Healthcare professionals, for the most part, tend to like their autonomy (Abbott, Reference Abbott1988; Freidson, Reference Freidson1988). They do not especially enjoy being told what to do by agents and institutions beyond their sphere of expertise and practice. This is not least when such instructions are issued from sites perceived as being underpinned by logics and concerns orthogonal to the operant values of the clinic. Policy edicts from politicians whose understandings of the needs of clinicians and patients are regarded as somewhat lacking can be especially poorly received.

Nevertheless, professionals must operate within such environments, and sometimes enjoin others to adapt to situations about which they themselves have doubts (Harrison and Dowswell, Reference Harrison and Dowswell2002; McGivern et al., Reference McGivern, Currie, Ferlie, Fitzgerald and Waring2015; Waring, Reference Waring2007). Few domains are more politically charged than healthcare, and – as a public body – the NHS must be responsive to the shifting priorities of governments and ministers. This includes changes in funding, and particularly limits on it. Since 2010, the UK government has created considerable challenges for the NHS through financial under-resourcing (Ham, Reference Ham2023). Commissioners, managers, clinicians, administrators, and other NHS staff have consequently had to torque their activities to suit a sociotechnical context within which many feel more is being demanded for less (Liberati et al., Reference Liberati, Richards, Ratnayake, Gibson and Martin2023). While initiatives such as NHS Talking Therapies have promoted certain kinds of practices and interventions, even these operate within a wider ecosystem. Comparatively well-resourced services never exist within their own hermetically sealed bubble, untroubled by bad weather and the choppy waters upon which they float.

In the case of clinical psychology, while individual practitioners might not like certain changes occurring within the psychological complex (Rose, Reference Rose1985), their practice can nevertheless sometimes be reconfigured in response. We have seen in previous chapters how professional developments and discourses can shape wider contexts, yet specific clinicians might still find themselves practising in circumstances within which they experience practical challenges and frustrations. Consequently, clinical psychologists make do and mend as best they can; like all healthcare professionals, they configure their labours in relation to the organisational constraints and affordances to which they are subject (Scheid, Reference Scheid2004; Strauss et al., Reference Strauss, Schatzman, Burcher, Ehrlich, Sabshin, Fagerhaugh, Suczek and Wiener1985), as well as, to a greater or lesser degree, seeking to contour these. They can, like other professionals (Bezes et al., Reference Bezes, Demazière, Le Bianic, Paradeise, Normand, Benamouzig, Pierru and Evetts2012; Waring, Reference Waring2007), also come to accommodate challenges. One means through which this occurs is via forms of ontological respecification (Schneider et al., Reference Schneider, Brenninkmeijer and Woolgar2022; Woolgar and Neyland, Reference Woolgar and Neyland2013). For instance, as we will see, clinical psychologists sometimes reframe – and thus transform – economic restrictions into useful encouragements towards good clinical practice.

In the previous chapter, I analysed the reciprocal configuration of patients, services, and professionals. This was part – and a result – of the process of working the boundary between certainty and uncertainty in relation to whether a clinical psychologist should work with someone following a referral (and, potentially, assessment). In what follows, I inspect these issues in greater depth, specifically to better comprehend how autonomy is imagined, negotiated, and performed in practice. The chapter will also go further in examining how targets, most strikingly in relation to waiting times for therapy, manifest within the accounts of clinical psychologists. I consider their role in (re)configuring the nature of psychological care and highlight the implications of this for access and exclusion.

Over the last two decades or so, NHS targets have come to focus not so much on the total numbers of patients on a waiting list as on the length of time from referral to treatment. It is, then, waiting times rather than lists per se that are key to governmental consideration (Sheard, Reference Sheard2018). While many clinicians will speak of challenges with waiting lists, the specific concern is how the length of those lists impact the time it takes for a person who is accepted into a service to receive therapy. Waiting time targets have commonly come to represent the metrics by which the accessibility of care is measured; accordingly, they often serve as the focus of attempts to ‘improve access’. How long are patients waiting for therapy, how many of those ‘breach’ the target, and how can waiting times be improved?

Notable examples of these technologies of government (Rose, Reference Rose1999) are targets relating to the Commissioning for Quality and Innovation (CQUIN) framework in England and the Local Delivery Plan (LDP) Standards – formerly the Hospital Efficiency and Access Targets (HEAT) – in Scotland. Launched in 2009 by the UK Department of Health, CQUIN provides financial incentives for actions such as reducing waiting times. As indicated earlier and as other sociologists have shown, these have fixed clinical attention on enacting initiatives that sometimes relate narrowly to an isolated target, rather than on good care more broadly (Bailey et al., Reference Bailey, Pierides, Brisley, Weisshaar and Blakeman2019; Montgomery et al., Reference Montgomery, Chisholm, Parkin and Locock2020; cf. Bevan and Hood, Reference Bevan and Hood2006). Operating between 2011 and 2015, the Scottish HEAT targets stated that no one should wait longer than 18 weeks from referral for psychological therapy to treatment, and this continues to be required through the LDP Standards. The HEAT targets LDP Standards likewise can be read as seeking to improve healthcare and encourage accountability for positive results. Just like they do in England, targets steer and shape Scottish clinical practice as a consequence (Greer et al., Reference Greer, Wilson and Donnelly2016; Schang and Morton, Reference Schang and Morton2017; Steel and Cylus, Reference Steel and Cylus2012).

