Much is said these days about the importance of mental health. It has risen as a policy priority internationally, reflected in and furthered by wider public and political interest across many countries. Associated epistemic and practical projects have likewise flourished, including the wide-ranging field of ‘global mental health’ (Ecks, Reference Ecks2016; Jain and Orr, Reference Jain and Orr2016; Littoz-Monnet, Reference Littoz-Monnet2022). This often takes as its focus a purported need to reduce the so-called treatment gap – the number of people deemed to require treatment minus the number in receipt of such – with this ‘gap’ playing a role in the consolidation of the field itself (Lovell et al., Reference Lovell, Read and Lang2019; Mills, Reference Mills2014; White et al., Reference White, Jain, Orr, Read, White, Jain, Orr and Read2017). At the national level, policymakers, health professionals, and wider publics across much of the world are also staking clinical, moral, and economic claims to the need to enhance access to care for (some) people understood to be living with mental ill-health (Béhague and MacLeish, Reference Béhague and MacLeish2020; Crespo Suárez and Machin Suárez, Reference Crespo Suárez and Machin Suárez2021; Fassin, Reference Fassin2012).

This ethic of access in relation to mental healthcare is part of a broader set of activist, clinical, and political discussions about care and treatment more generally. Calls to improve access to therapies for different kinds of ill-health resound internationally, propelling changes to policies, practices, and people’s lives. ‘Therapy’ is often taken to mean ‘drug treatments’, with campaigns and initiatives commonly associated with pharmaceuticals like antiretroviral therapies (ART) for HIV (Biehl, Reference Biehl2007; Cloatre, Reference Cloatre2013; Greene, Reference Greene2011). Often heated debates around the accessibility – or otherwise – of therapies are constitutive of the operations of global health and national healthcare. Concerns around access to mental healthcare, are not just about drugs, however; psychological modalities have attracted widespread interest and support, especially cognitive behavioural therapy (CBT).

Within the United Kingdom, psychological therapy came to particular attention over the past two decades or so, with political interest intensifying rather than reducing. First, it has been regarded by politicians and others as an important tool to address the ‘societal burden’ of mental ill-health. Second, it has been characterised as a major intervention to which patient access is deemed to require enhancement, with advocacy groups and clinicians making this point forcefully and repeatedly. Enhancing ‘access’ is generally rendered as developing additional mental health services, increasing the numbers of therapists available to provide care, offering a greater range of psychological therapies, and lowering waiting times for clinical assessment and treatment (with this latter point a matter of significant concern and activity) (Mental Health Foundation et al., 2006; Mind, 2024; Mind et al., 2013). There is also a growing emphasis on enhancing access in ways that address considerations of equity by explicitly focusing on the needs of a range of populations disadvantaged through structural prejudice and discrimination (Mad Youth Organise, 2025; Mind, 2024; Mind et al., 2013; National Collaborating Centre for Mental Health, 2023).

In this book, I examine how economic and social concerns, political and legal operations, and national and local policies interrelate with clinical knowledge, norms, and processes in relation to psychological therapy. I show how the interactions between these configure the broader contexts of healthcare, and the orientations and activities of those who deliver it. These configurations collectively shape the conditions of possibility for entry into – and exit from – therapy. Accordingly, I elucidate some of the wider effects of an ethic of access; in particular, I articulate the impacts on clinicians themselves. Finally, I reflect on what some of the implications of those could be for people seeking care.

Over the last two decades, the fields of the sociology of mental health, survivor research, and mad studies have grown significantly. Analysts within them have advanced important works focusing especially on lived experiences of distress – scholarship that holds both intellectual insight and normative force (Beresford, Reference Beresford2005; Beresford and Brosnan, Reference Beresford, Brosnan, Ikkos and Bouras2021; Beresford and Russo, Reference Beresford and Russo2022; Broer and Chandler, Reference Broer and Chandler2020; Brossard and Chandler, Reference Brossard and Chandler2022; Chandler, Reference Chandler2016; International Mad Studies Community, 2022; Lane, Reference Lane2020; LeFrançois et al., Reference LeFrançois, Reaume and Menzies2013; McWade, Reference McWade2020; Rogers and Pilgrim, Reference Rogers and Pilgrim2021; Spandler, Reference Spandler2006; Staddon, Reference Staddon2013; Sweeney et al., Reference Sweeney, Beresford, Faulkner, Nettle and Rose2009). I take a different path through the thicket of mental health and society here. I am principally interested in health professionals, and the profession of clinical psychology especially.

Clinical psychologists in the United Kingdom are doctorally trained psychological practitioners (generally holding a DClinPsy degree) specialising in the treatment of mental ill-health. They are often employed within the National Health Service (the NHS, which is devolved across England, Northern Ireland, Scotland, and Wales), as well as in private practice. Yet, unlike their medical colleagues, psychiatrists, studies of the professional development and practical foci of clinical psychologists are rather rare (though see Pilgrim and Treacher, Reference Pilgrim and Treacher1992). This is despite the fact that alongside psychiatry, clinical psychology holds considerable prestige within the landscape of mental healthcare. Entrance into the profession is extremely competitive, and by national standards clinical psychologists are well paid. They also often hold managerial roles within the NHS, such as leading services provided by other professions, including those associated with the prominent NHS Talking Therapies initiative (a significant endeavour to roll out psychological therapy at scale). Clinical psychologists contribute to shaping national and international debates about the meaning and practices of mental health and psychological therapy, and hence of wider understandings of the psychological. They surely merit our attention.

