evolving plans for mental health law. As we have seen, the 2002 Draft Mental Health Bill did not garner the support the government had hoped. It was, in the end, withdrawn, and another Bill was released in September 2004 (Department of Health, 2004a). Somewhat less controversial than its predecessor, the Bill marginally mollified detractors by reintroducing some treatability criteria for cases where involuntary compulsion was being considered. Despite this move, it was still critiqued for its emphasis on risk. Furthermore, some of its detractors claimed that the Bill ignored, for the most part, the views of mental health institutions. This was interpreted as exemplifying the indifference of the UK government both to the clinicians who would implement the MHA and the individuals who would be under its purview (Brown, Reference Brown2006).

The government, however, considered that it had ‘taken seriously the concerns raised about the first version of the draft Bill’ (Department of Health, 2004b, p. 4). Still, it refrained from pushing the second Bill forward. Seemingly in response to the massive criticism levelled against it over the previous seven years, the Department of Health instead made a different move. Specifically, it announced in March 2006 that, rather than completely replacing the 1983 MHA, it would instead amend it (Brown, Reference Brown2006). Accordingly, on 18 November 2006, a third Mental Health Bill was released (Department of Health, 2006a).

Predictably, the 2006 Bill was hardly uncontentious, not least since, like its predecessors, it forsook the treatability test. According to the Department of Health, this was because the test had led

By removing the treatability test, the legislation arising from the 2006 Bill would, clinicians and others were reassured, ‘take away some unnecessary obstacles to practitioners’ ability to use the Act where it is warranted by the needs of the patient and the degree of risk’ (Department of Health, 2006b, p. 3). In essence, the government was arguing that treatment, largely psychological in nature, was being unfairly denied to people who would benefit from it.

The treatability test was not completely abandoned, however. Rather, it was reconfigured into the ‘appropriate treatment test’. Similar to the 1983 treatability test, this revised set of criteria for detention included the key qualification that treatment should be readily ‘available’ rather than merely being a theoretical possibility. The appropriate treatment test would, apparently, call for ‘an holistic assessment of whether appropriate treatment is available, not focused only on the likely outcome of treatment’ (Department of Health, 2006b, p. 3). Psychological therapies were explicitly highlighted as coming within the purview of what the legislation would define as ‘medical treatment’, since ‘To exclude them would be inconsistent with the reality of mental health care and might inadvertently encourage the use of medication even where there are more appropriate alternatives available’ (Department of Health, 2006b, pp. 2–3).

By removing the treatability test and replacing it with the appropriate treatment test, the Department of Health sought to ensure that people who ‘should’ be involuntarily detained could be legally held, but with safeguards in place: at least some kind of treatment needed to be available. Nevertheless, what, precisely, a ‘holistic assessment’ entailed was unclear. So, too, was the procedure for establishing – or formally contesting – whether a particular treatment was ‘appropriate’. Moreover, many commentators were concerned that the Bill illegitimately conflated ‘appropriate’ with ‘effective’ treatment; in other words, that individuals could be detained as a consequence of some kind of treatment being available, irrespective of whether it was the right kind.

Despite these concerns, the Bill was eventually passed with some modifications. Thus, after almost a decade of political wrangling, a revised MHA for England and Wales was given Royal Assent on 19 July 2007. In marked contrast to the original plan for a radical reconstruction of the 1983 Act, the 2007 legislation was an amended and revised version of its predecessor. The chief detractors of the Department of Health were, for the most part, more or less mollified. Not surprisingly, though, some discontentment continued to be registered (Prins, Reference Prins2007).

Personality Disorder Is Treatable

On 22 June 2007, one month before the 2007 Act received Royal Assent, the National Forensic Mental Health R&D Programme officially closed. Given the emerging consensus on the treatability of personality disorder, the UK government seemed no longer to feel the need to continue to invest so significantly in research through this dedicated mechanism. As Frankie Pidd of the Department of Health’s National Personality Disorders Development Programme commented in an article co-authored with psychologist Janet Feigenbaum:

In highlighting this emergent evidence base, the comments above also tell a story of epistemic progress – reflected too in a British Psychological Society report on treatments for personality disorder (BPS, 2006), alongside various other opinion pieces and research articles. Though Pidd and Feigenbaum accepted that some clinicians might disagree, they asserted that this was based on a ‘false belief’ (Pidd Feigenbaum, Reference Pidd and Feigenbaum2007, p. 7) and, worse, one that would increase the stigmatisation of individuals diagnosed with a personality disorder. Pidd and Feigenbaum therefore evoked a discourse of destigmatisation, consistent with the trend in the mental health professions since at least the 1990s (Pilgrim Rogers, Reference Pilgrim and Rogers2005), which was especially apparent in recent years in discourse centred on personality disorders. In so doing, Pidd and Feigenbaum presented not only a therapeutic imperative to work with individuals labelled thusly but a moral duty as well.