Here, I am less concerned with the specificities of these targets than with their ambiguous role in practice, and their practical and affective ramifications. This includes analysing how clinical psychologists rework processes of entry into therapy, and the aims and character of care, to meet targets. Doing so illuminates how, despite – and indeed as one direct effect of – the disciplinary power (Foucault, Reference Foucault1989) of targets, practitioners find ways to perform autonomy within practice. In other words, clinical psychologists sometimes exercise their discretion precisely to address external demands, as opposed to meeting targets through practising in fixed, standardised ways. Attending to these matters indicates how shifts in psychological care in response to targets reconfigure clinical psychologists’ relationships to their work and their patients. Targets can thus be understood as contributing to ‘making up’ (Hacking, Reference Hacking1995, Reference Hacking2002) the subjects configured through therapy – as well as those excluded from it.

I regard autonomy as a kind of enacted, negotiated, and relational practice (Gauthier-Mamaril, Reference Gauthier-Mamaril2022) rather than one that is fixed or predetermined – hence my use of the term ‘perform’. In this respect, I draw on sociological scholarship that indicates how autonomy is experienced and performed, in part, through negotiating and reconfiguring its always ambiguous boundaries (McDermott et al., Reference McDermott, Astbury, Jacobs, Willis, Hindi, Seston and Schafheutle2023; Shuster and Lubben, Reference Shuster and Lubben2022; Waring, Reference Waring2014). To be sure, healthcare is often highly structured through national governance and a range of local tools (Berg, Reference Berg1997; Harrison and Ahmad, Reference Harrison and Ahmad2000). Yet, clinicians of different kinds demonstrate a marked capacity to improvise in the face of challenges (Kamp et al., Reference Kamp, Grosen and Hansen2023; Kuijper et al., Reference Kuijper, Felder, Bal and Wallenburg2022). That includes through measures introduced with the aim of standardising clinical praxis (Jensen and Vabø, 2023; Timmermans and Berg, Reference Timmermans and Berg1997). Autonomy might often be regarded by health professionals as being curtailed or limited, but it seldom seems to disappear completely.

My approach perhaps stands in slight tension with clinical accounts of care which contend that autonomy has concretely reduced. My choice of words here – ‘slight tension’ rather than ‘opposed’ – is deliberate. I do not want to refute the claims of professionals who are practising in a financially challenged NHS. That being said, my relational understanding of autonomy likewise precludes me from wholeheartedly endorsing the statements of concern I have encountered. Some styles of autonomous practice are indeed possible to perform, even if the act of doing so is itself enjoined by the same targets regarded as reducing it. The normative corollary of this is that practitioners’ claims around (a lack of) clinical autonomy need to be treated with respect but also require their own close inspection.

Waiting Lists

Let’s start with waiting lists. As we have seen, these can be challenging to work with and were a problem for a clear majority of my interlocutors in clinical psychology. Such issues were systemic rather than simply affecting certain teams; although Grace, for example, had not traditionally had a waiting list for her rural Scottish service, other clinical psychologists had started referring to her to manage their own workloads. This created fresh demands that might be ameliorated within a better-resourced system. Practitioners sometimes expressed deep disquiet at just how bad things were and often continued to be. Senior clinical psychologist Carl, for instance, told me how he was ‘grossly unhappy about the fact that people have to wait’ (emphasis in the original; same for all the quotes that follow). Louise, a more recent entrant into the profession working in an English city, described how ‘it can feel quite heart-breaking after an assessment to then say, “well, it looks like the service that’s best for you is an 18 month wait”’. Mid-career clinical psychologist Molly, who worked in the same NHS organisation as Louise, reflected:

Dealing with waiting lists, not least when confronted by the ‘postcode lottery’ (Ursula) of access to psychological therapy, consequently entailed an affective toll. This was in addition to the practical, cognitive, and moral labours inherent to the uncertainty work (Moreira et al., Reference Moreira, May and Bond2009; Pickersgill, Reference Pickersgill2011) of ascertaining who should get an intervention, what sort, and why. As Molly vividly described, she felt she had to ‘ration’ her ‘compassion’:

A range of emotions seemed to bubble below my interviews with clinical psychologists and sometimes surfaced starkly, such as when Grant, who worked in rural England, told me that ‘the whole NHS ethos … of more for less’ was ‘bullshit’. Such bluntly stated views were more commonly expressed once my recorder was turned off. Salient among the affects channelled were frustration with limited resources through which waiting lists might be reduced, sadness and even anger that patients had to wait so long, and on occasion guilt that more could not be offered.