The Social Life of Psychology

The importance of clinical psychology is itself a function of the wider societal significance of psychology writ large. As a range of historians and social scientists have clearly demonstrated, psychological findings, ideas, and terminology flow through societies across the world (Brinkmann, Reference Brinkmann2008; De Swaan, Reference De Swaan1990; De Vos, Reference De Vos2012; Duncan, Reference Duncan2018; Illouz, Reference Illouz2008; Jackson and Rees, Reference Jackson and Rees2007; Jimena Mantilla, Reference Jimena Mantilla2023; Lemov, Reference Lemov2005; Madsen, Reference Madsen2018; Pfister and Schnog, Reference Pfister and Schnog1997; Raikhel and Bemme, Reference Raikhel and Bemme2016; Rieff, Reference Rieff1966; Smith, Reference Smith2013; Thomson, Reference Thomson, Cooter and Pickstone2000, Reference Thomson2006). In so doing, they can help to animate or rework varied social, political, and therapeutic imaginaries (Armstrong, Reference Armstrong1995; Pulido‐Martinez, Reference Pulido‐Martinez2010; Grzanka and Mann, Reference Grzanka and Mann2014; Herman, Reference Herman1995; Hollin, Reference Hollin2014; McKay, Reference McKay2016; Vaughan, Reference Vaughan2016; Vorhölter, Reference Vorhölter2019; Whitehead et al., Reference Whitehead, Jones, Lilley, Pykett and Howell2017; Younis and Jadhave, Reference Younis and Jadhav2020). These can result in revised ways of understanding and managing subjects in the clinic, the classroom, the courts, and beyond (Barr-Haim, Reference Barr-Haim2021; Erickson et al., Reference Erickson, Klein, Daston, Lemov, Sturm and Gordin2013; Fassin and Rechtman, Reference Fassin and Rechtman2009; Jones et al., Reference Jones, Pykett and Whitehead2013; Ossa et al., Reference Ossa, Salas and Scholten2021; Robcis, Reference Robcis2013; Weinstein, Reference Weinstein2013; Yang, Reference Yang2015; Zhang, Reference Zhang2020). Indeed, such arenas are important in their own right for generating psychological notions and knowledge that configure the subjects ensconced within them (Armstrong, Reference Armstrong1983; Miller and Rose, Reference Miller and Rose2008; Rose, Reference Rose1996).

The configurations that might be implied by the advent and attempted instantiation of psychological knowledge are not, however, inevitable. Societal processes and concerns inform where and how psychological concepts and findings settle, if at all, within professional work, policy settings, popular media, and personal experience. Their reception depends on social circumstances and everyday epistemologies (Broer et al., Reference Broer and Chandler2020, Reference Broer, Pickersgill and Cunningham-Burley2022). Ideas about psychology configured through university research settings or inside the clinic cannot, then, be assumed to simply and straightforwardly diffuse into and instantiate within other discursive and practical sites (Capshew, Reference Capshew1999; Pettit and Young, Reference Pettit and Young2017). In the case of specific therapies, as their use extends beyond national borders, their practices of deployment – and even the assumptions underpinning these – can shift and change (Amouroux et al., Reference Amouroux, Gerber, Jaccard and Aronov2023; Wu and Wang, Reference Wu and Wang2016). The arrival of behaviour therapy in France is one example (Amouroux, Reference Amouroux2017; Amouroux et al., Reference Amouroux, Gerber and Aronov2022). This ‘American’ therapy was hardly welcomed by French clinicians; however, over time, it imbricated with pre-existing imaginaries and practices, evolving in ways that saw some measure of acceptance. It is in part through ongoing transit, and via discursive roadblocks to this, that psychological concepts and practices morph, with the meanings ascribed to them rewritten in the process (Lloyd, Reference Lloyd2006; Pettit, Reference Pettit2015; Turkle, Reference Turkle1978).

Different approaches to therapy, of the kinds practised by clinical psychologists and other psychological practitioners (like counsellors and some psychiatrists), also contain different models of the psychological. As these therapies and the ideas associated with them travel, they likewise entwine with other ideas about the self; for instance, those shaped through various biological idioms (Behrouzan, Reference Behrouzan2016; Ehrenberg, Reference Ehrenberg2020; Loughran, Reference Loughran2016). For some therapists, this means that acting upon the psychological can be understood to take place through the brain, as well as vice versa: that stimulating the brain can sooth the soul (Brenninkmeijer, Reference Brenninkmeijer2010; Moutaud, Reference Moutaud2022; Rose, Reference Rose, O’Malley and Valverde2006; Vidal and Ortega, Reference Vidal and Ortga2017). These reproachments between different ontologies and their enactments underscore the great extent to which different models of the psyche, and of being human more broadly, can sit together and articulate with one another in non-determinative ways (Craciun, Reference Craciun2018; Marks, Reference Marks2017; Pickersgill, Reference Pickersgill2010; Pickersgill et al., Reference Pickersgill2011; Richert, Reference Richert2019; Silverman, Reference Silverman2012; Shamdasani, Reference Shamdasani and Eghigian2017; Zhang, Reference Zhang2020).

The psychological knowledge that gives rise to and results from therapeutic intervention is also itself shaped through societal discourses and debates (Koczanowicz and Koczanowicz-Dehnel, Reference Koczanowicz and Koczanowicz-Dehnel2021; Solovey, Reference Solovey2001). These impact what is researched, why, how, and by whom (Dehue, Reference Dehue1995; Kusch, Reference Kusch1999; Pandora, Reference Pandora1997). In turn, research contributes to configuring professional training in applied psychology, although the expertise of clinicians can by no means be reduced to knowledge trickled down from laboratories (Ashmore et al., Reference Ashmore, Brown and MacMillan2005). Psychology, as Nikolas Rose (Reference Rose1996) has put it, is very much a social science; equally, the social is undoubtedly a product of psychological praxis.