More widely, journals such as Psychology, Crime and Law devoted entire issues to contributions on personality disorder, many of which illuminated the treatability of these conditions. As highly regarded psychologist Peter Fonagy noted in the introduction to one special issue, clinicians should ‘celebrate the emergence’ of ‘effective’ interventions (Fonagy, Reference Fonagy2007, p. 3). For internationally celebrated personality disorders expert John Livesley, the literature was now ‘clear that personality disorder can be treated’ (Livesley, Reference Livesley2007, p. 28).

Beyond Treatability

If today personality disorder has been authorised as treatable, with psychological therapies underscored as central modalities of intervention, so too has the category come to be increasingly ‘psychologised’. In line with the wider trends in clinical psychology discussed in Chapter 1, practitioners increasingly speak through an idiom of ‘complex emotional needs’ or ‘personality difficulties’ (Trevillion et al., Reference Trevillion, Stuart, Ocloo, Broeckelmann, Jeffreys, Jeynes, Allen, Russell, Billings, Crawford, Dale, Haigh, Moran, McNicholas, Nicholls, Foye, Simpson, Lloyd-Evans, Johnson and Oram2021). This includes within forensic contexts (Moran et al., Reference Moran, Jarrett, Vamvakas, Roberts, Barrett, Campbell, Khondoker, Trebilcock, Weaver, Walker, Crawford and Forrester2022; NHS England, 2023a). Such talk moves further away from what many see as the more psychiatric language of ‘disorder’. However, this de-medicalising shift would have been unimaginable without the efforts made to configure personality disorders (or difficulties) as treatable in the first place (and not least by psychiatrists), and thus as a proper target of psychological intervention.

Over time, services have increased, and the policy focus on personality disorders has expanded even further beyond the criminological considerations that once anchored so much debate (McBride, Reference McBride2017). Yet, the widespread reconfiguration of these categories as treatable never led to a panacea. The patchy provision of psychological care for people characterised as having a personal disorder remained (Royal College of Psychiatrists, 2020; The Consultation and Advocacy Promotion Service, 2011), and stigma and discrimination endure (Bax et al., Reference Bax, Chartonas, Parker, Symniakou and Lee2023; Bonington Rose, Reference Bonnington and Rose2014). Moreover, there are indications that the appropriate treatment test resulted in an increase in length of involuntary detentions for people diagnosed with a personality disorder who are based within the criminal justice system (O’Loughlin, Reference O’Loughlin2014). The ramifications of an ethic of access, then, are not necessarily always positive or straightforward.

With regards to the DSPD Programme more specifically, this initially continued to expand following the 2007 MHA. By 2008, alongside the original four high-security units, four medium-security units and some community services for DSPD were in operation (de Boer et al., Reference De Boer, Whyte and Maden2008). The costs, though, were significant. Following the 2008 financial crisis and a 2010 general election, the Conservative-led UK government came to reflect on just how much cheaper it was to undertake the treatment of offenders with a personality disorder within prisons rather than hospital-based DSPD Units (Department of Health/NOMS Offender Personality Disorder Team, 2011). The DSPD Programme was thereafter scaled down, before finally coming to an end in 2013 (Tyrer et al., Reference Tyrer, Duggan, Cooper, Tyrer, Swinson and Rutter2015). In its wake, the Offender Personality Disorder (OPD) Pathway was launched (O’Loughlin, Reference O’Loughlin2014). This ‘is a set of psychologically-informed services operating across criminal justice and health’ (NHS England, 2023a). Upon establishment, the OPD Pathway sought to expand access to treatment while, in the eyes of some, diverting resource away from special hospitals (Player, Reference Player2017). It, too, has had subjectifying effects, helping to further circulate psychological and psychiatric concepts within the criminal justice system (McBride, Reference McBride2017).