Managing Demand

To deal with busy workloads, demands for accountability, and emotionally laden moral and clinical decision-making, psychologists sometimes elect to use social and procedural technologies to manage waiting lists and referrals. These configure the referral process without necessarily or linearly determining it, and are examples of certain performances of autonomy that also create space for more. This might be through the discretionary classification – and hence subjectification (Hacking, Reference Hacking1995, Reference Hacking2002) – of people seeking care in particular ways that have implications for the temporalities of care (which can also be expected to have subjectifying effects). Amy, for instance, described how, in response to ‘ridiculous’ waiting lists, her service developed a process whereby (potential) patients were ‘split’ into ‘priority’ and ‘routine’ groups, with the latter ‘only’ receiving 30-minute assessment meetings. This agentic configuring of the service, and of the patient themselves, apparently ‘massively helped’ with the waiting list.

Other mechanisms for managing waiting lists and times are the delegation of decision-making to pre-packaged delivery models. Nonetheless, these are sometimes modified to better suit the contexts wherein they operate, and their operations can configure professional autonomy in turn. The Choice and Partnership Approach (CAPA) was an example of this noted in several interviews and conversations I had with clinical psychologists. CAPA is a model of engaging and assessing people for therapy, particularly in child and adolescent mental health (CAMHS) services, which centres an initial ‘choice appointment’. This is an initial appointment at a time of the patient or their carer’s choosing, as opposed to one that is decided in advance by the service team (Robotham et al., Reference Robotham, James and Cyhlarova2010). Dierdre summarised her use of this approach:

In this example, we can see how CAPA was reconfigured to become ‘doable’ (Fujimura, Reference Fujimura1987) in relation to the assemblage of personnel, demands, and concerns of Dierdre’s service. This is itself a performance of autonomy, and the operations of CAPA – even while creating space for patient autonomy – also enact a particular configuration of professional autonomy. Part of this is that the expert – or not – contribution of GPs is rendered less relevant. Accounted for in terms of timesaving, it also squarely positions the clinical psychologist as the principal agent in the process of referral and assessment. Such an elision of physicians implicitly contributes to a bigger project of professional autonomy within a medically dominated NHS.

As we saw in the previous chapter, some of the uncertainties associated with managing waiting lists and referrals can be tamed through a careful configuration of services as having their entry determined by referral criteria. Referral criteria – or commissioning criteria more generally – can be framed as restraining the autonomy of clinicians (Mladovky, Reference Mladovky2023). Still, there can be room for manoeuvre. Even in cases where there were ‘very detailed referral criteria’, clinical psychologists ‘might’, as mid-career professional Verity told me, see people who would not meet these (in this instance, from a different geographical region). The ‘might’ here is significant: it gives space for the performance and configuration of autonomy.

Brenda, who worked in secondary care in the south of England, told me that despite quite specific commissioning criteria ‘sometimes we plug gaps maybe, where we should … you know, ethically, it feels we need to plug the gap, we need to provide the service’. Yet as capacity became ever more restricted, things had to change: ‘It’s come to a point now where we have just too many referrals.’ Consequently, Brenda felt that she and her colleagues were no longer able to carry on in this way – an unofficial pathway into her service for individuals who did not meet its strict criteria was now ‘closed’. This was framed as an affectively and normatively challenging decision, but also one that was in some senses inevitable; as Brenda put it, ‘what else can you do?’ She went on: ‘If we carried on…with…we’re hiding a need that needs to be addressed.’ Within this account we can see that autonomy is not so much straightforwardly present or absent as it is reconfigured and enacted in different ways over time.

Despite a reflexive understanding of the necessity of finding creative ways to access services, clinical psychologists can also express frustration with referrals they regard as misaligning with their expertise and service. This was palpable in an interview with Louise, which underscored her autonomy over whether to accept particular people into her urban English service (and where the moral aspects of patienthood seemed also to emerge through talk of ‘worth’):

Esther, in rural Scotland, likewise appeared frustrated when describing how ‘psychiatry make referrals for people they don’t know what to do with’, in the hope that clinical psychologists might be able to help – yet, unfortunately, ‘it doesn’t necessarily mean we can do anything either’. Rory, a senior clinical psychologist working in CAMHS, implied that ‘inappropriate’ referral could act as a strategy to absolve clinical responsibility while nevertheless ostensibly ‘doing something’:

We can see that an unwillingness or inability to actively configure someone as suitable for a given service can result in another clear performance of professional autonomy: an intentional, rather than protocol-derived, denial of psychological care.