While psychology can be popularly celebrated for its contribution to care, it is also important to underscore that the sociality Rose points to can be regressive. Discriminatory societies and social institutions inflect the knowledge produced within them and the uses to which it is put (Asante and Vandi, Reference Asante and Vandi1981; Harding, Reference Harding1986; Martin, Reference Martin2022; Schiebinger, Reference Schiebinger1993). Psychology, then, has not merely been impacted by discrimination and oppression: it has been constituted through these processes (Caplan, Reference Caplan1993; Guthrie, Reference Guthrie1976; Howitt and Owusu-Bempah, Reference Howitt and Owusu-Bempah1994; Morawski, Reference Morawski1994; Richards, Reference Richards1997). As a range of academics and activists have pointed out, including many psychologists themselves, psychology both inscribes and contributes to social ills and structural violence (Capella Palacios and Jadhav, Reference Capella Palacios and Jadhave2020; Fine, Reference Fine1985; Henriques et al., Reference Henriques, Hollway, Urwin, Venn and Walkerdine1984; Morawski, Reference Morawski1997a; Parker, Reference Parker2015; Rutherford, Reference Rutherford2018; Spandler and Carr, Reference Spandler and Carr2020; Tyson et al., Reference Tyson, Jones and Elcock2011) such as homophobia, transphobia, racism, and sexism (Chaparro and Prado, Reference Chaparro and Prado2022; Cokley and Garba, Reference Cokley and Garba2018; Hegarty, Reference Hegarty2018; Hird, Reference Hird2003; Hubbard, Reference Hubbard2017; Hubbard and Griffiths, Reference Hubbard and Griffiths2019; Kitzinger, Reference Kitzinger1987; Parlee, Reference Parlee1979; Pyne, Reference Pyne2020; Spandler and Carr, Reference Spandler and Carr2022; Valasek, Reference Valasek2022; Waidzunas, Reference Waidzunas2015; Young and Hegarty, Reference Young and Hegarty2019). Psychological knowledge has also long been instantiated within, and generated through, practices of colonialism, war, and torture (Balfe, Reference Balfe2016; Capshew, Reference Capshew1999; Linstrum, Reference Linstrum2016; Oakes, Reference Oakes1994; Orr, Reference Orr2006; Reyes, Reference Reyes2008; Rohde, Reference Rohde2022; Samelson, Reference Samelson1977; Soldz, Reference Soldz2011). Clearly, psychology cannot be neatly separated from the social and normative practices through which it is configured.

As historians like Danziger (Reference Danziger1997, Reference Danziger1990), Morawski (Reference Morawski1997a), Richards (Reference Richards1996), and Smith (Reference Smith1997, Reference Smith2013) have discussed, the traffic between psychology and wider society puts psychologists in a particularly tricky position in relation to their role as authoritative crafters of knowledge about, and technicians of, the self. If psychological knowledge is constituted through social and interpersonal processes, and if the outputs of psychological research impact societies, subjectivities, and how we come to know them, then the self-making potential of psychology as a science and practice is dizzying. Likewise, the associated responsibility and reflexivity required from practitioners is considerable, not least given the issues outlined earlier (Brinkmann, Reference Brinkmann2005; Hearnshaw, Reference Hearnshaw1987; Morawksi, Reference Morawski, Fine, Weis, Powell and Wong1997b; Richard, Reference Richards1996). Many psychologists take seriously both the power of their discipline and the need to wield it thoughtfully. Nevertheless, there can be gaps between laudable therapeutic goals, for example, and the lived realities of those who encounter psychological knowledge and expertise.

Today, discriminatory logics continue to be discernible within psychological research and practice (Adams et al., Reference Adams, Kurtiş, Ordóñez, Molina, Oropeza, Wane and Todd2018; APA, Reference Amouroux2021; Riggs et al., Reference Riggs, Pearce, Pfeffer, Hines, White and Ruspini2019). They have ramifications for how therapeutic practitioners come to understand and relate to those with whom they work (Carr, Reference Carr2010; Charura and Lago, Reference Charura and Lago2021; Constantine, Reference Constantine2007; Hodges and McManus, Reference Hodges and McManus2006; Pilgrim and Patel, Reference Pilgrim, Patel, Hall, Pilgrim and Turpin2015). With regards to access to psychological therapy, for instance, it would be unwise to assume that assessments of whether someone is ‘ready’ for therapy, as various clinical psychologists put it, are somehow free from raced, gendered, and classed assumptions that might pave the way to access to care and treatment for some and not others. Better understandings of both how psychologists enact clinical decision-making and the wider context in which therapy is delivered can provide evidence and insight for activists and campaigners lobbying for more equitable access to care.

Introducing Clinical Psychology

What today is referred to in the United Kingdom as clinical psychology has its origins in a range of traditions, not least educational and industrial psychology (Stewart, Reference Stewart, Hall, Pilgrim and Turpin2015). Over its existence, the profession has been configured through – and helped to configure – wider initiatives in the NHS, health policy, and academia. Early training programmes included initiatives at the Maudsley Hospital and the Tavistock Clinic (both in London, England) alongside the Crichton Royal (Dumfries, Scotland), the scope and intent of which were shaped by the inauguration of the NHS in 1948 (Stewart, Reference Stewart, Hall, Pilgrim and Turpin2015). The Maudsley programme has long attracted particular attention, not least because of the significance of its founder to the history of psychology: prominent and controversial psychologist Hans Eysenck. Established in 1947 at the behest of psychiatrist Aubrey Lewis (Buchanan, Reference Buchanan2010; Derksen, Reference Derksen2001; Yule, Reference Yule, Hall, Pilgrim and Turpin2015), the programme developed in the context of a wider professional buoyancy for psychiatry and psychology following the Second World War (Jones, Reference Jones2004; Loughran, Reference Loughran2016; Thomson, Reference Thomson, Cooter and Pickstone2000). Psychological medicine, often practised by physicians, had for some time been institutionalised within the United Kingdom (Crichton-Browne, Reference Crichton-Browne1861; Jones, Reference Jones2010). However, Eysenck’s programme was a significant moment in the consolidation of clinical psychology as a distinct discipline that long exerted influence on the nascent profession (Derksen, Reference Derksen2000).

