Within the United Kingdom, IAPT/NHS Talking Therapies is surely the most visible example of attempts to enhance the accessibility of psychological care (Pickersgill, Reference Pickersgill2019b; Pilgrim and Carey, Reference Pilgrim and Carey2012). Beyond this well-resourced initiative, however, there have been funding changes for mental healthcare more broadly. These have resulted in cost-cutting measures and created workforce challenges, with claims made that patient care has been compromised as a consequence (Gilburt, Reference Gilburt2015). There are various effects of this on whether someone can access therapy (and if so, what kind and for how long). Even if a service is technically available, for instance, and a GP has referred someone to it, the referral might still be declined by a busy psychological practitioner.

This chapter examines how clinical psychologists manage, and make decisions around, patient referrals – the prefaces of care per se, which can either enable or preclude access to therapy. Such negotiations involve a rather different type of boundary work to that seen in the previous chapters: the negotiation of the boundary between certainty and uncertainty, and the subsequent substantiation of the decisions that follow from this. Following a referral, clinical psychologists must resolve an uncertain situation: Should they accept this, and continue forward to an assessment? Thereafter, they must decide whether the person referred is suitable for their service – and, indeed, for therapy more generally – and find ways to justify whatever happens next. These decision-making practices involve a form of morally inflected professional judgement (Styhre, Reference Styhre2013) that involves configuring different kinds of ontologies which entail their own set of boundaries.

One interpretation of uncertainty is as an affective state of individuals acting within specific sociopolitical and clinico-epistemic infrastructures. It can also be viewed as a constitutive characteristic of biomedical practice in which clinicians and researchers variously both live with and set about clarifying different kinds of ambiguity (Calnan, Reference Calnan1984; Fox, Reference Fox1980; Timmermans and Angell, Reference Timmermans and Angell2001). Uncertainty is not necessarily something that practitioners refrain from acknowledging (Gerrity et al., Reference Gerrity, Earp, DeVellis and Light1992). Still, it is often – but not exclusively – ‘worked upon in medical settings to effect its elimination’ (Ross, Reference Ross2017, p. 90), with certainty ‘a moral ideal to be achieved’ (Adamson, Reference Adamson1997, p. 135). In conditions of uncertainty, expert knowledge can act as a key resource within decision-making (Sulik, Reference Sulik2009), serving to reinforce the autonomy and power of practitioners within clinical interactions (Broom and Woodward, Reference Broom and Woodward1996).

The practices of clinicians might not be directly or primarily experienced and self-categorised as being carried in a state of ‘uncertainty’, while nevertheless the tasks being undertaken are precisely aimed at clarifying a hitherto undefined plan of action. Such manufacturing of certainty requires engagement with a range of epistemological and normative ambiguities: What do we know? How should we act? What will come to pass as a result of (in)action? Uncertainty is thus, in a sense, productive (Moreira et al., Reference Moreira, May and Bond2009; Reed et al., Reference Reed, Kochetkova and Whitby2016; Thompson-Lastad and Rubin, Reference Thompson-Lastad and Rubin2020). Moving towards its resolution can involve epistemic development and the production of sociality through the imagining of different subjectivities and futures, and the animation of affects and actions to realise or avoid them. Importantly, however, the risk remains that none of this will result in a situation regarded as satisfactory by healthcare professionals working the boundaries between certainty and uncertainty – or those seeking therapy who are subject to its effects.

Within clinical psychology specifically, practitioners must decide what patients to work with, and to what ends. This can be tricky, not least given the indeterminacy of therapy: what should be done about a referral is not clear in part because what will happen as a result of an intervention cannot be known in advance (cf. Halpin, Reference Halpin2022; Hayes et al., Reference Hayes, McCabe, Ford and Russell2020; Hollin, Reference Hollin2017). Decision-making around referrals – as with so much else – further involves assumptions about persons that can invoke gendered, raced, and classed imaginaries and which might ultimately be deleterious to potential service users (Kugelmass, Reference Kugelmass2016). Alongside these issues are the configuring and navigation of less obviously fraught yet nevertheless charged matters, such as particular framings of a service and of the expertise of therapists. Configuring these can also result in potentially iniquitous forms of professional action; for instance, when a service might have an informal policy of declining to accept for referral people who live with certain psychiatric diagnoses (such as borderline personality disorder) (King, Reference King2001).

In navigating uncertainty, clinical psychologists – like other health professionals (Kuiper et al., Reference Kuiper, Borry, Vears, Van Esch and Van Hoyweghen2023; McEvoy and Richards, Reference McEvoy and Richards2007) – juggle service demands and pressures, patient requests and concerns, and their personal ethical and epistemic frameworks for considering who should receive therapy and why. This juggling is itself a social process: ultimately, decisions rest with individuals, but choices are shaped through imagined socialities and actual engagements. The uncertainty work (Moreira et al., Reference Moreira, May and Bond2009; Pickersgill, Reference Pickersgill2011) of adjudicating access to psychological therapy can consequently itself be characterised as a social process, as well as the affective state noted previously.

In considering the prefacing practices of psychological care, I focus my analysis on clinical psychologists’ accounts of how decisions are made – that is, how certainty is synthesised – about what to do with people following processes of referral and assessment. Decision-making, I argue, requires configuring at least three kinds of ontologies: the ontology of a potential patient, the ontology of the service in which they work, and the ontology of their profession. Their configuration does not occur in isolation; rather, to different extents and in varying ways, these processes happen in concert. Moreover, it is important to stress that potential service users might strategically configure their own self-presentation in ways that can contribute to securing access to care and particular kinds of treatment (Hillman, Reference Hillman2014; Stivers and McCabe, Reference Stivers and McCabe2021; Wamsiedel, Reference Wamsiedel2020). Hence, my emphasis on professionals should not be taken to suggest that their power in defining situations or selves is anything like absolute. What sociologists have called the ‘candidacy’ of people for therapy necessarily involves particular presentations of the self by those seeking it (Dixon-Woods et al., Reference Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey, Hsu, Katbamna, Olsen, Smith, Riley and Sutton2006; Liberati et al., Reference Liberati, Richards, Parker, Willars, Scott, Boydell, Pinfold, Martin, Jones and Dixon-Woods2022; Mackenzie et al., Reference Mackenzie, Conway, Hastings, Munro and O’Donnell2013), which are likely to articulate with the ontologies principally under consideration here (Chinn and Abraham, Reference Chinn and Abraham2016; Kovandžić et al., Reference Kovandžić, Chew-Graham, Reeve, Edwards, Peters, Edge, Aseem, Gask and Dowrick2011).

Aside from the insights from the literatures noted earlier, my approach in this chapter and the ones that follow is, as noted in the introduction to this book, shaped by the scholarship of Ian Hacking (Reference Hacking1995, Reference Hacking2002) and Nikolas Rose (Reference Rose1985, Reference Rose1996), among others (e.g. Danziger, Reference Danziger1990, Reference Danziger1997; Foucault, Reference Foucault, Martin, Gutman and Hutton1988, Reference Foucault1989; Woolgar and Neyland, Reference Woolgar and Neyland2013). More specifically, I take from them as useful the notion that ontologies are brought into being through discursive and practical work, including processes of classification and categorisation (rather than necessarily and straightforwardly pre-existing social interaction). These processes of configuration are also open-ended. While working the boundary between certainty and uncertainty might result in a particular course of action under specific circumstances, decisions can be challenged and revised, and the ontologies of patients, services, and professionals are subject to reconfiguration. Another assessment, a patient complaint, staff burnout, and so on can all reposition the boundaries of particular ontologies, and thus – at the same time – the boundary between certainty and uncertainty. A formal revision to service criteria, for instance, might reconfigure multiple ontologies, involving the re-specification of various boundaries as a result – triggering, perhaps, the making of different clinical decisions. The ontologies that form the focus of this chapter, then, are very much works in progress: processes of configuration have products that can always be unsettled and remade.

In what follows, I articulate the (overlapping) ways through which ontologies are configured in interviews with clinical psychologists based in a range of services, from highly urban to very rural, in England and Scotland (data which will also ground the two chapters that follow this one). To begin with, though, I summarise how processes of referral and psychological assessment play out at a general level. Within my analysis I respond critically to my interlocutors’ accounts while also taking seriously the notion of psychological expertise and their expressions of frustration – and sometime despair – that therapy was not better accessible (Matza, Reference Matza2018; Zhang, Reference Zhang2020).

The Process of Referral

Unlike seeing an IAPT therapist, most people must be referred by another health professional before they can access a clinical psychologist, for example a GP or even another psychological practitioner. This referral may be in the form of a letter to a relevant clinical psychologist or can be sent to a service as a whole for consideration by a team. That team could either be comprised primarily of clinical psychologists or include a range of practitioners such as community psychiatric nurses, social workers, and occupational therapists. Despite the concerns of some clinical psychologists about psychiatry (discussed in Chapter 1), the service team could in fact involve a psychiatrist as well: despite disputes between the professions of clinical psychology and psychiatry, individual professionals often collaborate well together. In multidisciplinary teams, decisions must be made not only whether to accept a referral but also whether the person seeking access to therapy should see a clinical psychologist specifically. Emma, who worked in a multidisciplinary team in rural England, described how ‘we have a team meeting every Wednesday morning, where we look through the new referrals, and then decide who is going to go and do the assessment’. This entails a set of assumptions about potential patients, as well as the negotiations of boundaries between professionals: Whose expertise is best suited for the subject that has been produced through the process of referral and the referral meeting itself?

Services vary with regard to which parts of the NHS referrals come from as well as who issued them. Services admitting, for instance, ‘people with serious mental health difficulties, or quite complex difficulties’ (Brenda) might largely take referrals from a Community Mental Health Team (CMHT) (emphasis in the original; same for the quotes that follow throughout the chapter). Referrals for people experiencing distress relating to a physical complaint, such as cancer, could be from a nurse. In these instances, the referrer might speak to a clinical psychologist prior to a formal referral to get a sense of fit for service. As Felicity (who worked in the same NHS organisation as Emma) told me, a cancer nurse might ‘ring me up or email me about someone, and we’d have a discussion with them’. Hence, and as will be unpacked later, decision-making around referrals can take place prior to their instantiation.

Referrals can also come from beyond the NHS altogether. Susannah, a senior practitioner in Scotland, told me that referrals to her child and adolescent mental health service (CAMHS) could come from schools and social work. This practice is less common outside of CAMHS, and we might speculate about how in those setting referrals from beyond statutory services are considered compared to those from well-known and trusted NHS referrers – given the extent to which the perceived expertise of referrers is salient to clinical psychologists (as we will see later here and in the next chapter). At the same time, however, clinical psychologists can sometimes have very close relationships with third-sector bodies, with this positively influencing their considerations of referrals from such organisations. This is in contrast to, for instance, unknown GPs based in large practices in big cities, whose propositions might perhaps be subject to more rather than less scrutiny.