Technologies of Exclusion and Forms of Strategic Inaction

Informal techniques for managing waiting lists and referrals can be regarded as what sociologists like Claire Laurier Decoteau (Reference Decoteau2013) consider to be technologies of exclusion within healthcare. As we saw in the previous chapter, building walls around a service in the form of rigid exclusion and inclusion criteria can assist clinical psychologists in managing their personal or team’s resource through forms of healthcare rationing that privilege some patients while disadvantaging others. Take the CAPA approach, for instance. Verity described having ‘adapted’ this for her urban service and liked that it meant ‘people have to opt into it’. This was helpful because ‘it kind of gets rid of all the people who DNA [did not attend] their first appointment, and who actually were not really on board with coming along’. Verity noted that she and colleagues would always ‘contact referrers before we discharge people’ – for example, if there are ‘concerns about vulnerability for the family’. Nevertheless, clinical and normative concerns clearly interact to configure a space of autonomy within which psychologists ultimately have the discretion to continue to see or exclude someone from their service.

On occasion, the disadvantages for patients of high walls around services were explicitly discussed by my interlocutors. Ivor, a senior clinical psychologist working with older adults, was one example:

The lack of a clear conclusion about what should be done to prevent patients ‘falling through the cracks’ implies another approach available to clinical psychologists to take to manage an overwhelming workload: what organisational studies scholars call ‘strategic inaction’ (Whittle et al., Reference Whittle, Mueller, Gilchrist and Lenney2016). In this respect, autonomy is performed via decision-making not to do something. Arthur, who worked in an early intervention service for psychosis, articulated how waiting lists themselves could be regarded as a technology of strategic inaction:

In some cases, inaction was itself configured as a form of action: a purposeful refusal to take on more patients to manage a waiting list. In a similar way, inaction can manifest as a strategy of generating low expectations (Gardner et al., Reference Gardner, Samuel and Williams2015); Rory, for instance, noted that for some time his team had ‘made a point’ of ‘not overselling ourselves’:

Autonomous inaction could nevertheless have affective implications for interprofessional work, which were clear from senior clinical psychologist Irene’s reflections:

The affective and practical aspects of in/action were also baldly stated by Louise: ‘I don’t accept self-referrals, as a gatekeeping mechanism. I just think I would be in danger of being overwhelmed if that was the case.’ This assertion is striking because there is, unusually, no attempt made to position the decision as clinically necessary, epistemically warranted, or morally just. Rather, Louise’s comments simply and straightforwardly underscored the considerable pressures practitioners are under and the mechanisms they must (not) put in place to make it through the day.

Prioritising Patients

Long waiting lists generate normative dilemmas around prioritisation (Allen et al., Reference Allen, Griffiths and Lyne2004; Vassy, Reference Vassy2001), contributing to wider practices of local ‘micro-rationing’ of care (Hughes and Griffiths, Reference Hughes and Griffiths1997). As Sylvia (a mid-career clinical psychologist working in an English city) told me, while external pressures meant that ‘we have to prioritise’, an almost unanswerable question emerged from this: ‘How do you prioritise people who technically are all struggling?!’ The intractability of such dilemmas could be interpreted as generating what philosopher Andrew Jameton (Reference Jameton1984) termed ‘moral distress’. This manifests through contexts of economic and symbolic restraint within healthcare, inflecting professional understandings of their potential to enact desirable therapeutic action (Molinaro et al., Reference Molinaro, Polzer, Rudman and Savundranayagam2023). Dealing with ongoing challenges around resourcing, waiting lists, and targets clearly generated different kinds of distress in some of my interlocutors. In the words of Anita, a senior clinical psychologist working in primary care in a large English city,

Dierdre, working in a more rural location in Scotland, also contemplated how pressures and challenges configured practices of prioritisation and their normative dimensions:

The economic context of concerns like those above was often made apparent. Echoing social scientific work into the effects of targets on professional practice (Bevan and Hood, Reference Bevan and Hood2006), Arthur noted that ‘when money is very tight there can be quite a pressure on managers to organise the service in order to meet, to meet the target’. He elaborated as follows:

In some cases, prioritising patients when also dealing with targets did not necessarily generate normative dilemmas, since the appropriate clinical response might be deemed clear. Yet, it nevertheless generated additional accountability work (Neyland and Coopmans, Reference Neyland and Coopmans2014; O’Reilly et al., Reference O’Reilly, Dixon-Woods, Angell, Ashcroft and Bryman2009) as actions needed to be substantiated. This is indicated in comments made by Susannah, a clinical psychologist working in CAMHS in Scotland:

Technologies of exclusion, strategic inaction, and their dynamic relationship with practices of prioritisation must then all be interpreted against the background of increasingly stretched services and governmental initiatives aimed at enhancing access despite the constraints experienced by clinicians.