The style of clinical psychology fostered by Eysenck drew from the influential field of educational psychology (Rose, Reference Rose1985). It underscored the import of psychological testing, the cultural traction of which had been a key mechanism for the professionalisation and expansion of psychology (Thomson, Reference Thomson, Cooter and Pickstone2000). This focus on testing purposely framed out therapy (Buchanan, Reference Buchanan2010; Derksen, Reference Derksen2000); Eysenck (Reference Eysenck1949, Reference Eysenck1953, Reference Eysenck1959) was especially critical of the kind of therapy expounded by Freud and psychoanalysts, noting often and at length its limits as a scientific practice. This was in contrast to some of the early members of the British Psychological Society (BPS), founded at University College London on 24 October 1901 as the then and still principal professional society for UK-based psychologists (Hearnshaw, Reference Hearnshaw1964). Many BPS members were physicians orientated to psychological treatment, including psychoanalysis (Pilgrim and Parry, Reference Pilgrim, Parry, Hall, Pilgrim and Turpin2015). Consequently, the establishment and rollout of the Maudsley programme over its early years entailed a slightly rocky relationship with the BPS (Yule, Reference Yule, Hall, Pilgrim and Turpin2015), before the highly influential Eysenck gained traction there too (Buchanan, Reference Buchanan2010).

The focus of psychological testing via psychometrics, rather than therapy, had professional as well as epistemic advantages. Serving as a form of practical boundary work (Gieryn, Reference Gieryn1983) between the disciplines, it ensured that psychology avoided a direct contest with physicians (Pilgrim, Reference Pilgrim2010) while also contributing to the reification of psychological science (Stewart, Reference Stewart, Hall, Pilgrim and Turpin2015). By framing their identifies around testing, psychologists could demarcate an increasingly autonomous space for themselves in ways that highlighted their unique skills and utility. Since this zone of praxis did not overtly threaten the far more powerful profession of medicine, there was plenty of scope for it to further expand.

Still, professional context changes over time, in a dynamic interrelationship with the epistemic content that fills it. Eventually, Maudsley psychologists came to engage in therapeutic practices as well. This was, in part, through the rising influence of Eysenck’s colleague Monte Shapiro in the early 1950s, with whom he had a somewhat challenging relationship at times (Buchanan, Reference Buchanan2010). Shapiro had a rather different approach to psychology than Eysenck (Derksen, Reference Derksen2001) and helped to initiate psychological treatment within the Maudsley (Yule, Reference Yule, Hall, Pilgrim and Turpin2015). As the years went by, the import of a more overtly therapeutic emphasis for psychology was increasingly asserted across the profession. Eysenck himself ended up becoming a vocal supporter of empirically orientated behaviour therapy (Eysenck, Reference Eysenck1959; Yule, Reference Yule, Hall, Pilgrim and Turpin2015), following long-standing interests in behavioural conditioning, and in 1965 he co-authored the first major textbook in this area with Stanley Rachman (Marks, Reference Marks and Dryden2012).

At the same time, the BPS more generally was embroiled in what historian Roderick Buchanan has called ‘the somewhat tortuous process of professionalization’ (Buchanan, Reference Buchanan2010, p. 220). To this end, it engaged extensively with the government and with the evolving NHS. In 1965, a Royal Charter was granted to the Society, and then, in 1966, the BPS Division of Clinical Psychology (DCP) was founded (Hall and Wang, Reference Hall, Wang, Hall, Pilgrim and Turpin2015). That year saw membership of the Division stand at only 163, while the BPS as a whole had 3,300 members (Hall et al., Reference Hall, Hall, Pilgrim and Turpin2015). As the 1960s progressed, psychologists working clinically only numbered in their hundreds (Buchanan, Reference Buchanan2010). Nevertheless, alongside the establishment of the DCP, the 1960s saw a range of other clinical psychology programmes develop within the United Kingdom, and the demands for psychologists within the NHS grew (Hall et al., Reference Hall, Hall, Pilgrim and Turpin2015). In the 1950s, aside from the London Institute of Psychiatry, the Tavistock Clinic and the Crichton Royal were the only ‘approved’ training courses for clinical psychologists seeking work within the NHS (Hall et al., Reference Hall, Hall, Pilgrim and Turpin2015). By the end of the 1960s, however, the BPS had formalised a Diploma in Clinical Psychology, and ‘in-service’ NHS training programmes were also operating (Lavender and Turpin, Reference Lavender, Turpin, Hall, Pilgrim and Turpin2015).

The lot of clinical psychologists improved further in the 1970s and, to an extent, into the 1980s. The call for clinical psychologists, and psychological practitioners more generally, continued, including within both primary care and outpatient settings (Burns and Hall, Reference Burns, Hall, Ikkos and Bouras2021). Clinical psychology separated further from psychiatry, heartened in this respect by a significant 1977 Department of Health document, the Trethowan Report (DHSS, Reference Evans, Mellor-Clark, Margison, Barkham, Audin, Connell and McGrath1977). Led by William Trethowan, a psychiatrist at the University of Birmingham, this entailed a significant review of clinical psychology services. Clinical psychologists were, for instance, regarded as fully competent to accept referrals from general medical practitioners (GPs; what some countries refer to as family doctors/physicians), with recommendations made to expand service provision (Hall and Wag, Reference Hall, Wang, Hall, Pilgrim and Turpin2015). By the end of the decade, clinical psychology training was provided through either two-year Masters programmes, or the aforementioned in-service diploma route (Lavender and Turpin, Reference Lavender, Turpin, Hall, Pilgrim and Turpin2015). At the same time, psychologists also themselves became involved in the training of physicians and psychiatrists via the establishment of posts within medical schools (Hall, Reference Hall, Hall, Pilgrim and Turpin2015). Through this, psychological knowledge became increasingly interpolated within medical curricula. The therapies these emboldened psychologists were delivering, and the theoretical debates to which they contributed, also became increasingly heterogeneous (Parry, Reference Parry, Hall, Pilgrim and Turpin2015; Pilgrim and Patel, Reference Pilgrim, Patel, Hall, Pilgrim and Turpin2015). This heterogeneity tended not to result in particularly seismic professional ructions, although the applications of behavioural techniques in relation to the ethically troubling aversion therapy became increasingly contested (Carr and Spandler, Reference Carr and Spandler2019; Marks, Reference Marks, Hall, Pilgrim and Turpin2015).