It can also be possible – as has been championed by IAPT/NHS Talking Therapies – for people to refer themselves for psychological therapy. Nevertheless, this remains relatively rare beyond primary care settings. Anita, a senior manager who worked in such a setting in a large city, was one of the few clinical psychologists I spoke with whose service accepted self-referrals. She described her and her team’s hard work at seeking to grow self-referral despite capacity constraints and concerns: ‘We market materials in different languages, you know, bus stops, on stations, newspapers, we leaflet every household, we publicise ourselves in the newspaper or any magazine that might be going out.’ However, even when a clinical psychologist might in principle be ‘happy to accept self-referral’ (Harriet), this is, as mentioned, uncommon. Indeed, my interviewees on occasion expressed overt scepticism or disquiet about it, with Ivor (a senior practitioner in rural Scotland), for instance, cautioning that ‘the danger is you get a lot of worried well people coming forward’. On the one hand, some clinical psychologists can be alarmed at the need that lies outside their existing waiting list, with further lowering of barriers to access having the potential to make a challenging job even harder. On the other, practitioners can be alert to the possibility of a kind of ‘false need’ and its potential to distract from those regarded as truly requiring their care.

Regardless of the mechanism by which someone comes to be referred to a clinical psychologist, what happens afterwards depends sometimes on its urgency, but also – as in other healthcare settings (Buchbinder, Reference Buchbinder2017) – on what professionals judge to be the nature of the service. This includes who it is targeted towards, staff capacity, and its position vis-à-vis other services. In some cases, a single person will screen all referrals, refusing and accepting different patients and taking some to a team meeting for further consideration. Within other settings, in the words of senior psychologist Esther (based in a rural Scottish service): ‘every referral has to be considered at a team meeting before they get allocated’. Having introduced the seldom simple process of referral, I next turn briefly to consider what generally happens if someone is considered potentially appropriate for the service to which they have been referred.

The Process of Assessment

Following what is often termed a ‘successful’ referral, people seeking treatment will commonly be ‘assessed’ by a service team member. Assessment seeks to ascertain the nature of the presenting problem and whether psychological therapy (and that particular service) is the best means of addressing it. If it is a multidisciplinary service, assessment will not necessarily be undertaken by a clinical psychologist; instead, another clinician with psychological expertise might work with the referred person to jointly articulate their requirement (or not) for therapy. The time taken to see someone for an assessment varies – this reflects, for example, the service size, location, and focus. It can, on occasion, proceed at pace; Arthur, who worked in an early intervention service for psychosis in rural England, told me: ‘What we try to do as a team is, get hold of people, preferably on the same day that we get a referral at least by phone and arrange to see them within a week.’ Others, however, might wait much, much longer. Time from referral to assessment is also shaped by varied waiting list targets. For example, Irene, a senior clinical psychologist practising in adult mental health in the north of England, described to me how targets drove ‘how quickly you have to respond to those referrals’. Waiting lists, targets, and their roles in configuring access to therapy will be considered more closely in the next chapter.

Assessment is sometimes framed as the beginning of therapeutic work itself. This might be in terms of building what clinical psychologists regard as an alliance and collaboration with a patient that will provide a good basis for therapy. It could also entail the recommendation of psycho-educational resources through which people seeking care can ‘skill themselves up and inform themselves’ about the nature and purpose of psychological treatment, as described by Harriet, a mid-career psychologist who worked in adult mental health in rural Scotland. Some clinical psychologists described the boundaries between ‘assessment’ and ‘treatment’ as blurrier still, imbricating the prefacing of care with therapy per se. One interviewee working in secondary care, Grant (based in the north of England), reflected candidly on this: ‘To be honest, I struggle to distinguish assessment from treatment.’ For him, ‘as soon as you start hearing somebody’s story and you start listening to somebody’s story you’re giving them space to do something that can create change’.

Yet, assessment and treatment were clearly and sharply bounded by other clinical psychologists with whom I spoke: Irene – quoted earlier, and part of the same NHS organisation as Grant – very explicitly accounted for assessment and treatment as distinct. This was part of a longer answer to a question I asked about how she preferred to manage her waiting lists. She reflected regretfully how she might say to someone at the point of assessment that ‘unfortunately this isn’t, this isn’t us beginning therapy’, before telling them that they will ‘be waiting for possibly two years’ for treatment – when that estimate was itself ‘sugaring the pill’. Such a sweetener was needed because ‘I can’t bear to look someone in the eye and say, “you’ll be waiting three years”’. Consequently, we can see that the boundaries between assessment and treatment might be understood as more necessary to retain in situations where resources were tight and waiting lists long.

The process of assessment also enables the assessing clinician to form an understanding of what they see as the ‘suitability’ (sometimes described as ‘readiness’) of someone for psychological therapy. As will be illustrated in the following sections, appraising suitability requires the resolution of an array of uncertainties. Will the individual referred for care engage sufficiently with the therapeutic process such that enough gains are made to justify seeing them over and above another on a waiting list? Are there any predisposing factors that might interfere with therapy? Are they the kind of person the service should be seeing? An assessment thus involves not only configuring the presenting issue but also the subjectification of the person being assessed.

Configuring Patients

Towards the end of my interview with Ivor, a senior clinician working with older adults, I asked what complaints would be made ‘when psychologists get together’. His answer: ‘probably the workload, number of referrals that come in’. This refrain is common. Lots of referrals make for long waiting lists, and these can sometimes be felt to be endless – with associated targets something that, as senior CMHT psychologist Liam described to me, ‘dominates my daily life, my nightly life’. Decisions around prioritisation are always a challenge within healthcare (Allen et al., Reference Allen, Griffiths and Lyne2004; Berg, Reference Berg1997; Dew et al., Reference Dew, Stubbe, Macdonald, Dowell and Plumridge2010; Hoeyer et al., Reference Hoeyer, Jensen and Olejaz2015; Vassy, Reference Vassy2001) and can be difficult to make and to defend. The following is a lengthy extract from my interview with Irene, whose comments illustrate how moral and procedural uncertainties around prioritisation can be rendered explicit and subject to reflexive work:

The problems of workload and waiting lists are compounded – and rhetorically managed – when referrals are framed as ‘inappropriate’. As Briony, an early-career clinical psychologist in an urban Scottish service, told me, ‘sometimes you’ll get referrals and you’ll think, “that’s definitely not for us”’. A referral might, for instance, be configured as inappropriate if someone was drinking alcohol or consuming illegal pharmaceuticals in a fashion that clinical psychologists considered excessive and in ways regarded as contraindicative to therapeutic success. Consequently, illegal substance use is not an uncommon exclusion criterion for a service; senior practitioner Esther noted that if someone had not ‘stopped’ drinking they would be sent ‘back to another service’.

Dierdre, who worked with children in Scotland, described an inappropriate referral as follows:

Another senior clinical psychologist in an urban English service, Ursula, reflected that she might not accept a referral into her service as a consequence of ‘social’ issues:

Key, then, to the work of determining whether to accept a referral is a requirement to configure a perceived need for (a certain style of) treatment within someone seeking care. This process is contoured by understandings and experiences of wider service pressures, resource challenges, and forms of priority setting (Allen et al., Reference Allen, Griffiths and Lyne2004; Vassy, Reference Vassy2001), which are themselves politically shaped (Joyce, Reference Joyce2001; Moreira, Reference Moreira2011; Syrett, Reference Syrett2003). However, need itself is not enough, and configuring the patient exceeds the configuring of need per se. Important as ontologies of distress are, so too are the wider psychosocial dimensions of a person that are deemed to modulate distress and the possibilities of intervening in it.

This configuring might initially be undertaken in the absence of the very individual seeking or referred for therapy. In this respect, decision-making is made actionable through inscriptions of people found within referrers’ letters, any additional locally available information, and perhaps an informal conversation with the referrer. Leanne’s reflections illustrate this point:

Such conversations can place uncertainty work upstream of the actual referral. As Leanne said,

Naturally, practices vary. For instance, Grace, a senior clinical psychologist working in physical health in the same NHS organisation as Leanne, said she would undertake an assessment even in the case of an ostensibly inappropriate referral:

However, Grace also stated that she was sent inappropriate referrals only ‘Very very rarely’. Hence, the extent to which the ontology of a patient is configured at a distance seems, to an extent, to be a function of a wider workload that itself relates to how the service is construed both by the psychologists working in it and by those referring to it (see, relatedly, King, Reference King2001).

A mid-career clinical psychologist working in adult mental health in Scotland, Harriet, also emphasised the importance of meeting with everyone who passes an initial referral screening ‘to determine if psychology’s for them’. This determination is a key point during a process of ontological configuring: it is where a psychologist makes certain that the patient is the kind of person who not only fits with the service but will benefit from therapy. Such a framing of assessment implicitly configures psychologists as having specific expertise not only in the administration of psychological therapy but also in ascertaining its likely success. This notion of the expert psychologist will be explored more fully later in this chapter.

The attribution of ‘readiness for therapy’ is a salient aspect of the uncertainty work of determining if psychological therapy should progress, and clinical psychologists tend to strongly emphasise its import. Ascertaining ‘readiness’ might involve configuring someone as being suitably ‘psychologically minded’. This is a term that has circulated within the psy-professions for more than 50 years now (e.g. Appelbaum, Reference Appelbaum1973). Epistemic authority for ascertaining this can, to an extent, be delegated to various technical instruments. One of these is the Psychological Mindedness Scale (Shill and Lumley, Reference Shill and Lumley2002), which was used by Brenda, a clinical psychologist working in secondary care in the south of England. However, not all practitioners use this kind of tool; most I have spoken with instead deploy clinical experience and judgement to configure and perceive psychological mindedness within someone.

The determination of psychological mindedness can have significant effects: it subjectifies a person as psychologically minded, itself hardly a morally neutral ontology within the context of (potential) psychological care. The concept also reaffirms the expertise of clinical psychologists, since they can often claim to have the best skills among an interdisciplinary team to recognise psychological mindedness. This does not necessarily afford benefit to specific patients, however, since an expert (and hence hard to challenge) declaration of the absence of psychological mindedness can contribute to the preclusion of therapy.

One senior clinical psychologist, Esther, spoke of the importance of psychological mindedness while simultaneously reflecting about its lack of conceptual clarity: ‘I don’t think anyone’s come up with the definitive idea on that.’ Esther described how she would often be asked to do assessments for ‘difficult’ cases, with a particular view of ascertaining whether someone would benefit from psychological therapy. I asked her, ‘How do you make those calls?’ She answered:

Esther’s concluding question relates to the professional skill of clinical psychologists in appraising a person’s capacity to benefit from therapy. Other sociological scholarship on mental health has underscored the continued moral dimensions of the psychological complex and the varied ontological, epistemological, and practical exclusions that can occur within it (Brossard and Chandler, Reference Brossard and Chandler2022; Lane, Reference Lane2020; Mladovsky, Reference Mladovky2023). We might, then, take the position that there are good reasons to assume that the synthesis of certainty in this respect will be far from free of bias (Kugelmass, Reference Kugelmass2016). As the final substantive section of this chapter will elaborate, navigating the question of whether to work with an individual deemed unable to benefit from therapy itself contributes to configuring clinical psychologists’ professional ontologies.