Targeting Therapy

Clinical psychologists are often deeply concerned about the wider context of healthcare and its shaping of their practical circumstances. While targets themselves were not necessarily framed by my interviewees as radically new – ‘there has always been targets’ – the germane issue was that ‘now there is more of a pressure to meet them’ (Verity). Senior practitioner Olivia, for instance, spoke of ‘an increasing, sort of push towards seeing a certain number of people a week’, while Dana – a clinical psychologist working in physical health – reflected ‘that the numbers and things that we are expected to see aren’t really realistic’. Frank, another psychologist with many years of experience, judged targets to be ‘destroying clinician, individuality, clinician led thinking’; in other words, targets were judged to compromise professional autonomy.

An exchange with senior clinical psychologist Ursula is illustrative of the operations of governmental power exerted with and through targets, and the normativities entangled with them. She noted that ‘our service level agreement for our bit of the service is eight weeks from referral to assessment, and then a further eight weeks from assessment to being in therapy’. This SLA was ‘imposed on us’. When asked whether it was easy to work, Ursula responded:

In Scotland, the aforementioned HEAT targets included clear waiting time targets, and these played a big role in the work of many, though not all, of the clinical psychologists I spoke with. Amy, for instance, noted that ‘the scrutiny that we are under now … in terms of our waiting lists and who we see, when and why is huge’. She went on:

The burden of scrutiny, then, was not necessarily carried by all clinical psychologists in the same way. However, even Amy’s comments noting that the ‘worry’ over meeting targets was apportioned to managers rather than herself ambivalently reposition responsibility to her also: Amy notes how hard she has worked, and how her ‘contribution’ to the team meeting targets was through having ‘cleared this big backlog’. Despite the somewhat humorous tone through which Amy narrated her experiences, a sense of pride also came through. At the same time, patients themselves – individuals in distress and seeking care – are aggregated and depersonalised as a problem to be solved. Targets can thus be viewed as disciplining and configuring the subjective relations clinical psychologists have with their labour, and well as subjectifying those with whom they work.

Amy’s comments also hint at the efforts that had to be made to monitor a service, specifically in relation to data collection, for it to be accountable to targets:

Natasha, a senior clinical psychologist in a Scottish city, underscored that such data work (Bossen et al., Reference Bossen, Pine, Cabitza, Ellingsen and Piras2019) was an issue even when targets were being comfortably met: any data input errors generated alerts and concerns that had to be swiftly addressed to demonstrate that her service was, in fact, delivering according to the priorities set and demanded by the government.

Some clinical psychologists advanced concerns about the quality of care that could be provided for people in the context of target-focused services. Indeed, Ivor, in his relatively rural service, felt that the pressure of targets ‘sometimes leads to discharging people where you think they could make more progress with more sessions’. Sylvia, from the perspective of working in a highly urban service, similarly reflected that targets in the absence of substantive additional resource meant ‘a dilution in terms of what we’re offering to clients’:

This ‘firefighting’ was also presented as having affective ramifications for staff – stress, sickness, and burnout – which, given the intersubjective nature of psychological therapy, means implications for patients in turn:

The affective impacts of targets (Liberati et al., Reference Liberati, Richards, Ratnayake, Gibson and Martin2023), and the kinds of service organisation these enjoined, were also mentioned by some other respondents: Ivor spoke of the ‘stressful’ nature of being confronted by people who ‘might benefit from long-term therapy’ without being ‘in a position to provide that’. For her part, Susannah described an ‘incredible pressure on professionals to meet the HEAT targets’ and underscored the ‘scrutiny’ of waiting lists from ‘senior management’. She went on:

Such pressures can be regarded as reconfiguring, rather than always and simply reducing, the autonomy of clinicians as they act to actively remake their work to meet targets.

‘Pressure’ and ‘Focus’

For a smaller number of clinical psychologists, targets lacked salience; they were, rather, a problem for someone else. Their accounts emphasised, for instance, performances of temporal autonomy (cf. Goodin et al., Reference Goodin, Rice, Parpo and Eriksson2008; Bailey and Madden, Reference Bailey and Madden2017), as in remarks from Tina, an early-career clinical psychologist based in an English city:

Still, the spectre of the comparator loomed large: Tina framed ‘meeting the clients’ needs’ as being afforded a particular ‘luxury’, while colleagues felt the ‘pressure’ of managerial demands. Accordingly, the configuring of her own psychological work seemed dependent on the wider role played by targets. Not only one form of content within the wider terrain of mental healthcare, targets have become the context through which the psychological is configured.