During the 1980s, clinical psychologists continued to enjoy a significant degree of professional autonomy in the NHS (Hall et al., Reference Hall, Hall, Pilgrim and Turpin2015), despite the challenges of NHS reforms and budgetary issues under a Conservative government. So-called deinstitutionalisation through the closures of ‘mental hospitals’ (Scull, Reference Scull, Ikkos and Bouras2021) meant that, in theory, clinical psychologists were better integrated into the wider NHS workforce. With the rising influence of managerialism in the NHS, they also came to occupy sometimes powerful positions leading large, multidisciplinary teams (Pilgrim and Patel, Reference Pilgrim, Patel, Hall, Pilgrim and Turpin2015). The BPS supported this through DCP management training (Hall and Wang, Reference Hall, Wang, Hall, Pilgrim and Turpin2015). Professional debate and knowledge production were also furthered via periodicals such as the British Journal of Clinical Psychology (first issue 1981), which evolved from the long-standing British Journal of Social and Clinical Psychology; Clinical Psychology Forum (first issue 1986), developed from its forerunner, the DCP Newsletter; and, The Psychologist (first issue 1988), a rebranding of the Quarterly Bulletin of the British Psychological Society (established in 1948) (Hall and Wang, Reference Hall, Wang, Hall, Pilgrim and Turpin2015). The reconfiguration of these texts reflected an increasingly ambitious profession of psychology in general and of clinical psychology especially. The ambitions of the latter were also furthered through the Manpower Planning Advisory Group of the Department of Health (Richardson, Reference Richardson, Hall, Pilgrim and Turpin2015). Under the leadership of psychologist Derek Mowbray, this produced a key report foregrounding the importance and expertise of clinical psychology for the NHS (Management Advisory Service, 1989), galvanising many hopes and expectations about the future (Pilgrim and Treacher, Reference Pilgrim and Treacher1992).

The authority and autonomy of clinical psychology were further consolidated in the 1990s through the reconfiguration of core training from a two-year Masters qualification to a three-year doctorate (although not without considerable debate; Lavender and Turpin, Reference Lavender, Turpin, Hall, Pilgrim and Turpin2015). In a medically dominated NHS, much benefit was seen to be afforded through the title of ‘Dr’ in relation to prestige and professional recognition (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004). Following the 1997 general election and the coming to power of a Labour government, investment in mental health services also improved and the numbers of clinical psychologists employed within the NHS grew (Richardson, Reference Richardson, Hall, Pilgrim and Turpin2015). During this decade, it also became clear that some clinical psychologists were beginning to engage in more dialogic ways with people to whom their therapeutic expertise had been applied (Foster, Reference Foster, Hall, Pilgrim and Turpin2015). This move was powered by an increasingly organised and influential advocacy sector and service-user movement (Beresford and Brosnan, Reference Beresford, Brosnan, Ikkos and Bouras2021; Campbell, Reference Campbell, Bell and Lindley2005; O’Donnell and MacLean, Reference O’Donnell, MacLean, Sapouna, Gijbels and Sidley2019; MacLean, Reference MacLean2021; Rogers and Pilgrim, Reference Rogers and Pilgrim1991), even if this itself faced a range of obstructions and practices of relegation (Carr, Reference Carr2007; Lambert and Carr, Reference Lambert and Carr2018; Lewis, Reference Lewis2009, Reference Lewis2014; Sweeney, Reference Sweeney2016). While engagement with people who use psychology services was not a significant feature of clinical psychology in the 1990s, subsequently there has been a gradual shift in this respect (Foster, Reference Foster, Hall, Pilgrim and Turpin2015; Soffe et al., Reference Soffe, Read and Frude2004). That said, organisations and individuals involved in mental health advocacy and the user and survivor movements continue to demonstrate that too many of their critiques of existing services and concrete suggestions for reform go unheeded (Farmer and Blackshaw, Reference Farmer, Blackshaw, Ikkos and Bouras2021; Russo and Sweeney, Reference Russo and Sweeney2016; Sapouna et al., Reference Sapouna, Gijbels and Sidley2019).