In summary, referral and assessment generally entail the configuring a patient as being like ‘X’, where ‘X’ is a multifaceted biopsychosocial matrix. ‘X’ might, for instance, encompass (1) someone’s demographic categories like age and ethnicity; (2) psychological identifiers such as the nature of the presenting issue and ‘readiness’ or ‘motivation’ for therapy; and (3) social and personal indicators including employment status, and the existence of networks of support beyond the NHS. Importantly, ‘X’ might also be defined in the negative, and more clearly enact ontological boundaries, as in ‘not like A, B, or C’ (e.g. not a regular user of illegal substances, such as heroin). The subjectification that results from such uncertainty work produces typifications that make professional work more straightforward to undertake. At the same time, people seeking therapy are also situated within a larger moral order of value in relation to how viable they are as successful therapeutic subjects, and what factors are taken to impact on such viability (Latimer, Reference Latimer1997). While patient ontologies were often concretised in person, through the aforementioned accounts we can see that certitude about the (in)appropriateness of a referral can also be synthesised in the absence of the very person subject to such adjudication. In these instances, inscriptions of them within the text and talk of other professionals are framed as more valuable in limited-capacity services than time spent assessing someone face-to-face. (Pre-)Assessment in the absence of the individual referred for psychological care can thus act as a kind of implicit or even explicit healthcare rationing. A provisional configuration of a patient as like ‘X’ can be later substantiated, or further clarified, through actual discussion with them. Aside from the dimension of readiness for therapy, the centrality of certifying whether a someone is like ‘X’ is to ensure compatibility with an ostensibly predefined service ontology, legitimising initial decisions made about the acceptance or denial of a referral. However, as we will see, service ontologies are also often configured through the prefacing practices of clinical psychologists.

Configuring Services

During my fieldwork, I was occasionally informed that the establishment of IAPT had resulted in disinvestment in other services and/or longer waiting lists. Some respondents who were involved in the development of IAPT itself hotly contested such claims of disinvestment. Still, the lived experience of many clinicians – at least as narrated to me – was one within which IAPT had impacted the wider mental health ecosystem in a range of ways, including some that were overtly negative. As Kent, a senior clinical psychologist in urban England, put it: ‘commissioners feel that they’re already funding services to take care of patients’ needing psychological therapy, ‘but then the services that are being funded don’t really feel that they have the capacity, or the skills’ for particular individuals. Ursula, who worked in an English service geared towards ‘complex’ forms of psychological ill-health, asserted that ‘we’re getting more referrals that IAPT won’t see’, which ‘increases the demand on our service, whereas actual resources aren’t getting any bigger’. Some practitioners – like Dana, a clinical psychologist working in physical health in rural England – were concerned that there was ‘such a gap in service between primary and secondary mental health care that lots of people are falling in that’. Similar reflections are often made by people seeking access to psychological care, who can experience being too unwell for entry into some kinds of services at the same time as being not unwell enough for others.

The impact of the mental health and social care ecosystem on specific services is not just restricted to the ramifications of IAPT, however. Rather, wider shifts in the landscape of formal services and the finances of third-sector organisations in light of the politics and economics of austerity in the United Kingdom have shaped what is possible for patients and what is doable by clinicians. This creates circumstances within which psychologists are confronted with uncertainties that might not otherwise be encountered. Dana foregrounded this through an example of being referred a patient – such as someone with a head injury – on the basis that the referrer did not ‘know how or what to do with that person’. She reflected that ‘if there were local [third-sector] services for them’, then ‘they would be doing those things in the community’. Accordingly, an absence of wider health and social services can coerce clinical psychologists into ontological negotiations they would rather leave for someone else.

Clinical psychologists often told me that waiting lists placed them under a great deal of pressure. As noted above, this will be unpacked more in the next chapter; here, it suffices to say that such experiences of pressure shape decision-making about referrals. Partly to manage demand, some services – like the CAMHS service mid-career clinician Verity worked in – had ‘very detailed referral criteria’ and inclusion/exclusion criteria for what kinds of people should be seen. Some clinical psychologists were critical of these: as one senior secondary mental healthcare practitioner put it, ‘I hate services that are precious’ (Louise). Nonetheless, inclusion/exclusion criteria and tightly defined service remits are common.

Such criteria are not, however, necessarily immutable. Senior clinical psychologist Arthur, for instance, framed his rural English service remit as feasible to flex to accommodate people judged to be most in need; in his words, there could be ‘a kind of stretching of the services’. In a resonant account, Carl – another senior practitioner in the same NHS organisation – discussed how he managed a service focusing on ‘the severe and complex part of, of psychology, related to adults’. Sometimes, however, individuals were accepted who were regarded as belonging to ‘a group who are, if you like, severe and not complex’. This was, as Carl admitted, ‘probably quite a small number’. Still, it is clear that some clinical psychologists are, on occasion, able to reconfigure the boundaries of their service to accept patients who they perhaps formally should not. This is suggestive of a kind of moral economy, participation in which itself implies a resistance to bureaucratised forms of care that has the potential to stifle compassion and empathy (Matza, Reference Matza2018). At the same time, it also raises questions about equity of access in relation to potential patients who are not accepted following a referral – in other words, the people for whom services do not ‘stretch’.

Less commonly, some interviewees were explicit about the boundaries of their service, reporting a lack of facility to stretch it. Leanne, a clinical psychologist in Scotland early in her career, underscored how the presence rather than absence of other services impacted how she saw her own service and those referred to it. She indicated how the existence of other options for people seeking care enabled her to reify service boundaries, as part of a process of what sociologist Mara Buchbinder (Reference Buchbinder2017) terms ‘facilitative’ gatekeeping. In a discussion about referral processes, Leanne simultaneously described both limits for her service and a kind of person who would not necessarily benefit from it, and noted that exclusion could feasibly be beneficial:

Resource restrictions and allocations were also sometimes deployed within the interviews as devices through which to configure and legitimate service boundaries. Leanne configured an identity for her service in relation to the funds that were available to support its operations:

Limits to capacity were alluded to by Esther while discussing assessment:

Clinical psychologists working in services where they managed the psychological issues relating to physical ill-health generally appeared to have less difficulty in clarifying service ontologies and making decisions about access. In essence, choices were made largely in relation to the physical issue for which a service was specifically funded to provide care. When I asked Felicity, a relatively recently qualified practitioner, whether there would ever be instances where a decision would be reached that a referral was in some sense not quite right for her service, she replied:

However, even for ostensibly closely characterised services aimed at addressing the psychological dimensions of physical ill-health, ontological stretching could still occur when, for instance, ‘clinical judgement’ (Amy) suggested this was necessary. As Felicity continued,

These comments demonstrate that the stretchiness of a service is itself a property that can shift and change over time. Again, this is accounted for as a consequence of the wider ecology of services. In Felicity’s case, a decision was reflexively made to exclude people seeking care to galvanise support to develop an additional service. Hence, denial of access can be presented as a rational course of action that reflects the clinical and economic realpolitik of the NHS. In so doing, the pain of specific individuals becomes reconfigured as a resource to support the expansion of psychological therapy for a larger population.

To recap, formalised service boundaries were often in place to manage waiting lists, yet clinical psychologists could sometimes renegotiate inclusion/exclusion criteria to accept particular people into therapy. Reconfiguration of a service ontology might be in response to wider resource challenges and the risks of patients falling between the cracks of different services. Resources were similarly introduced by respondents to account for why they might not take on particular individuals, ossifying service ontologies. Likewise, the presence rather than absence of alternative services could be invoked to concretise service boundaries. The discursive processes through which clinical psychologists configured service ontologies, then, was in part a function of the wider economic and organisational context within which those clinicians were embedded. At the same time, clinicians also exercised individual agency in how they engaged with this context in the resolution of ‘uncertainty moments’ through implicit and sometimes explicit judgements about who is most in need of access to psychological care. Sometimes, this will mean accepting people for therapy even though they do not quite seem to align with the formal service remit. Others who are referred for different reasons or whose presenting issues are constructed differently by a clinical psychologist will not, however, be accepted into a service. Service ontologies are consequently negotiable, yet not infinitely so, further complicating the algebra of healthcare rationing, and (dis)advantaging some patients over others.

Configuring Clinical Psychologists

Through talk of referrals and assessments, the clinical psychologists with whom I spoke tended to configure their own ontologies as professionals alongside those of patients and services. During my fieldwork, two key moral and epistemic constructions commonly emerged: the good clinical psychologist and the expert clinical psychologist. Within these, practitioners as individuals and as a professional group can be regarded as synecdochical.

Earlier I described how the prefacing practices involved in accepting a referral often entail a requirement for a given clinical psychologist to configure a potential patient as being compatible with a particular NHS service. I also showed how a seemingly settled service ontology can sometimes be reflexively reconfigured to accommodate a particular (kind of) person. This can even include someone characterised as ‘unready’ for therapy. Arthur reflected on this as follows:

This account appears to be framed critically, on two counts. First, Arthur seemed to imply that clinical psychologists should not take on people who were ‘unready’ for therapy. Second, he critiqued the ‘pressure’ placed on professionals to nevertheless do, thus exonerating clinical psychologists for acting in ways that might otherwise be undesirable. In this respect, Arthur paints a complex picture, one in which the challenges of delivering care for many results in it being apportioned to some specific individuals who otherwise might and – according to the epistemologies of practice performed by a variety of clinical psychologists – perhaps even should go without. While morally ambiguous, the professional figures painted here are nevertheless, ultimately, good: they are clinical psychologists who do what they can to help in difficult circumstances.

Notions of readiness and psychological mindedness were leveraged in some interviews in discussions that presented exclusion from therapy as a form of care, and which consequently preserved the clinical and moral identity of a psychologist as ‘good’. Brenda explained that it was important to ascertain that someone was ‘ready’ for therapy before accepting a referral, reflecting:

Yet, through the course of the interview it appeared that Brenda’s default position was in fact to accept someone into therapy. She described how she would undertake psycho-educational activities with a patient to increase ‘psychological mindedness so that they really are open and ready’ for therapy. Consequently, Brenda’s talk configures her as a good clinical psychologist who exercises evidence-based clinical judgement (Timmermans and Angell, Reference Timmermans and Angell2001) in three ways: first, by describing work with patients to actively configure them as subjects amenable to therapy; second, by implying that not accepting someone for therapy is a form of care, since it would prevent them ‘feeling quite a failure’ if not ready for a psychological intervention; and third, by alluding to research that grants epistemic legitimacy to her account.