While the clinical psychologists I interviewed and engaged with more widely were generally critical of targets, resonant forms of the ambivalence that threaded though Tina’s reflections above were sometimes expressed by, particularly, clinicians working in Scotland (connecting, perhaps, to a wider rhetoric of progressiveness within Scottish health politics and policy; Greer et al., Reference Greer, Wilson and Donnelly2016; Stewart, Reference Stewart2013). Liam, for example, was a senior clinical psychologist in a community mental health team (CMHT) whose role was presented as requiring an unremitting focus on targets. Yet, these were nevertheless regarded as ‘hugely beneficial’ in terms of raising the visibility of clinical psychology within the NHS and affirming that ‘it’s just not acceptable that people should wait that long, for such an important service’. Based in a far more rural setting than Liam’s urban Scottish practice, mid-career practitioner Megan likewise spoke about some of the pros and cons of the HEAT targets:

For her part, early-career clinical psychologist Briony spoke both of a ‘pressure on services’ as well as about their ‘concern’ that ‘you can maybe meet the target, but how are you ensuring’ the provision of ‘quality therapy’ alongside ‘decent outcomes for people as well?’ However, she too felt that targets also had some benefits:

Esther similarly deployed an idiom of ‘focus’, noting that the HEAT targets had contributed to having ‘really modernised us’ and ‘actually kind of responsibly demonstrating what we do’ – albeit with challenges for clinical psychologists themselves:

Verity illustrated some of the labour involved in configuring services to meet targets, but also enrolled them into a mode of ‘doing good care’ (Pols, Reference Pols2003, Reference Pols2006). Adhering to targets – and discharging patients to meet them – thus became part of how Verity configured herself as a good psychologist:

Another clinical psychologist, Chloe, working in primary care and part of the same overarching NHS organisation as Verity, Liam, and Briony, spoke of similar themes:

Despite, as we have seen, Arthur’s concerns about targets, he likewise framed these as having some advantages: ‘I actually think that without those targets the [early intervention] services [in my locality] wouldn’t exist at all!’ Accordingly, targets can ‘have their benefit[s]’. Nevertheless, ‘there can be problems’ with targets: they can, for instance, ‘start to distort the service’. To illustrate this point, Arthur gave the example of an IAPT service where a conversation with a potential patient following referral was conducted by telephone; classifying this as ‘assessment’ rather than simply a ‘screening’ ‘had a massive impact’ on whether the service met its targets. For Arthur, this was ‘an example of how you can design the service to meet the targets, not necessarily to meet the needs of the people who are accessing the service’. Some clinical psychologists are, clearly, well aware of the ‘gaming’ effects of targets that social scientists such as Bevan and Hood (Reference Bevan and Hood2006) have highlighted.

These reflections underscore the professional autonomy clinical psychologists can have to reconfigure their work to address targets, with implications for the ontologies of psychological care – and, of course, for patient access and experience. Performances of professional autonomy intrinsic to such reconfigurations of therapeutic temporalities and practices were not, however, necessarily straightforward. Rather, the clinical innovation of individual practitioners was sometimes presented less as an agentic and knowingly strategic move and more as an almost inevitable response to a kind of structural coercion. Similar to some other interlocutors, Anita highlighted how group therapy had become one answer to the question of how to manage waiting lists:

Despite the discourse of inevitability (Leonardi, Reference Leonardi2008; Pickersgill, Reference Pickersgill2024) threading through such accounts, professional autonomy and creativity are evident in terms of how clinical psychologists meet the very significant challenges they face, in a manner that might not be feasible for others imbricated within the psychological complex (e.g. CBT therapists).

In sum, certain clinical psychologists seemed to find mechanisms of accommodating targets, including through framing them as enjoinments to good therapeutic practice. Such ontological respecification (Schneider et al., Reference Schneider, Brenninkmeijer and Woolgar2022; Woolgar and Neyland, Reference Woolgar and Neyland2013) in turn foregrounded particular configurations of the good psychologist. At the same time, performances of autonomy were also commonly cast as responses to economic, political, and institutional structures. In this respect, autonomy can itself be considered as a kind of local ‘workaround’ (Clarke and Casper, Reference Clarke and Casper1996) to adapt to structural impositions that reconfigured the content of psychological care.

Limiting Therapy?

Sometimes, services operate with limits on the number of times a clinical psychologist can meet with someone for therapy. Before concluding this chapter, I will talk briefly about the management of those limits, since they serve as an additional example of how waiting lists and associated targets shape psychological care. Their negotiation again demonstrates both the challenges and potential for performances of professional autonomy.

When discussing session limits in interviews and elsewhere, I was generally given figures ranging from 6 to 20 sessions, depending on the nature and complexity of the service and the cases seen. Session limits can align clinical and bureaucratic rationales; they might appear ‘in a lot of clinical guidelines’ while also being ‘management based’ (Grant), and psychologists commonly recognise that there are ‘really big political, economic, resource reason[s]’ (Irene) for their existence. Consequently, practitioners can explicitly seek to emphasise the limits to therapy at the very start of seeing a patient. By not doing so – and instead, for instance, ‘at the beginning you say, “we’re here to solve your problems”’ – some psychologists were cautious of ‘inviting a sort of an eternal therapy’ (Carl).