Other challenging matters around which the profession is increasingly concerned are the stigma and marginalisation of a range of groups within and by clinical psychology, including in relation to race and ethnicity as well as gender and sexuality. Since the 1990s there has been an intensification of attention within psychology to the forms of prejudice that can exist in the profession (Adetimole et al., Reference Adetimole, Afuape and Vara2005; Hodges and McManus, Reference Hodges and McManus2006; Wood and Patel, Reference Wood and Patel2017). Some progress has been made to address this: for instance, the much campaigned-for Lesbian and Gay Section of the BPS was finally established in 1998 (Kitzinger et al., Reference Kitzinger, Coyle, Wilkinson and Milton1998), which became the Psychology of Sexualities Section in 2009 (Hubbard and Griffiths, Reference Hubbard and Griffiths2019). In the face of ongoing structural, institutional, and interpersonal forms of racism that impact access to mental healthcare (Bowl, Reference Bowl2007; Burr, Reference Burr2002; Haarmans et al., Reference Haarmans, Nazroo, Kapadia, Maxwell, Osahan, Edant, Grant-Rowles, Motala and Rhodes2022; Halvorstud et al., Reference Halvorsrud, Nazroo, Otis, Brown Hajdukova and Bhui2018; Nazroo et al., Reference Nazroo, Bhui and Rhodes2020), there is also increasing problematisation of the fact that clinical psychologists are overwhelmingly a white, middle-class (Palmer et al., Reference Palmer, Schlepper, Hemmings and Crellin2021) workforce (Odusanya et al., Reference Odusanya, Winter, Nolte and Shah2018). With this, there has been some recognition too of how a lack of demographic diversity within clinical psychology configures the logics of healthcare delivery and the subjects of therapy (Wood and Patel, Reference Wood and Patel2017). However, discourse in relation to the whiteness of psychology has often been articulated through the idiom of diversification rather than the more direct register of discrimination or racism (Pilgrim and Patel, Reference Pilgrim, Patel, Hall, Pilgrim and Turpin2015; Wood and Patel, Reference Wood and Patel2017). While the volume of calls to address power and privilege within clinical psychology is increasing, much work remains to be done (Cohen-Tovée, Reference Cohen-Tovée2020; Fernando, Reference Fernando2017; Wood and Patel, Reference Wood and Patel2019).

Professional competition and relationships with other disciplines also continues to be a challenge for clinical psychology. Besides psychiatrists, clinical psychologists have long worked with other health professionals, not least of which are other kinds of psychological practitioners, such as counselling psychologists. Maintaining good relations while securing professional autonomy and advancement can involve some delicate organisational and personal manoeuvring. This relationship work became more pressing as policy in the late 20th century (notably the Department of Health’s (2007) ‘New Ways of Working’ agenda) came to emphasise the important place of clinical psychologists within multidisciplinary teams, as well as supervisors of other kinds of therapists, for example people with a diploma in CBT who were specifically hired to deliver that particular therapy (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004). Clinical psychology also found itself in a slightly tricky position with the formation of the Health Professions Council (now the Health and Care Professions Council (HCPC)) in 2003 as a legal regulator of professional practice. While the formal regulation of psychology was in many respects welcome – and legal restrictions on who could use the ‘protected title’ of clinical psychology particularly so – worries circulated, and still do, that more bespoke regulation for psychologists remained lacking.

Today, clinical psychology is firmly established as a therapeutic profession – one necessarily engaged, to varying degrees, with policymakers, academia, other mental health professions, and advocacy groups. Clinical psychologist David Harper (Reference Harper2010, p. 13) reads the shift away from testing to therapy as ‘a bid for autonomy from psychiatry’. In this respect, clinical psychology has had clear success. With a distinct doctoral training route which can result in a well-renumerated, relatively autonomous, and commonly secure job in or beyond the NHS, clinical psychology will look to many like a profession that has done well for itself. No longer simply an adjunct to psychiatry, through contributing to healthcare policymaking and clinical guideline development, clinical psychologists now shape the work of psychiatrists themselves (Parry, Reference Parry, Hall, Pilgrim and Turpin2015). Still, the originating purpose of the Maudsley programme is not without contemporary impact. Furthermore, for all its evident import, and to the understandable chagrin of some practitioners, the social and economic standing of clinical psychology is not parous with psychiatry. These issues appear to reverberate in some of the discord that can at times remain discernible between the professions, and which contributes to the professional politics – and thus instantiation within healthcare services – of the psychological disciplines.

Introducing (Cognitive Behavioural) Therapy

If clinical psychology is a therapeutic profession, what therapies are practised, where, and with what foci? As noted, many clinical psychologists work in the NHS, where they draw on a range of therapies to address a variety of forms of disease and subjective distress: addiction, eating disorders, low mood, psychosis, and more. Different therapeutic approaches can be used alongside each other, and the assumptions underpinning these are wide-ranging. Take, for example, cognitive-analytic therapy: this draws on elements of psychoanalysis and cognitive psychology in ways that might be anathema to some specialists in either tradition.

The ontological variety and complexity between and within therapies generally does not, however, get in the way of actual therapeutic work. Rather, clinical psychologists take what they need, interweave what they regard as helpful, and leave the rest behind (cf. Luhrmann, Reference Luhrmann2000). As such, practitioners of clinical psychology commonly describe their therapeutic style as ‘integrationist’. Implicit to this characterisation of professional practice is an epistemic claim to know about a range of techniques, and to know (best) how to braid and deploy them in different ways for particular patients. This claim itself helps to support the position of clinical psychologists within the wider NHS ecosystem, within which there exists a great many other providers of psychological therapy.

At the same time, many clinical psychologists also draw significantly on the widely regarded, if also sometimes hotly contested, technique of CBT. This is one of the most popular psychological treatments in the world, used in diverse ways in a range of contexts (Marks, Reference Marks, Hall, Pilgrim and Turpin2015). A preference towards CBT is marked out from training onwards, if not before – for instance, during pre-doctoral work within psychological services. While students on clinical psychology doctorates must acquire competencies in two therapeutic modalities, one of these has to be CBT (BPS, 2019). Consequently, although CBT is by no means a therapy clinical psychologists can uniquely claim as their own, it is nevertheless central to their work – with that centrality enjoined by the BPS itself.

CBT entails psychological and behavioural strategies aimed at lessening the subjective impact of what are considered ‘maladaptive’ patterns of thinking about and relating to the self and the world. It has developed over successive ‘waves’ and builds on various pre-existing therapeutic approaches, including rational therapy (Craciun, Reference Craciun2018; Pilgrim, Reference Pilgrim2011; Stark, Reference Stark2017). As its name indicates, it has origins in both behaviourist and cognitivist traditions of psychology (and psychiatry). CBT consequently represents an amalgam of approaches that draw from figures such as Hans Eysenck, psychologist Albert Ellis, and psychiatrist Aaron Beck (both trained in the Eastern United States) (Marks, Reference Marks and Dryden2012; Pilgrim, Reference Pilgrim2009). The conjoining, and even blurring together, of the ‘C’ and the ‘B’ of CBT became essentially taken granted in the United Kingdom by the early 1990s, and the influence of the therapy grew and grew (Marks, Reference Marks and Dryden2012).