Similar sentiments were expressed by Chloe, an early-career psychologist working in Scotland:

An account of readiness was not always essential in constructing a clinical psychologist as ‘good’ when not accepting someone for therapy, however. For instance, Clarisa, a senior clinical psychologist in urban England, noted that ‘if the person doesn’t really sit with us’, then ‘I think it’s our responsibility to really help the person to be signposted’ to another service. Through underscoring the assistance that would be provided to a person in absence of psychological treatment, Clarisa (and several other interviewees) configured themselves within their talk as caring practitioners even while describing a context in which they would refuse access to their services.

Closely relating to the good clinical psychologist was the figure of the expert clinical psychologist, who was, for instance, skilled in making judgements about readiness in the first place. Issues of expertise were commonly raised in discussions about access to services, with respondents sometimes foregrounding the different kinds of understanding, knowledge, and experience clinical psychologists brought to bear in practices such as multidisciplinary assessment (or discharge) meetings, as well as in treatment itself. Regarding assessment, Anita, a senior practitioner working in primary care, reflected that some CBT therapists are ‘not able to really fully assess or formulate and think about engagement’ whereas clinical psychologists ‘are able to do that. And I think that skill is quite unique, which really enables engagement.’ In relation to treatment, Leanne described how in her service ‘the slightly, I suppose, less complex cases, would go with the CBT therapist, and the clinical psychologist would take the more complex ones’. These comments are a reminder of some of the points underlined in the first part of this book: that in times of strained resources, where clinical psychologists are an expensive professional group and waiting lists threaten to grow and grow, configuring the boundaries of expertise can be a well-rehearsed and strategically enacted process.

Configurations of expertise were also supported by a discourse of scarcity (Frank, Reference Frank2013); in Leanne’s words, psychology was a ‘really limited resource’. One dilemma relating to this was reflected on by Carl, who talked about the challenges of undertaking some kind of ‘stop-gap’ work with people on long waiting lists in his rural English service, for example ‘bibliotherapy with occasional meetings’. However, a consequent ‘conundrum’ is that ‘every time you do that, you take away from, you’re using the same resource that’s been used to do the end-point therapy’. Carl did not think ‘psychologists should be doing that, actually’; rather, ‘someone else should be doing it!’ – presumably someone less well paid. Akin to the notion of therapeutic wastage discussed in Chapter 2, clinical psychologists can thus configure themselves as having highly specialist, uniquely important, and very valuable skills subject to selective apportionment between different patients and purposes.

Expertise and a discourse of scarcity also figured in Carl’s account and that of some other senior clinical psychologists when discussing who they might themselves see for assessments and/or therapy (e.g. Esther in Scotland, and Irene in England). Since the capacity of clinicians in senior management roles to work with patients directly was limited, they or their team might carefully select individuals who would be deemed to benefit from their particular constellation of experience and expertise. As Carl described, his team ‘would ask me to see particular people who they thought it would be a good idea if I saw them’. Carl went on to configure himself as follows: ‘[My team] know that I’m a reasonably flexible, integrative sort of therapist, and that I can form working alliances with, with difficult people.’ For senior clinical psychologists, then, the uncertainty work regarding not just whether someone should be seen but also who should see them enjoined a reflexive process of configuring their own identity in relation to skillset, experience, and indeed disposition. Of course, central to this was also a configuring of patient ontologies prior to therapy itself: Were they the sort of person who required the costly resource of senior staff time – for example, were they sufficiently ‘complex’ (Irene)?

In this section, I have illustrated how the ontologies of both the good clinical psychologist and the expert clinical psychologist come into play within practices of referral and assessment, and the work of making certain that a particular patient should be seen for therapy. These ontologies are, again, also a function of the wider healthcare and political circumstances within which clinical psychologists are situated. For instance, claims to (greater) expertise are strategically useful in an economically orientated mental health policy context that positions other professionals, like CBT therapists, as the answer to the problem of restricted access to services. Constructions of the good clinical psychologist also legitimate difficult decisions made by practitioners when not taking on a person for therapy, or when contravening professional and epistemic norms to do so. Finally, the realisation of professional ontologies and the praxis of working the boundary between acceptance into and preclusion from therapy are reciprocally constituted. In other words, it is in part through ascertaining whether to take on someone for therapy that professional ontologies emerge and are validated and sustained, shaping future engagements with potential service users.

Reciprocal Configuration

Following a referral, decision-making about whom to accept for therapy (and how long to continue it) entails the (partial) resolution of uncertainty. In essence, clinical psychologists must address a question that has an answer which is only ever legible within particular epistemic, economic, and moral contexts: What, practically speaking, should happen next to the patient? This procedural uncertainty relates to the matter of therapeutic indeterminacy (cf., Hayes et al, Reference Hayes, McCabe, Ford and Russell2020; Hollin, Reference Hollin2017): there are multiple possible outcomes of therapy, including null or even negative effects. The work of responding to procedural uncertainty entails a form of skilled judgement (Styhre, Reference Styhre2013) involving the configuring of three key ontologies: that of the patient, the service, and the clinical psychologist (as both an individual and a professional group). In this respect, movement through uncertainty moments is (psycho)socially productive: action, affects, and ontologies are realised through the synthesis of certitude (Kuiper et al., Reference Kuiper, Borry, Vears, Van Esch and Van Hoyweghen2023; Moreira et al., Reference Moreira, May and Bond2009; Reed et al., Reference Reed, Kochetkova and Whitby2016) as part of the prefacing of (potential) care.

Rather than merely reflecting realities, the processes of configuration clinical psychologists engage in can be regarded as helping to bring them into being (Hacking, Reference Hacking1995, Reference Hacking2002). While patients, professionals, and services obviously pre-exist uncertainty work, ontologies are clearly configured and sometimes reconfigured through this, as opposed to necessarily patterning outcomes in a straightforward fashion (Moreira et al., Reference Moreira, May and Bond2009; Pickersgill, Reference Pickersgill2011). Those seeking therapy – and, to an extent, those who might provide it – can be marked deeply, for better or for worse, by the certainties clinical psychologists produce at the point of referral or assessment, perhaps especially if a decision is reached to offer no treatment at all.

Even if accepted for therapy, working the boundary between certainty and uncertainty configures patients (and providers) in particular ways; given the intersubjective nature of psychological practice, this can be expected to have implications for future care. The configuring of ontologies within clinical psychology consequently has normative dimensions, beyond barriers to access per se. These further include the role of bias (Kugelmass, Reference Kugelmass2016): not as some kind of exogenous entity introduced into a dispassionate and objective professional appraisal, but as a constitutive element of clinical experience that shapes and directs the management of uncertainty and therapeutic (in)action. Clinical psychologists, it seems, are able to exert power to configure patients and services – even within limits imposed by wider economic and organisational factors – in a fashion that can stretch or shrink a service remit and facilitate or deny access to it to particular people. An epiphenomenon of this autonomy will likely sometimes be the reproduction of forms of structural discrimination within the micro-sociology of the assessment.

Navigating procedural uncertainties further participates in the configuring of clinical psychologists as both expert and good: synthesising certainties enjoins invocations and practices of the resourceful application of credentialed knowledge towards enabling or enhancing care. What is important to note, however, is that clinical psychologists can produce different modes of care that are moulded by context (Pols, Reference Pols2003; Schwennesen and Koch, Reference Schwennesen and Koch2012). For instance, both seeing someone who is deemed unready for therapy and not seeing them can be configured as worthy acts. In effect, the denial of access to care can in some cases affirm professional identity as a good psychologist. As we will see in the chapters that follow, resonant issues can play out in the management of waiting lists and with regards to the sometimes involuntary discharge of individuals from therapy.

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).

Clinical work is always enacted in relation to the organisation of healthcare systems, and the economic and political rationalities shaping these (Scheid, Reference Scheid2004; Strauss et al., Reference Strauss, Schatzman, Burcher, Ehrlich, Sabshin, Fagerhaugh, Suczek and Wiener1985). Local policies and routinised bureaucratic practices are key elements of the infrastructures undergirding care (Timmermans and Almeling, Reference Timmermans and Almeling2009). These can be reconfigured in relation to the shifting salience of national matters, such as waiting time targets. In Chapter 5, I analysed the configuration and performance of professional autonomy within clinical psychology against the backdrop of targets and financial constraint. Here, I explore the uncertainty, affective, and moral work inherent to clinical psychologists’ adjudications of what should happen to people who do not attend the therapy appointments that have been scheduled for them. I consider in turn how such arbitration can be both enabled by and enabling of autonomous action in ways that have serious implications for potential or ongoing access to psychological care.

Formal and informal patient attendance policies are key infrastructural arrangements supporting professional decision-making in relation to what many term DNAs (people who ‘did not attend’ appointments). As such, these policies can prompt exclusion from services and contour clinical perspectives around why this might be desirable. Over the last 15 years or more, I have encountered multiple articulations of concern about how psychological services manage non-attendance. These have been advanced by people who have accessed services (or tried to), activists, and advocacy organisations, as well as some health professionals themselves. In my interviews with clinical psychologists, responses to queries about DNAs could be lengthy. They not only described the processes per se but also indicated how they related to DNA policies and to the broader labour of psychological care. I interpret these interview data against the backdrop of more casual conversations I have had with practitioners about ‘non-attendance’. Such dialogues often made explicit many of the matters that can be implicit within my structured research encounters, and accordingly have shaped the analysis I present.

While healthcare is powerfully shaped by policies and guidelines (Berg, Reference Berg1997; Timmermans and Berg, Reference Berg1997), healthcare professionals are also well known for their improvisation skills (Jensen and Vabø, Reference Jensen and Vabø2024; Kamp et al., Reference Kamp, Grosen and Hansen2023; Kuijper et al., Reference Kuijper, Felder, Bal and Wallenburg2022;) and can take a more ‘discretionary’ (Johannessen, Reference Johannessen2017) approach to practice (Dew et al., Reference Dew, Stubbe, Macdonald, Dowell and Plumridge2010; Kellogg, Reference Kellogg2011). Attendance policies are no exception, with nuanced negotiations of these often apparent within clinical psychology. As we will see, these are underpinned by processes of moral characterisation and configurations of expertise, which both unfold from and are constitutive of accounts of DNAs.