Session limits affirm the need for patient prioritisation and extend the normative challenges related to those processes; as Will (a senior clinical psychologist in urban Scotland) reflected, difficult decisions sometimes had to be made in services ‘where you can only have 10 sessions or something, or whatever random number gets picked out’. Specifically, should ‘I continue to work with this person until I feel they’ve got the optimum benefit from it’ if ‘it means other people are having to wait’ as a consequence? Dana, in rural England, reflected:

My interview with Brenda was also illustrative of how session limits relate to waiting lists and the wider healthcare context. When I asked how long she might work with someone, she replied:

Like targets more generally, then, session limits can be reconfigured as beneficial to public and individual mental health. In the preceding extract, ‘luxury’ is deployed with some irony, but also almost pejoratively, in ways that attribute the benefit to longer-term therapy to psychologists themselves rather than those with whom they work. In so doing, Brenda, similar to other interviewees mentioned in this chapter, undertakes moral boundary work (Lamont, Reference Lamont2000; Pryma, Reference Pryma2017) between different kinds of clinicians.

Similarly, while not ‘totally set in stone’, the idea of session limits appeared to discipline early career clinical psychologist Leanne’s practice, in that if the number of therapeutic sessions with a specific patient was ‘creeping up’, she would discuss it with a supervisor. Adhering broadly to them was one means by which she configured herself as a good psychologist through drawing implicit boundaries between herself and others:

More generally, just as waiting time targets per se could be respecified to substantiate some forms of psychological praxis, so too could session limits – at least in principle. Arthur, who, as noted earlier, accounted for the positives in waiting time targets, described how session limits could act as ‘a kind of stimulus to be more creative’ within therapy. He gave the example of brief interventions delivered in groups, asserting that these were ‘actually better’ in terms of ‘the amounts of clinical change’ for patients than ‘longer individual therapies’. While this was not a common claim, its utterance demonstrates how autonomy can be performed in ways that enable clinical psychologists to adapt to the pressures upon them with patients configured as potential – even likely – beneficiaries of these adaptations.

Further, again similar to targets, session limits are not always an issue for individual practitioners. This is despite considerations of their wider significance. For instance, while mid-career clinical psychologist Natalie (based in physical health in an English city) was aware that other colleagues ‘have got to have capped sessions’, she was ‘generally able to offer patients the number of sessions I feel that they need’. Still, sometimes she might meet with some individuals ‘maybe sometimes less frequently than you might be, might be desirable, to fit in the people that you need to see’. Megan, who also worked in physical health, was likewise not overtly troubled by session limits, although she noted: ‘I think my manager would be a bit peeved if every person I saw for, like, six months’, given the ramifications of this for staff and service capacity and patient throughput.

Unlike waiting list targets, however, session limits are more negotiable as a consequence of the credentialed expertise clinical psychologists can claim and leverage. One mechanism for performing autonomy in this regard is through the reinterpretation of such policy as ‘guidance’ (Grey and Silbey, Reference Grey and Silbey2014). When I asked Grant, who worked in rural Scotland, if he had session limits, his reply was:

As with some others I interviewed, Molly framed herself as ‘lucky’ in relation to the governance of session limits, in this case because her manager ‘trusts us to monitor that’. Patricia, working in a CMHT in the same metropolitan area, also invoked the language of luck. When responding to a query about session limits, she described how her team was ‘kind of lucky at the moment’ because ‘it hasn’t got that far yet’. However, she also noted wryly: ‘It will, it’s coming to me, I know it is!’ Patricia described how she would ‘try and utilise my self-discretion’ in relation to how long she would see people for therapy, but ‘unfortunately I’m inheriting this big waiting list so probably I will have to be tighter’. She reflected that it was important to consider how to go about ‘balancing that and thinking about what’s appropriate for each person’. Her mechanisms for doing so appeared to meet with wider approval – or at least did not seem to have caused any alarm: ‘I’ve not been told off yet.’

These extracts illustrate how autonomy can be performed while also indicating how the spectre of harder limits on the number of sessions within which psychological care can be delivered haunts accounts of therapeutic practice. Adjacent services can provide worrying contrasts against which professionals frame themselves – despite wider challenges – as ‘lucky’. Further, while clinical judgement can be exercised, supported by assertions of expertise, this may nevertheless require the data work of reporting and/or living with the possibility of being ‘told off’. One clinical psychologist early in her career, Chloe, spoke of how she was ‘very anxious’ about the possibility that if ‘somebody’ looked at her records, they would see that she regularly exceeded session limits. In sum, session limits are shaped through waiting list and time targets and, like them, contribute to configuring psychological work.