As for the MHA, it is – again – being reconsidered. In 2017, an Independent Review of the Mental Health Act was announced, chaired by Professor Sir Simon Wessely of King’s College London. A resulting 2018 report highlighted, among other issues, a rise in detentions under the 2007 Act (Wessely, Reference Wessely, Lloyd-Evans and Johnson2018; see also Wessely et al., Reference Wessely, Lloyd-Evans and Johnson2018). Wessely argued that ‘looking back we can see that some of the decisions taken by government leading up to the 2007 Act were an overreaction’ – with the concept of DSPD implied as an example (Wessely, Reference Wessely2017, p. 7). Subsequently, a further Mental Health Bill was promised (Department of Health and Social Care and The Rt Hon Matt Hancock MP, 2021), although this was acknowledged to have progressed more slowly than expected (Department of Health and Social Care, 2021). A draft Bill was ultimately published in June 2022 (Department of Health and Social Care and Ministry of Justice, 2022), and the following month a Joint Committee on the Draft Mental Health Bill was appointed by the House of Commons and the House of Lords to consider it in more detail. In January 2023, the Committee published a report responding favourably to some elements of the Bill (Joint Committee on the Draft Mental Health Bill, Reference Layard2023). This included how the Bill had reconfigured the appropriate treatment test in light of the critique it had attracted: to underscore therapeutic benefit rather than merely the availability of therapy. However, despite high hopes, the year 2023 concluded with no announcement that the Bill would make its way into law. This was to the considerable chagrin of many clinicians and people with lived experience of mental ill-health (BPS Communications, 2023; Mind, 2023).

With the arrival of another (Labour) government in 2024, a revised Mental Health Bill was produced in November of that year (Department of Health and Social Care, 2024). This was generally met with optimism, after several years of frustration. One of the actions that the Bill aimed to achieve, and perhaps a legacy of the political and legal debates discussed earlier, was ‘supporting offenders with severe mental health problems to access the care they need’ (Prime Minister’s Office, 2004, p. 84). As a news item in the BMJ remarked, mental health charities, on balance, ‘hailed’ the Bill, yet nevertheless ‘emphasised the need for investment in services and buildings’ (Dyer, Reference Dyer2024, p. 1). These concerns were mirrored by clinicians (Goddard, Reference Goddard2024), who – like Roman Raczka, President of the British Psychological Society – highlighted the need to invest specifically in the therapeutic workforce as part of programme of funding (BPS Communications, 2024). At the time of writing, the Bill has not yet progressed to law. Accordingly, its ramifications for access to care and the ontology of personality disorder remain ambiguous.

Configuring Law and Practice

Reported inside journal pages, argued through presentations in large conferences and small seminars, and attested to by healthcare professionals, claims about the treatability of personality disorder resound powerfully through clinical discourse. This chapter has explored how personality disorders came to be broadly deemed legitimate sites of effective therapeutic action – how they became ‘treatable’. In doing so, I have sought to highlight how in some cases access to therapy can be shaped by interlocking penal and clinical concerns in the context of disquieting political demands.

While law is a powerful tool for ordering the social, debates over legislative changes cast into sharp relief the ambiguities legislative mandates and processes are designed to manage. They also illustrate how law participates in configuring the ontologies of the entities upon which it acts (Cloatre, Reference Cloatre2013; Seear, Reference Seear2020). Attempts to rewrite the 1983 MHA directed attention to long-standing problems associated with the category of personality disorder and those characterised with it, animating clinical discourse. Moves to remove the treatability test from the Act to facilitate detentions were particularly controversial, resulting in backlash against successive bills. Yet, revised legislation seemed more palatable after those plans were diluted and individuals labelled with personality disorder were reconfigured as patients who could – and should – access therapy. While the government profited from this revised understanding, so too did clinicians who had long held that belief – including through professional acceptance and direct support in terms of funding and employment opportunities (Manning, Reference Manning2002).

Professional perspectives can, at times, have significant influence on mental health policies (Grob, Reference Grob2008; Prior, Reference Prior1991; Schatzman Strauss, Reference Schatzman and Strauss1966), and in the United Kingdom practitioners mobilised alongside others to contest and eventually influence the 2007 update to the 1983 MHA. In so doing, they shaped the law that would govern their practice. This underscores the capacity of clinicians to purposefully torque the psychological matrix (Rose, Reference Rose1985) wherein they operate, and which itself subjectifies them and configures the nature of their professional work. We can see too that while mental health law, policy, and practice sometimes operate antagonistically (Greig, Reference Greig2002), they are also reciprocally configured, with potentially significant effects on the persons acted upon by these (Pickersgill, Reference Pickersgill, Flear, Farrell, Hervey and Murphy2013).

Access to therapy is not just about providing more services or enhancing throughput within these of people seeking psychological care. It also entails the classification and subjectification of particular people as in need of therapy (Hacking Reference Hacking1995, Reference Hacking2002), with the disorder to which they are ascribed configured as malleable through the application of therapeutic expertise. The significant shift vis-à-vis treatability that occurred for personality disorders has been a direct consequence of the interactions between, and reciprocal contouring of, professional and policy debates, moral and epistemic discourse, and law and clinical action. Attention to these reveals how regimes of normativity (Pickersgill, Reference Pickersgill2012b), mental health praxis, and the psychological per se can be (re)configured together. This, in turn, implies urgency for even deeper consideration of what kinds of legislative and therapeutic futures we want.