Non-attendance and Healthcare Resource

Patient attendance is an enduring issue for healthcare systems. Often, resource-related arguments about non-attendance inform discourse within political and policy arenas. An illustrative example comes from political reporter William Russell (Reference Russell1984), writing in the British Medical Journal, which triggered various letters in response. Russell’s article described a discussion in the UK House of Commons around people not attending appointments, and the introduction of computers into the NHS to help monitor this. According to Russell, the then Under Secretary of State for Health, Conservative MP John Patten, asserted ‘the need for hospital patients to recognise their moral responsibility to turn up on time for appointments in order not to waste valuable NHS resources’ (Russell, Reference Russell1984, p. 1928). While the politics of the NHS – and the associated responsibilisation of patients (Miller and Rose, Reference Miller and Rose2008) – ebb and flow, such sentiments could still be encountered decades later. As one senior official commented following the rollout of more digital ‘solutions’ to DNAs within the NHS:

The financial dimensions of patient non-attendance at clinical appointments have also sometimes been made clear with regards to worries about waiting times following the COVID-19 pandemic (which has had significant impacts on how quickly people can be seen by services; Shah et al., Reference Shah, Robertson and Sheikh2024). Guidance released by NHS England in February 2023, for instance, included on its list of ‘Benefits of reducing DNAs’ the claim that reductions would contribute to ‘improving the efficiency of resource allocations by systems and therefore improve how providers can use their capacity to deliver care’ (NHS England, 2023b). Such coupling of concerns about DNAs and resource allocation is not unavoidable, however: resonant guidance on waiting times produced by the Scottish Government (2023) later that year centred attendance but avoided discussion of financial imperatives in relation to this (placing responsibilities on the NHS and individual clinicians rather than those seeking care). These rhetorical differences matter: rhetoric, after all, configures reality. Still, some in Scotland might argue that NHS England were simply more willing to ‘say the quiet part out loud’: Scottish health professionals are all too aware of the financial (and political) considerations shaping the policies that govern them.

Clinicians themselves have for decades reflected on who does not attend treatment, why, and what might be done about it (e.g. Baekeland and Lundwall, Reference Baekeland and Lundwall1975; Dengrove and Kutash, Reference Dengrove and Kutash1950). This includes considerations and concerns around the economic and practical implications for services, which can also intertwine with worries about patients per se. In relation to the latter, unscheduled missed appointments are often regarded as having adverse impacts such as enhancing ‘the risk of further deterioration, relapse and hospital readmission’ (Mitchell and Selmes, Reference Mitchell and Selmes2007, p. 423). Apprehensions can also be articulated as worries that health services themselves are not always doing all they can to support people to attend appointments. For example, one British Medical Journal article, published a few years after Patten’s reported comments, noted in its introduction that missed appointments in ‘outpatient departments may lead to inefficient use of facilities and result in unnecessary costs and delays in assessing patients’ (Frankel et al., Reference Frankel, Farrow and West1989, p. 1343). However, the paper went on to argue that this was not ‘a reflection of patients’ generalised indifference to the service offered’, but more an issue of ‘communication and administration’ (Frankel et al., Reference Frankel, Farrow and West1989, p. 1345). Directly quoting Russell’s article, it concluded: ‘Before attributing the problem of non-attendance in the United Kingdom’ to supposed patient irresponsibility, ‘it is important to ensure that the administrative arrangements are likely to facilitate attendance’ (Frankel et al., Reference Frankel, Farrow and West1989).

Clearly, as a ‘matter of concern’ (Latour, Reference Latour2004), different problematisations of non-attendance can operate in concert, with narratives of people not attending healthcare appointments reflecting varied political, normative, and clinical perspectives. Nonetheless, worries about the financial ramifications of non-attendance can be keenly felt, not least within the context of a health service that is widely understood to be underfunded and, relatedly, often short-staffed. Psychological therapy services in particular are often regarded as a ‘scarce resource’ (Houghton et al., Reference Houghton, Saxon and Smallwood2010, p. 510), with non-attendance framed as a problem in relation to a logic of efficiency (Veblan, Reference Veblen1983 [1921]) that has come to configure clinical services and practices. These issues interact with and are shaped through health service debates and wider discussions of waiting lists (Pope, Reference Pope1991), since a missed appointment can contribute to slowing a person’s journey through a service. Consequently, tackling DNAs is regularly perceived at the clinical coalface as one means by which waiting time targets can be met (Tweed and Salter, Reference Tweed and Salter2000).

Despite ongoing sociotechnical innovation aimed at maximising attendance, DNAs continue to be a feature of clinical life. Accordingly, health professionals repeatedly negotiate (non-)attendance as part of their day-to-day work. In practice, clinical psychologists can experience a missed appointment in varied ways, including as ‘rude’ (Tweed and Salter, Reference Tweed and Salter2000, p. 472). However, this can also be framed as a ‘relief’ (Tweed and Salter, Reference Tweed and Salter2000): the time that would have been spent working with someone for direct therapy is ‘freed up’ for the clinical psychologist to deal with one of the many other tasks that demand their attention (e.g. writing notes about the last person they saw). Nonetheless, at national and organisational levels there remains a drive to decrease non-attendance, with ensuing responsibilisation (Miller and Rose, Reference Miller and Rose2008; Rose, Reference Rose1996) and subjectification (Hacking, Reference Hacking1995, Reference Hacking2002) of healthcare professionals and people seeking care. As the following sections will show, how this agenda instantiates within the NHS varies among clinical psychologists and services yet commonly acts to configure practitioners as autonomous experts. This is even as formal policies and procedures can act to prompt or nudge them in the direction of discharge.

What Do ‘DNA Policies’ Look Like?

DNA policies seek to encourage a particular disposition and set of actions on behalf of individuals referred to or engaging in therapy: most ideally, to be a regular and timely attender of appointments – and so to be a cooperative, ‘good’ patient (Lorber, Reference Lorber1975). However, DNA policies also configure clinical psychologists themselves. Specifically, professionals are incited through DNA policies to work with people in ways that are regarded as likely to reduce the likelihood – indeed, the organisational ‘risk’ – of non-attendance, and so decrease the chance of discharge. In other words, DNA policies act as a technology of government (Rose, Reference Rose1999) which enjoin clinicians to practise in ways that seek to delimit the conditions of possibility for someone to be configured as a ‘problem’ (Lorber, Reference Lorber1975) or even ‘bad’ (Dingwall and Murray, Reference Dingwall and Murray1983) patient. At the same time, people can be configured as such precisely because of and through such policies.

DNA policies are wide-ranging, although a rule of ‘three strikes and you’re out’ (with three missed appointments leading to exclusion) is not uncommon. However, some services ostensibly permit only one unarranged missed appointment prior to potential discharge. Where I work in Edinburgh, the local Child and Adolescent Mental Health Service (CAMHS) – part of NHS Lothian – includes the following caution on its webpage:

Harriet, a mid-career clinical psychologist, described a similar policy in her adult mental health service elsewhere in Scotland:

Given that the capacity of primary care is notoriously limited, one might wonder how likely it is that a GP would in fact ‘chase’ someone in this way. However, positioning GPs as having the capacity and expertise to engage a potential patient for psychological services and prepare them for therapy can help to absolve clinical psychologists of the practical and moral responsibility of doing so themselves. In the preceding extract, this absolution is also emphasised through presenting the task of engaging with people as discretionary rather than demanded by clinical judgement: GPs were said by Harriet to sometimes ‘want’ rather than ‘need’ to ‘chase [patients] up’.

Other clinical psychologists likewise operated with slightly different policies for first as opposed to subsequent appointments, with procedures around discharge sometimes reflecting the patient groups the service was designed to work with. Also important was how long a person might have waited for therapy in the first place. Senior clinical psychologist Irene worked in England with people categorised with personality disorder, and her policy for assessment was similar to Harriet’s approach for later appointments:

Harriet went on to describe her policy for therapeutic appointments in ways that reciprocally configured the ontology of her service, her patients, and herself:

Much like Irene, senior clinical psychologist Ursula was sensitive to how a missed appointment might relate to particular contexts:

Through this extract we can, first, see the efforts to which professionals will sometimes go to reduce the likelihood that a person is discharged prior to or at a very early stage of work with a clinical psychologist. Second, it is apparent that, on occasion, other healthcare staff – including non-psychologists – can be configured as having sufficient epistemic authority to contribute to the synthesis of certainty about what to do about ‘a DNA’. Third, different strategies to managing non-attendance can be related to and help to solidify particular configurations of patients that might then have implications for therapy.

Structuring Care in Relation to DNAs

Given wide-ranging clinical and health services concerns about patient non-attendance, a variety of techniques are employed by services for clinical psychology – and psychological therapy and mental health more generally – to encourage people to come along to appointments for assessment and treatment. A regularly touted method of enhancing engagement with services is a simple telephone call reminding someone of their upcoming appointment (Pennington and Hodgson, Reference Pennington and Hodgson2012). Over the 15 years or so, SMS messages have become increasingly routine as well (Sanghara et al., Reference Sanghara, Kravariti, Jakobsen and Okocha2010). These can even be used as an adjunct to therapy itself (Furber et al., Reference Furber, Jones, Healey and Bidargaddi2014) – reworking long-standing temporalities and sites of therapeutic interventions, and reflecting a wider digitalisation of mental health (Pickersgill, Reference Pickersgill2019a). For early-career clinical psychologist Emma, reminders had been notably successful as an infrastructure to support patient attendance. As she reflected during a discussion about what she might do in relation to a DNA:

Expectations around attendance could also shape the content of clinical encounters. As Briony, another relatively recently trained clinical psychologist, reflected when discussing DNAs:

Arthur, who worked with people who had experienced psychosis, likewise made clear the salience of various material and discursive techniques to enjoin attendance:

Attendance contracts of the kind mentioned by Arthur appear to be designed to cement expectations, with patients configured as having the facility to exercise the autonomy to sign them freely. In the process, considerations of the relations of power that shape the contents and enactments of such contracts in the first place are elided.

As mentioned in the preceding chapters, individuals seeking therapy might also be able to ‘opt-in’ to some services and book an appointment at a time convenient to them. ‘Opt-in’ approaches to service design and delivery are purposefully leveraged to limit non-attendance. They also come with the possibility of excluding people – especially already marginalised groups – who have not, for a range of possible reasons, actively opted in within a particular time-frame. Nonetheless, a requirement to opt-in to a service is a popular social technology configuring access to therapy, and which consequently shapes experiences of psychological care. As Amy, who was employed by a multidisciplinary weight management service, summarised:

Perhaps mindful of the ways in which the structuring of her service could be cast as potentially exclusionary, such opt-in procedures were framed by Amy as having ‘hugely reduced the number of people who were referred’ yet who ‘never knew they were referred’. Also flagged were people who might ‘have just said “yes”’ following a suggestion from another clinician that Amy’s service might afford them some benefit ‘because they don’t want to upset the doctor or the practice nurse, or whoever’. These reflections configured patients as rather acquiescent to biomedical power, even as they were assumed to have the autonomy to clearly advocate for their psychological need through an iterative process of opting-in.

The rather lengthy process of ongoing opting-in to Amy’s service, which required people seeking care ‘to demonstrate quite a lot of commitment to their weight management, before they even get in front of any of us’, aligned with other structural interventions:

Just as Amy made plain how opt-in procedures were a strategy for managing non-attendance, so too in the preceding comments does she render explicit how DNA policies relate to waiting lists.

In a similar way to Amy, Ursula also underscored the value of individuals actively opting in to services. The importance of this was articulated through configurations of patients who ‘don’t know’ why they have found themselves within a service:

Again, this extract simultaneously presents opt-in procedures as having value through decreasing the service ‘DNA rate’ while also, in effect, saving patients from seeing a clinical psychologist when they did not ‘know why’ they had been referred in the first place.