The Constraints of Care

In this chapter, I have underscored some of the salient challenges and concerns that clinical psychologists have with waiting lists and times, and especially targets in relation to these. Over the 21st century, healthcare targets have proliferated (Bevan and Hood, Reference Bevan and Hood2006; Sheard, Reference Sheard2018) alongside the intensification of financial challenges to the NHS across the United Kingdom (Ham, Reference Ham2023; Liberati et al., Reference Liberati, Richards, Ratnayake, Gibson and Martin2023). Here, I have explored how targets function as a technology of government (Rose, Reference Rose1999). I examined how clinical psychologists describe the nature and ramifications of targets, and leveraged their accounts to generate further understanding of how professional autonomy is performed through conditions of ‘targeted’ care.

Waiting lists and targets operate as both circumstantial issues for healthcare professionals and more systemic matters shaped by harsh economic realities. Clinical psychologists, for instance, lament their effects on the care they provide, or they anxiously anticipate deleterious impacts in the future. Accordingly, targets can be considered as, in a Foucauldian sense, ‘productive’ (Foucault, Reference Foucault1989). This includes through channelling affects of anger, frustration, and sadness, and stimulating or recasting professionals’ epistemic, practical, and accountability work (Neyland and Coopmans, Reference Neyland and Coopmans2014; O’Reilly et al., Reference O’Reilly, Dixon-Woods, Angell, Ashcroft and Bryman2009). Consequently, targets can be regarded as (re)configuring the subjectivities of the individuals – clinicians and, I suggest, people seeking or undertaking therapy – that are embroiled within the psychological complex (Rose, Reference Rose1985).

The intensification of professionals’ work in response to policy shifts can enjoin styles of practice that result in reduced support for those whom they ostensibly labour (Watkins-Hayes, Reference Watkins-Hayes2009). In the case of clinical psychology, resolving the problems of waiting lists and associated waiting time targets often involves processes of prioritisation that can employ implicit – and at times explicit – strategies of exclusion and even inaction. These techniques result in various kinds of informal categorisations of people seeking psychological care, which contribute to how people are ‘made up’ prior to and during therapy (Hacking, Reference Hacking1995, Reference Hacking2002). In turn, we might expect these processes of subjectification to become imbricated with how clinical psychologists practice with particular patients (e.g. those classified as unlikely to be ‘appropriate’ for a given service), contouring the nature and outcomes of therapeutic praxis. The social and organisational technologies employed within healthcare can thus be understood as having the potential to participate in the constitution of the psychological itself.

There are also more tangible implications for people seeking care. We have seen, for instance, how some clinical psychologists account for themselves and their acts as being configured through a kind of externally imposed pressure (Mladovky, Reference Mladovky2023) that can encourage discharge. In that respect, decisions can be framed as active and autonomous. This is as opposed to an unreflexive failure to ‘let go’ of patients who are judged as unlikely to benefit further from the additional application of psychological expertise, or who were unlikely to benefit in the first place. Despite the challenges of healthcare targets, then, some clinical psychologists find ways to accommodate these and align them with pre-existing and reworked therapeutic rationalities (cf. Harrison and Dowswell, Reference Harrison and Dowswell2002; McGivern et al., Reference McGivern, Currie, Ferlie, Fitzgerald and Waring2015; Waring, Reference Waring2007). Doing so folds the kinds of practice targets enjoin into ideals of good care (Pols, Reference Pols2003, Reference Pols2006).

On occasion, clinical psychologists narrate their tribulations through a discourse of inevitability (Leonardi, Reference Leonardi2008; Pickersgill, Reference Pickersgill2024), explaining actions as logical consequences of wider contexts and individual circumstances. Still, practitioners are able to perform autonomy in certain ways, even if only to adapt to the pressures they experience. Such performances simultaneously advantage and disadvantage different patient groups, resulting in a kind of ‘exclusionary inclusion’ (Decoteau, Reference Decoteau2013). Referral criteria, for instance, are a mechanism for ensuring that clinical resource is, ostensibly, apportioned to those deemed most in need, while also serving to address waiting time targets by effectively narrowing the population of potential service users. Understandings of need itself, however, can be regarded as configured by political exigencies around what money is invested and the epistemic politics of clinical psychology. These shape what is known about ‘what works’ and for whom – and thus who, ultimately, can access care. Often developed by practitioners themselves, referral criteria can consequently act upon others as technologies of exclusion. Given what we know about the imbrications of psychology and society (as discussed in the introductory chapter), the resulting ‘micro-rationing’ (Hughes and Griffiths, Reference Hughes and Griffiths1997; Vassy, Reference Vassy2001) might serve to benefit some seeking therapy over others. In the next chapter, I will attend further to some of these matters through an analysis of how clinical psychologists involuntarily discharge patients who do not attend appointments (DNA).