Professionals who centre CBT within their practice commonly locate as their primary concern ‘patient’s thoughts and actions’ rather than placing emotions as salient (Craciun, Reference Craciun2018, p. 985). Relatedly, CBT tends to have a relatively immediate temporal focus as compared to a deep dive into distant personal histories that characterises many other therapies (although childhood experiences, for instance, are not necessarily disregarded) (Craciun, Reference Craciun2017). It is generally a more targeted and shorter-term modality than techniques such as psychodynamic psychotherapy or psychoanalysis. Within the United Kingdom, this temporal structure has contributed to the consolidation of CBT within an overstretched NHS (as well as in public and private healthcare elsewhere; Lakoff, Reference Lakoff2005; Scott, Reference Scott2006; Zhang, Reference Zhang2020), where psychologists and other practitioners are often asked to undertake their work within fewer therapy ‘sessions’.

Many professionals regard this situation as undesirable – as do numerous people who are asked to engage in such ‘brief interventions’ as the sum total of their psychological care (Greener and Moth, Reference Greener and Moth2022; Moth et al., Reference Moth, Greener and Stoll2015). Likewise of concern has been the alignment of the temporalities of CBT with managerialist approaches to organising services. For instance, when a certain number of sessions are commonly anticipated by NHS managers as being appropriate for a particular presenting issue – for example, anxiety or low mood – targets can be set for professionals in relation to how many sessions of CBT should take place. Consequently, CBT is also easily aligned with the kind of audit culture (Power, Reference Power1999) that anthropologist Paul Brodwin (Reference Brodwin2013) has characterised within US community mental health, and which many clinical psychologists and other therapeutic professionals in the United Kingdom frequently lament. This is not least because extended modes of audit and accountability contribute to the reconfiguration of that which is to be audited (Miller and Rose, Reference Miller and Rose2008), ostensibly impacting the autonomy of practitioners and underscoring in turn how this is itself always shaped through relations of power (Dingwall, Reference Dingwall2016).

As a highly standardisable intervention, CBT has been particularly valued within the international move towards ‘evidence-based medicine’ from the late 20th century onwards (Craciun, Reference Craciun2018; Pickersgill, Reference Pickersgill2019a). At the same time, CBT is flexible enough to be worked up as a specific treatment for particular kinds of formally recognised psychiatric disorders. This has meant that clinical trials could be conducted on its efficacy in ways that rendered it comparable with pharmaceutical interventions (Harper and Townsend, Reference Harper and Townsend2021; Sadowsky, Reference Sadowsky2021), in turn helping to ensure its wider acceptability in the NHS and in privatised healthcare systems beyond the United Kingdom (Craciun, Reference Craciun2018; Lester, Reference Lester2019; Zhang, Reference Zhang2020). This ambiguous existence as standardised yet flexible means that it is well suited for use by practitioners with a range of trainings and ontological commitments. While some regard CBT as a fruitful treatment for psychiatric disorders, many in clinical psychology are wary of, and sometimes antagonistic towards, what they see as a medical model of ill-health. These practitioners would be disinclined to position CBT as a specific, tailored treatment for a discrete, defined disorder, even as they might make use of the therapy for their own ends.

With its focus on recasting rather than deciphering patterns of thought, it has been feasible to constitute CBT as suitable for practitioners to use via the telephone, as well as through online modalities. It is in this computerised form that the therapy is sometimes recommended as a first step to people seeking psychological care through the NHS (Pickersgill, Reference Pickersgill2019b) – as well as to divert people away from stretched face-to-face services (Lane, Reference Lane2020). Apps for managing experiences of anxiety and depression can also make use of CBT, and are used in a context where some people are electing or being encouraged not to seek access to NHS services due to concerns about long waiting lists for therapy (Crosby and Bonnington, Reference Crosby and Bonnington2020). Self-directed delivery both online and through handbooks is also common (Zeavin, Reference Zeavin2021), and ‘CBT-like’ conversations with generative artificial intelligence such as ChatGPT are now feasible (Ellis and Tucker, Reference Ellis and Tucker2021). CBT has escaped the confines of the clinic in other ways as well, and in a range of countries: for instance, it is deployed as an ostensibly humanitarian intervention within resource-restricted settings internationally; is a feature of the criminal justice system; is situated within or accessed through employment centres; and is inscribed within popular self-help texts (Armstrong, Reference Armstrong2002; Brownlie, Reference Brownlie2004; Frayne, Reference Frayne2019; Friedli and Stearn, Reference Friedli and Stearn2015; Madsen, Reference Madsen2018; Torre, Reference Torre2021). All these settings and uses have elicited a range of concerns from within and beyond the psychological professions, not least clinical psychology.

Initiatives to enhance access to psychological care often emphasise the provision of CBT. But this does not always sit well with clinical psychologists, nor with some other professionals. Concerns circulate widely that CBT is sometimes used as a quick and, in the eyes of some, even simplistic approach to therapy orientated primarily towards the rapid movement of people into and then out of services, rather than at substantively addressing their individual needs. Prominent arguments around its economic effectiveness as a treatment modality (Layard et al., Reference Layard, Clark, Knapp and Mayraz2007) have raised alarm bells for many; as senior clinical psychologists John Marzillier and John Hall (Reference Marzillier and Hall2009, p. 399) put it in BPS periodical The Psychologist, ‘Psychological therapy should be not be travestied as routine application of particular methods or techniques that can somehow deliver happy, adjusted people at low cost’ (see also Binnie, Reference Binnie2015; Dalal, Reference Dalal2019; Mollon, Reference Mollon2009; Moloney, Reference Moloney2013; Ratnayake, Reference Ratnayake2022, among a range of other critiques from within and beyond psychology). Clearly, while some practitioners, such as the highly influential clinical psychologist David Clark (Clark, Reference Clark2018; Layard and Clark, Reference Layard and Clark2014), speak often of the benefits of mass CBT, not everyone agrees.