Moralising Non-attendance

People who do not attend scheduled clinical appointments are commonly subject to moral characterisations which cast them as ‘irresponsible’ or even ‘irrational’ (Buetow, Reference Buetow2007; Lester et al., Reference Lester, Tritter and Sorohan2005). Often ignored or minimised in the process is the wider social and personal context within which non-attendance occurs. There are a whole range of reasons why someone might ‘DNA’, including poor transport links to clinics, caring responsibilities that necessitate rapid reprioritisation, and homelessness which results in appointment letters never reaching their intended recipients. For mental health services specifically, the stigma and discrimination associated with psychological distress, including from some NHS staff, can discourage people from attending appointments (Rogers et al., Reference Rogers, May and Oliver2001). Diagnostic and therapeutic journeys might also involve encounters with a range of different professionals which result in repeated affectively challenging requests to narrate difficult personal experiences (Biringer et al., Reference Biringer, Hartveit, Sundfør, Ruud and Borg2017). Further, people are on occasion dissatisfied with the service they have received to date (Binnie and Boden, Reference Binnie and Boden2016) and doubtful about the efficacy of the therapy they are offered (Rogers et al., Reference Rogers, May and Oliver2001). Perhaps unsurprisingly given some of the underpinnings of non-attendance, DNA rates are higher for people living in very socio-economically deprived circumstances, compounding the inequities to which they are already subjected (NHS Health Scotland, 2015).

Still, the moralisation (Strong, Reference Strong1990) – that is, the casting of events and actions in moral terms – of patient attendance is not uncommon within healthcare. Moralised configurations of patients have also been evident within many of my encounters with clinical psychologists and others who provided psychological care. These can interact with wider political projects of health-related responsibilisation (Miller and Rose, Reference Miller and Rose2008; Rose, Reference Rose1996) – i.e. a normative encouragement to ‘take responsibility’ for one’s health (notwithstanding the plethora of social, political, economic, and commercial determinants of illness). Emma’s comments about her previous work in an IAPT service provide one example of such subtle moralisation and responsibilisation:

Moralising discourses can prompt exclusion from services before someone has even been seen by a psychological practitioner, as is clear in the following extract from an interview with senior clinical psychologist Esther. In this, she notes the problem of ‘bad attenders’ – some of whom are judged to be outright lying to healthcare professionals:

Within my encounters with clinical psychologists, I did not find overt moral ascriptions to be as typical as more implicit forms of moralisation. For instance, when I asked Leanne, a clinical psychologist quite early in her career, whether she had a DNA policy, she replied:

The language of ‘toughness’ is important here. To be ‘tough’ can be a valorous, sometimes moralised position, and in the preceding extract it is explicitly aspirational: Leanne and colleagues are purposefully ‘trying’ to be ‘tougher’, presumably in the face of experiences – of patients – which are found challenging. Leanne further reflected on what she ‘should’ do more of in the face of non-attendance:

Natalie was, among my interviews, uncommonly straightforward in her description of how she made use of involuntary patient discharge to manage non-attendance:

I asked her whether, following this, there were instances where someone might try to regain access to her service. She replied as follows:

Natalie cast people seeking therapy following non-attendance as creating work, and she configured herself as ‘soft’. An implication of such a framing is the possibility that she could instead act in ‘hard’ ways (or perhaps ‘tougher’ ways). The term ‘soft’, then, and the assertation of what she would not do – specifically, ‘go back to the GP’ – suggest that requiring a patient seek another referral could be interpreted as a kind of administrative punishment for not attending an appointment. In these comments, it was precisely through providing an example of an alternative course of action in relation to non-attendance that Natalie underscored how unscheduled missed appointments can be moralised.

Sometimes, clinical psychologists explicitly or implicitly relate non-attendance to psychological ‘readiness’ for therapy. For instance, Roisin, who worked within a Community Mental Health Team (CMHT) in urban England, reflected:

As noted in Chapter 4, readiness is not only an epistemically loaded notion but a morally laden one as well; after all, in everyday life it is generally considered that ‘being ready’ for something is better than being unprepared. One example of how configurations of readiness operate in relation to (non-)attendance comes from a lengthy conversation with Leanne. During this, she further reflected on what might happen with a patient who frequently does not attend appointments:

Leanne clearly attempted to engage with people who do not attend therapy, and in the preceding extract reflected on an example of an apparently justifiable reason why this might happen, namely if someone was ‘anxious’. However, this framing of the challenge experienced by a patient nevertheless participates in configuring them as not being ‘appropriate’ or ‘ready’ for the service. Despite the mutability of service ontologies discussed in previous chapters, it is the patient here who is deemed to need to change for the service, rather than vice versa. The moral dimensions of both non-attendance and readiness itself are strikingly clear within Leanne’s suggestion that ‘there comes a point where you can’t keep making allowances’ – a phrase which is colloquially associated with ‘bad behaviour’.

Mental health policy and practice within the United Kingdom has long evinced forms of circular logic that can result in adverse outcomes for potential patients (such as those diagnosed with a personality disorder; Wootton, Reference Wootton1959). In the preceding extracts, we can see how this occurs through the articulation of psychological notions of readiness with institutional policies of exclusion. The former legitimates the latter, and the latter contributes to the veracity of the former: non-attendance is taken to signify a lack of psychological readiness, which is reified as a justification for terminating someone’s therapeutic journey. As such, the ‘fault’ of non-attendance is configured as sitting with – indeed within – the patient. This is as opposed to, for instance, a framing of the clinical psychologist themselves as ill-suited to working with a particular person. In the process, the morality and expertise of the clinician come to be implicitly reaffirmed by discharge itself.

Negotiating DNA Policies

As the previous sections have indicated, formalised DNA policies do not necessarily remove the potential for clinical judgement and discretion. Rather, they can create spaces for the performance of professional autonomy. Senior clinical psychologist Esther, for instance, told me that if a person had ‘accepted an appointment and then DNA’d, it’s up to the clinician to decide whether they want to give them another one or not’. Another senior interlocutor, Susannah (based in CAMHS), likewise underscored the formal role of clinical autonomy in relation to discharge:

Similar to other cases discussed earlier, we can see how Susannah and her team actively worked to ensure that discharge was not a predetermined outcome of a missed appointment, despite the presence of infrastructure which might prompt that. I queried what factors would come into the final decision to discharge someone and was told the following:

The inclusion of a wider social context within Susannah’s account is notable and illuminates the extent to which many clinical psychologists are keenly aware of and can closely consider the wider circumstances in which their patients live, and which can shape the possibilities of their attendance at therapy appointments. At the same time, expert judgement – sometimes based on various assumptions, as well as the considered view of other professionals – is central to configuring a patient who is either in need of more support or who should be discharged from psychological care.

Sometimes, clinical psychologists seek to ascertain ‘the meaning of the DNA’, in the words of Charles, a senior practitioner in a large English city working with people ‘who have a long-term condition’ alongside ‘a psychological difficulty’. He reflected:

Charles clearly associated his adjudication of what should happen following ‘the DNA’ with the kinds of patients he saw, which was also apparent in my interviews and conversations with other clinical psychologists. Clarisa, for instance, was likewise a very established practitioner in the same city as Charles and explicitly related her approach to managing non-attendance to the nature of the patient group she worked with. She also, more implicitly, associated her mode of practice in relation to non-attendance with her expertise in being able to make a ‘clinical judgement’ about what should happen following a missed appointment:

Importantly, DNA policies can also be more purposefully elided. Some of their flexibility and interpretability – and how those entwine with configurations of psychological expertise – are apparent within CMHT psychologist Roisin’s observations:

Patricia, who also worked within a CMHT in the same city region as Roisin, was unusually frank about occasionally evading her service DNA policy:

This extract speaks to the moral configurations that come with a DNA policy – Patricia casts herself in a moral role by describing her disposition as ‘lenient’ – while also underscoring one way through which autonomy can be performed in clinical psychology. Yes, there is a policy; no, it does not have to be followed. The conversation continued:

Subtle moral adjudications can thus come into play in decisions about whether to continue with therapy: Patricia draws boundaries between people who have been given ‘a fair chance’ and who perhaps begin to attend appointments more regularly and those for whom it is deemed right to ‘insist on the policy’. These different and patient-specific responses to non-attendance act in concert to configure Patricia as a good clinical psychologist: first by being compassionate; second by providing quality care; and third by being able to leverage expert knowledge to determine what might be ‘going on’ with a patient – and what the psychological ramifications of this might be – to chart a morally and epistemically legitimate course of action.

When There Is No Policy

While the consideration of non-attendance is almost ubiquitous within psychological care, not every service has a formal DNA policy. Such an absence could provide additional opportunities for the performance of professional autonomy, including positive discretion, as in comments made by Jason (who was based in secondary care in a rural English county):

Accounts of an absence of an attendance policy could also serve as vehicles for conveying the morality of clinical psychologists, as well as illuminating their facility and authority to control patient access on a case-by-case basis. As Olivia, another CMHT psychologist, described to me,

In these comments, Olivia articulated both how understanding she was of the challenges that some of her patients lived with while also undertaking the moral boundary work (Lamont, Reference Lamont2000; Pryma, Reference Pryma2017) of sketching out some of the circumstances in which she would ‘try and be kind of flexible’.

Less ‘flexible’ was Kent, a senior clinical psychologist working with people with physical health conditions. He also described a somewhat moralised informal process for managing non-attendance in the absence of a formal service DNA policy:

Molly worked with people around the psychological ramifications of physical ill-health, and provided an even more explicitly moral account of the management of patient non-attendance:

At this point in the interview, I felt that Molly looked somewhat uncomfortable. When I asked her about that, she paused before reflecting:

This extract entwines different rationalities for determining what do in the event of an unarranged missed appointment. Economic, moral, and epistemic modes of approaching non-attendance ‘interfere’ (Pols, Reference Pols2003) with each other, resulting in ambiguity and, indeed, ambivalence. Notably, the ‘human’ perspective is validated in terms of what seems ‘clinically … effective’. In other words, the exercising of everyday morality is configured as professionally appropriate in ways resonant with other domains of healthcare (Dingwall and Murray, Reference Dingwall and Murray1983; Roth, Reference Roth1972; Shuster, Reference Shuster2019). In doing so, the humanity of Molly’s clinical work is underscored at the same time. This also defends against perceived attacks that refusing to discharge is economically wasteful. Molly was thus a good clinical psychologist in more ways than one.

Clinical Discretion and Exclusionary Inclusion

Unarranged missed appointments by patients occur across healthcare, with debates ensuing about the implications of this for resourcing and waiting lists. Local policy relating to (non-) attendance – commonly called ‘DNA policies’ – are one mechanism through which NHS organisations and services navigate this challenge. These act as a technology of government (Rose, Reference Rose1999), aimed at shaping the expectations and experiences of clinicians and patients. DNA policies bind these parties together in a kind of transactional relationship (cf. Davis, Reference Davis2013). In effect, access to care becomes dependent on the realisation of certain circumstances – most obviously and importantly that a patient attends a pre-arranged appointment – which can sometimes be reduced to the assumed dispositional and agentive actions of individuals seeking therapy. Where someone ‘fails’ to attend a scheduled therapy appointment, the possibility of care can be withdrawn. Indeed, some DNA policies mean that (potential) patients might never get to meet with a clinical psychologist in the first place. This could be due to automatic discharge following an initial missed appointment.

Through the infrastructure of DNA policies, clinical psychologists are supported to engage in ‘negative discretion’ (Barnard, Reference Barnard2023). In other words, practitioners can say ‘no’ – to actively elect to discharge people from therapy. Entailing uncertainty, affective, and moral work, decisions reached around discharge can be narrated through a discourse of inevitability (Leonardi, Reference Leonardi2008; Pickersgill, Reference Pickersgill2024). Within this, exclusion comes to be configured as a principal mechanism to deal with non-attendance.

Processes of moralisation play a part here. For instance, a ‘tough’ approach to dealing with non-attendance is sometimes valourised by clinicians. Individuals can also be judged not to have a ‘good reason’ for being unable to make an appointment. When clinical psychologists classify people as, for instance, ‘bad attenders’, this action does not sit adjacent to and separate from psychological work. Subjectification occurs through categorisation (Hacking, Reference Hacking1995, Reference Hacking2002), and the informal categories that healthcare professions identify patients through (e.g. as ‘a DNA’) are well known to have implications for the scope and limits of the care provided (Latimer, Reference Latimer1997; Vassy, Reference Vassy2001). We might expect, then, that morally laden categorisations of patients contribute to the dynamics of psychological care that people who are not ultimately discharged come to experience.

Clearly, DNA polices can be regarded as a form of gatekeeping and a mechanism for modes of subjectification that might have adverse implications. Yet, they can also on occasion be facilitative of care (cf. Buchbinder, Reference Buchbinder2017). This is when their existence serves not to prompt exclusion, but rather to stimulate therapeutic work precisely to preclude this. An example is when DNA policies stimulate collaborative considerations of whether there are psychological dimensions to non-attendance that could be addressed by clinical psychologists. Alternatively, policies might catalyse a deeper exploration of the social conditions shaping ‘the DNA’. An unscheduled missed appointment can be configured by clinical psychologists as a signal of other issues that might form the foci of therapy. This means that non-attendance and discharge are not always and quintessentially coupled.

When making a decision about discharging a person who ‘DNA’d’, clinical psychologists necessarily produce or affirm a particular ontology of their patient. Elements of this might be acquired from a range of sources, precisely to resolve an uncertainty similar in nature to that considered in Chapter 4 regarding referral. Specifically: Should someone be enabled – in fact, be permitted – to continue with therapy? Determining this enfolds psychological and sometimes even psychologistic characterisations of patients. Accordingly, decision-making about discharge can act as well to channel and reify the expertise of the clinical psychologist exercising their discretion. However, by defining a situation in principally psychological – as opposed to, for example, social – terms, it is hard to conclude that anyone other than a clinical psychologist should make discharge decisions. Potentially, those decisions are consequently more difficult for others, including people seeking therapy, to contest. This might be a particular issue when non-attendance is configured as evidence of someone not being ‘ready’ for therapy.

In sum, DNA policies connect therapeutic experience to the wider epistemic and economic dimensions of healthcare. Amid challenging waiting time targets and capacity constraints, they can prompt clinical psychologists towards the exclusion of some individuals to improve access to therapy for others. Indeed, DNA policies can compound pre-existing forms of disadvantage and marginalisation by excluding individuals living within circumstances that limit the possibilities of regular or timely attendance at clinical appointments. Accordingly, they underscore the logic of ‘exclusionary inclusion’ (Decoteau, Reference Decoteau2013) that contributes to configuring psychological care. The existence, operationalisation, and negotiation of DNA policies thus represent a striking example of how an ethic of access can also have problematic effects.

An ethic of access circulates internationally, underpinning global and local strategies aimed at proliferating the availability of care and treatment (Biehl, Reference Biehl2007; Cloatre, Reference Cloatre2013; Fassin, Reference Fassin2012; Greene, Reference Greene2011). In the United Kingdom, this ethic has driven forward policies and practices orientated to improving access to psychological therapies – not least the iconic IAPT programme itself. These have been widely heralded, served as international exemplars, and catalysed research and innovations on therapeutic interventions and in relation to notions of the psychological per se. Crucially, many more people have experienced therapy as a result. Challenges, however, remain. An imperative to get through increasingly long waiting lists within tight time-frames, for instance, can result in care being enabled for some patients by restricting it for others.

Over the preceding chapters I have examined some of the social dimensions and ontological implications of endeavours to enhance the availability of psychological care, and of their ramifications for clinical psychology in particular. My analysis has been grounded in a range of texts (journal articles, policy documents, clinical guidelines, and more) and interviews (predominantly with clinical psychologists, as well as policymakers, advisers, and others who hold power to shape the contexts of psychological care). It was also situated against a backdrop of wider work I have undertaken exploring what Rose (Reference Rose1985) calls the psychological complex. This includes research and dialogue with patients and campaign groups, and increasingly as a direct collaborator with clinical psychologists and psychiatrists.

In part given these assorted engagements, I had various potential readers in mind when writing this book. First were sociologists like myself, and colleagues in adjacent fields. For them I have illustrated how a seemingly progressive and widely shared ethic can imbricate political, legal, epistemic, and affective operations across scales in ways which reconfigure professional praxis such that a range of issues and ontologies are also constituted as a consequence. There are, I suggest, relevant insights here for researchers working in different contexts and jurisdictions that are trying to understand better how ostensibly valorous initiatives can sometimes lead to unfortunate results.

Second, I thought this book might find its way into the hands of some mental healthcare professionals themselves, especially clinical psychologists. To these readers I want to be clear that I respect psychological expertise, and am cognisant of the considerable benefits that people can be afforded by a positive therapeutic relationship with a thoughtful, compassionate clinician. I am optimistic that any practitioner who reads this work will agree with me that close yet supportive scrutiny of clinical contexts and norms is always important for enhancing practice. Hopefully, then, this at times critical account of psychological work will further contribute to the necessary reflexivity of professionals that is overall a hallmark of healthcare.

Third, I imagine some readers will be drawn by their own experiences of psychological therapy, not least if these have been difficult or adverse. I know very well that exposure to psychological services can be detrimental as well as beneficial. Negative experiences of therapy – and of particular therapists – can and do occur. Many people are also structurally or interpersonally prevented from accessing care in the first place. By showing, for instance, how processes of entry into and involuntary exit from services are adjudicated, I hope to have provided additional evidentiary support to all those campaigning to improve the accessibility and operations of psychological therapy.

Condensing Configurations

Politics, policies, and everyday exigencies reciprocally configure the contexts of therapy, the care practitioners provide, and the identities of therapeutic professionals. Take, for instance, professional claims-making about what clinical psychology is and should be, particularly in relation to psychiatry (e.g. formulation focused, non-diagnostic, and so on). Claims about the profession do not merely reflect the nature of clinical psychology; they actively configure it. The tactics and processes of boundary work clinical psychology performs in relation to other professions have helped to stabilise it within the NHS as a key provider of psychological care. Accordingly, debates within, assertions about, and the practices of clinical psychology play a role in setting agendas about the nature and delivery of psychological therapy more broadly. Ultimately, these inform the kinds of expertise that people seeking care find themselves with access to, and thus how their subjectivities are configured through therapy (cf. Hacking, Reference Hacking1995, Reference Hacking2002).

As such boundary-work underscores, clinical psychology is but one facet of a larger psychological complex, even as it is among the most salient within that. Understanding the instantiation and ramifications of an ethic access to psychological care in the United Kingdom thus also requires consideration of other activities and initiatives, which themselves shape the work of clinical psychology. IAPT/NHS Talking Therapies is, as noted, a signature example of how access to psychological interventions has proliferated, with clinical psychologists’ roles within it emphasising leadership and management more than therapy directly. At the same time, that initiative has also pushed clinical psychology towards a far more metricised form of practice. This is in part via the significant political support that the data and cost-orientated approach to IAPT attracted.

IAPT is certainly not alone, however, in shaping the wider experiences of clinical psychologists and other psychological practitioners, and the ways in which therapy is accessed. The changing understandings of personality disorders documented in Chapter 3 are particularly noteworthy in this regard. Through the discourse and activities propelled by the updating of the 1983 Mental Health Act of England and Wales, personality disorders became configured as treatable – with psychological interventions commonly foregrounded. People detained in prisons and forensic mental healthcare settings consequently found psychological therapy more accessible, albeit constituted through overtly disciplinary logics. Beyond these contexts, psychological care also became somewhat more available to other individuals living with a label of personality disorder. This was due to those reworked understandings of treatment efficacy and of treatability per se. As ‘personality disorders’ have become increasingly framed as dimensional ‘personality difficulties’, the focus of clinical psychologists and other psychological therapists on these has intensified. Such shifts illustrate how legal innovation participates in configuring the focus and availability of therapy, the spatial dimensions of its accessibility and administration, and the psychologies of those to whom clinical (and penal) intervention is directed.

While initiatives to improve access to therapy are often portrayed as laudable, they nevertheless clearly have inherent normativities that demand consideration. Psychological practitioners are themselves often all too aware of these: of how economic restraint in some areas – and largesse in others – configure the contexts in which they work, and of how political and professional machinations impact their therapeutic foci. For these practitioners, the metrics that have come to govern psychological care (e.g. how many patients does a service see, and how quickly) are a significant concern. Worries circulate about what happens as a result. This includes anxiety that CBT is over-emphasised in UK mental health, given its suitability for the time-limited approaches favoured to facilitate greater movement of people into and out of services. This centring of CBT is widely understood to have implications for the innovation, evidence production, and implementation of other forms of psychological therapy which could improve population and individual mental health.

As indicated earlier, one consequence of an ethic of access is that psychological care has become subject to a range of (ac)counting practices. In outpatient settings, where most treatment is delivered, these direct the attention of clinicians not only to the person in the room with them but also to all the people waiting to be so. The temporalities and possibilities of care are often closely defined, metricised as a more or less prescribed number of ‘sessions’ with a patient (even as clinical psychologists can sometimes evade the limits they are encouraged to adopt). This brings the end of treatment into its beginnings, with projections about the duration of therapy shaping practitioner engagements with those whom they treat, including as part of patient assessment and even decisions about whether to accept a referral. Within these processes, the clinical gaze is also now commonly orientated to a person’s ‘readiness’ for treatment, and thereafter their attendance at therapy appointments is a key object of governance.

If psychological therapy has become ever more configured through bureaucratic, economic, and sometimes directly political considerations, experiences of delivering care also appear to have shifted. Many clinical psychologists, for instance, speak of being under intense pressure. One corollary of this can be an affective disposition to those with whom they work that itself generates feelings of concern. As Molly described in Chapter 5, clinicians are implicitly enjoined to ‘ration’ their ‘compassion’: moral distress (Jameton, Reference Jameton1984) appears to be increasingly characteristic of psychological care. A logic of ‘exclusionary inclusion’ (Decoteau, Reference Decoteau2013) consequently permeates psychological services, allowing practitioners at least to try to manage growing demands and to make it through the day while preserving their professional, epistemic, and moral identities.

Psychological Manoeuvres

The need to improve access is thus experienced not simply as a straightforward matter of fact by therapists but also as a matter of quintessential concern (Latour, Reference Latour2004). Clinical psychologists, among others, widely believe that there is considerable unmet need for psychological care. This sentiment aligns with that of policymakers who have introduced healthcare targets as one attempt to stimulate the increased accessibility of care. Yet, the capacity of psychologists to provide this is not unlimited. Given the financial challenges imposed on the NHS across the United Kingdom (and, indeed, health systems in many other countries), targets are ever more challenging to meet.

Within this context, local policies and actions which aim to enhance patient throughput and reduce waiting lists can flourish. Service-level opt-in procedures and attendance/DNA policies are key examples. As a result, processes of referrals and discharge become embroiled with an ethic of access in ways that generate or intensify practical uncertainties with moral and affective valences. Should someone be accepted into a busy service, for example, if they do not quite ‘fit’? Under what conditions should a person who misses a therapy appointment be involuntarily discharged? To what extent does – or should – the length of a waiting list matter in relation to managing the uncertainty work of who should be granted access therapy? These are not easy questions to answer, and clinicians are generally not well supported to grapple with them.

Despite wider challenges, clinical psychologists continue to have opportunities for enacting their professional autonomy. This includes the performance of negative discretion (Barnard, Reference Barnard2023), such that practitioners can say ‘no’ to referrals and ‘no’ to someone continuing with therapy. The discretion of clinical psychologists is shaped by infrastructures like DNA policies, which might ostensibly define whether a patient should be involuntarily discharged. However, autonomy is also channelled precisely through these, such as when policy ambiguity configures a therapist as central in deciding whether to discharge someone based on their ‘poor’ attendance. The exercise of negative discretion can also generate positive effects for someone else seeking care: through the release of clinical capacity, it affords a therapist the opportunity to say ‘yes’ to them. As devices which help to enact and configure the disciplinary power of therapists (Foucault, Reference Foucault, Martin, Gutman and Hutton1988), waiting times targets and DNA policies are thus intrinsically ambivalent. Specifically, they operate simultaneously as what we might refer to as engines of access alongside what Decoteau (Reference Decoteau2013) calls technologies of exclusion.

Sometimes, as we have seen, a person who might prima facie be an ‘inappropriate’ referral can still gain entry to a service. Doing so entails a certain set of ontological alignments between (shifting) understandings of a patient’s subjectivity, of the nature of a service, and of the professional identity of the practitioner adjudicating the referral. Other people might not obtain access in this way, however. Clinical psychologists are adept at justifying their decisions, leveraging different epistemic, moral, and professional registers to do so. But if all choices that practitioners might make can easily be accounted for as ‘correct’, this leaves individuals who are denied therapy little room for contesting professional power and accessing care. Decision-making around access to therapy that is based on ostensibly psychological grounds (e.g. unreadiness for therapy) might be especially hard to challenge given the epistemic and administrative authority of clinical psychology within the NHS. As discussed in Chapter 1, there are, to be sure, other psychologies circulating in this ecosystem. Still, clinical psychology holds considerable power and has worked extremely hard to achieve and maintain that. If a clinical psychologist configures a person as not really ‘ready’ for therapy, or simply a ‘bad attender’, then an ontological respecification (Woolgar and Neyland, Reference Woolgar and Neyland2013) that enables their care to continue is not straightforward to achieve.

It is obviously essential that clinical psychologists employ their expertise when deciding who should access their care, as well as regarding the possible cessation of therapy. A healthy degree of clinical autonomy is vital to this. Nonetheless, potentially significant space remains for personal prejudices to unintentionally become inscribed within decision-making. In the introduction to this book, I underscored how the social is constitutive of psychological praxis; accordingly, expert judgements cannot be assumed to exist in hygienic isolation from, for instance, raced, gendered, and classed perspectives on persons seeking therapy. It is entirely possible to imagine a situation in which an overwhelmed clinical psychologist unreflexively attributes a person as insufficiently psychologically minded and not ‘ready’ or ‘suitable’ for therapy. Such a scenario could be more likely in stretched services with long waiting lists, wherein practitioners are expected to deliver results increasingly quickly, and limits are placed on opportunities for self-interrogation of clinical decisions. Even within contexts where autonomy is experienced as severely impacted by systematic underinvestment in healthcare, the accountabilities of clinical psychologists thus cannot and should not be elided. When autonomy is presented as being so curtailed that providing care to some people necessarily requires others to go without, close consideration is still needed of what forms of autonomous action remain, what it does and does not afford, and who it (dis)advantages.

Moving Forward

We need to think more collectively and creatively about how clinical psychologists are enabled by healthcare infrastructures to make the best – most clinically appropriate, most ethical, most equitable – decisions they can within often very difficult circumstances. Currently, the degree to which there are checks and balances in place regarding decisions about access to or curtailment of therapy across different services is not always clear. More constructive challenge as part of team-based referral or involuntary discharge discussions could help, notwithstanding the issues about epistemic hierarchies I raised earlier. Returning to the example of someone not being ‘ready’ for therapy, the fact that this characterisation is so hard to refute is precisely why its deployment within decision-making demands reflection. When the enactment of decisions that can prevent or curtail therapy requires consultation between colleagues, we might expect an even more robust consideration of potential exclusions to result.

Further, despite the problems with DNA policies, these can at least provide a route by which patients might, potentially, contest professional decision-making (e.g. through presenting the circumstances of a missed appointment in ways that configure these as recognisably ‘legitimate’). However, I am somewhat ambivalent about the utility of more policy to address access. National policies can overlook the needs of local contexts, and service-level polices can sometimes be transplanted to other psychological settings without sufficient consideration of their applicability and utility. Policy is accordingly – and as many clinicians rightly attest – far from the answer to everything (Kellogg, Reference Kellogg2011; Watkins-Hayes, Reference Watkins-Hayes2009). It at once ameliorates some concerns and generates others.

IAPT has shown us that ambition and purpose can have profound effects on the provision of therapy; equally, it has illustrated that prescribing too rigidly what a service is and how it should operate causes its own issues. Over time, the initiative – and now NHS Talking Therapies – has grown in ways that grant increased flexibility to providers. There are, however, notable limits to this, configured in part by policy that dictates the large volume of data clinicians are required to collect. I maintain that there must be scope for services – within and definitely beyond NHS Talking Therapies – to evolve over time. This should be explicitly via ongoing, dynamic engagement with those they seek serve.

Rather than finite policy recommendations, then, what I instead propose here is that a companion to an ethic of access is required; namely, an ethos of reconfiguration. This can be characterised as a programmatic willingness to be operationally flexible, to embrace community-driven service (re)development, and to further animate and support healthcare professionals to actively seek out opportunities for this. An ethos of reconfiguration would emphasise variability and malleability, within mental healthcare in general and the provision of psychological therapy in particular. Services should be enabled to reconfigure themselves in light of ongoing user and community feedback and changing needs. Instead of being seen as a failure to get it right in the first place, ongoing processual revision could be championed as evidence of substantive community engagement, responsiveness to changing needs, and critical clinical reflection.

As part of this ethos, different NHS organisations, and individual services and clinicians within them, must be granted the dedicated time and resources to work in partnership with communities to ascertain how best to deliver enhanced access to care, for whom, and what that care should look like. In some cases, this could result in the development of ‘simple’, bespoke solutions. For one service, it might be that therapy appointments shift to take place in the evenings; in another, it could entail practitioners moving to a new building with better public transport links. In some contexts, it might mean doing away with appointment letters altogether and instead discussing arrangements for care directly over the phone. Elsewhere, it could be that online therapy sessions become the norm. Perhaps some services should avoid diagnostic terms; maybe in others counselling psychologists rather than clinical psychologists should comprise the majority of the team. The point is that there is no one-size-fits-all model for the provision of psychological therapy; this is highly contextualised not only by the economic and professional considerations of NHS bodies but also – and more importantly – by the material and psychosocial circumstances within which these operate.

If these examples look like nothing more than tinkering around the edges, this only underscores the gravity of the situation. When I have discussed these matters with clinicians, the response is often the same: even seemingly limited changes can feel impossible to make given the pervasive lack of funding for mental healthcare. X, Y, and Z might help, but where will the resources to make those modifications come from? Every little change in the NHS takes time, and therefore costs money. Healthcare professionals are too often unable to manage even their current work under existing funding arrangements, without taking on extra labour to find better ways of delivering care.

Money, Money, Money

For at least two decades now, reports by advocacy groups and activist collectives (Mad Youth Organise, 2025; Mental Health Foundation et al., 2006; Mind, 2024; Mind et al., 2013) have provided personal testimonies and quantitative figures about the difficulties many people face in accessing psychological care, with long waiting times commonly underscored. Recommendations about how to address this issue sometimes emphasise the need for waiting time targets and almost always the requirement of greater financial resource. I worry how the former can be used by politicians as a means of responsibilising the NHS without granting them the ability to deliver. However, I agree wholeheartedly with the latter point. It remains entirely apparent to me that NHS services are significantly underfunded, and clinicians alarmingly overstretched.

The impact resources have on the instantiation of an ethic of access cannot be overstated. These are intrinsic to the structural conditions that configure care, and they need to be vastly improved. It is a lot easier to support someone to undertake therapy within a healthcare system where clinicians are not constantly being urged to consider all the other people waiting to see them – sometimes for years. If this book is, among other things, a critique of how professional discretion within psychological services can at times be problematic, it is also a demonstration of how the politics and economics of austerity contribute to configuring those circumstances and, indeed, the psychological itself. The possibilities of subjectification I have highlighted would obviously be textured differently in a less impoverished NHS.

Healthcare professionals across disciplines are doing difficult jobs in challenging circumstances, and clinical psychologists are no exception. During my fieldwork and after, I have also consistently encountered what I experienced as genuine concerns for individuals and for populations. Despite my critique, I align with an ethic of access. This is even as I insist on the necessity of problematising some of its specificities and ramifications. Such criticality absolutely does not confute the proposition that so many activists, academics, clinicians, and policymakers have advanced in the past, and still widely articulate; specifically, that more, much more investment in mental healthcare is needed – locally, nationally, and internationally. Without it, services will continue to come and go, clinicians will continue to have to find workarounds that benefit some and hurt others, and many people will continue to go without care.

Demanding more money for public services is, of course, a cliché. Unfortunately, it is one for a reason. As such, and in seeking to resist the discourse of inevitability that substantiates chronic underinvestment, it is one with which I am forced to conclude.