Descriptive and normative statements can easily blur together within the professions (Dingwall, Reference Dingwall1977). As such, criticisms from clinical psychologists especially cannot be neatly separated from wider disciplinary politics (Cheshire and Pilgrim, Reference Cheshire and Pilgrim2004). Claims made about the limits of CBT often implicitly and sometimes explicitly underscore the importance of other varieties of therapy (and therapists), and the need to go ‘beyond’ CBT, especially in cases deemed to be particularly ‘complex’. Consequently, they lend important support to clinical psychologists as well as counsellors and other practitioners who generally prioritise a longer-term therapeutic relationship than an exclusively and narrowly CBT approach is usually supposed to enjoin. This relates back to my earlier point about the epistemic claim of clinical psychology to be expert not only in CBT but also in knowing how and why to go beyond it and entwine other therapeutic approaches – to be ‘integrationist’. None of this is to say that clinical psychologists’ concerns reduce simply and straightforwardly to professional self-interest. Rather, these overlapping forms of claims-making illuminate how ideas about who should receive therapy, what kind of therapy should be administered, what services are for, who should deliver psychological care, and what makes a good therapist are synthesised together and reciprocally configured.

Taking a Step Back

I have used the word ‘configure’ and its derivatives several times now – including, of course, in the title of this book itself. Some readers will have spotted that I employ it in a similar way to how humanities and social science scholars tend to use the word ‘construct’. Historian of psychology Kurt Danziger (Reference Danziger1990) provides a key example of this in his pathbreaking book, Constructing the Subject. Why, then, use ‘configure’ at all? For one, I appreciate its connotations of ordering or rearrangement so as to get something to work. This aligns with how I think about clinical psychology. I understand this field to operate through an assemblage of material and semiotic entities and devices – policies, guidelines, waiting lists, and so on. Changes to them reorder or rearrange the nature of professional work, how it is delivered, and thus what psychology is (cf. Woolgar and Neyland, Reference Woolgar and Neyland2013). My view of therapy is that it is a form of praxis largely geared towards (re)configuring the psychological in ways that aim to ease distress – and, in so doing, (re)frames and (re)configures subjectivities (rather than building these up from scratch). In effect, and in line with the writers I drew upon earlier, I see psychological power as transformative but not unlimited, nor completely determinative.

I am also drawn to the word ‘configure’ because of its association with technologies (alongside its use within the sociology of technology). Consumers and/or users configure technologies, and professionals also configure the infrastructures within which these are employed – and are themselves also configured in the process. Think of the configuring of a computer, for instance, and the circuits and networks that enable its operations for purposes of work, leisure, or both. Most users do not build or construct these from scratch; rather, they configure what already exists for their own ends, and there are material and practical limits to what these might be. These artefacts likewise contour how users themselves operate and relate to technologies (Woolgar, Reference Woolgar1990). Further, configuration does not necessarily have a clear endpoint: software is updated, and computer usage changes over time, resulting in an interplay between use, user, object, and the contexts within which all of these are situated. Processes of configuration are consequently non-linear and potentially multidirectional, since they always happen within social and economic milieu which shape what is imaginable and actionable (Mackay et al., Reference Mackay, Carne, Beynon-Davies and Tudhope2000; Oudshoorn and Pinch, Reference Oudshoorn and Pinch2003; Oudshoorn et al., Reference Oudshoorn, Rommes and Stienstra2004; Suchman, Reference Suchman, Lury and Wakeford2012). Similarly, psychological praxis is configured and made manifest through particular organisational and epistemic environs, while at the same time psychologists can contribute to shaping the semiotic and even material settings within which configuration occurs.

Resonant metaphors have long existed within critical work on the history and philosophy of psychology (Derksen et al., Reference Derksen, Vikkelsø and Beaulieu2018). This is exemplified by Michel Foucault’s (Reference Foucault, Martin, Gutman and Hutton1988) phrase ‘technology of the self’: as in, an operation or set of operations that people engage in alone or with others as an exercise in constituting selfhood (Esteban-Guitart, Reference Esteban-Guitart and Teo2014). Like Craciun (Reference Craciun2018), Pilgrim (Reference Pilgrim1997), Rose (Reference Rose1992), and many others, I consider psychological therapy to be such a technology. As with other forms of technology, it is configured through use and configures both its principal users and the institutions wherein that use plays out.

The arrival of Foucault into the text seems like a good point to be even more explicit about some of the concepts and debates through which this book has itself been configured. Foucault (Reference Foucault, Martin, Gutman and Hutton1988, Reference Foucault1989) certainly influenced my work, although I owe more immediate intellectual debts to those who have experimented with and expanded his ideas, especially Nikolas Rose (Reference Rose1985, Reference Rose1989, Reference Rose1996) as well as Ian Hacking (Reference Hacking1995, Reference Hacking2002). I am, however, mindful of the concerns of feminist psychologists and others that structural power relations are occluded within some writings by analysts inspired by Foucault (Busfield, Reference Busfield1991; Kitzinger, Reference Kitzinger1991; Morawski, Reference Morawski2015). Further, I am more reluctant than some post-Foucauldian scholars to characterise processes and techniques as intrinsically new or novel (given that such characterisation is itself a sociological process; Pickersgill, Reference Pickersgill2021). While not completely opposed to this, I remain wary of over-reliance on attributions of fundamental novelty as an analytic pivot. Instead, I am more interested in the social work entailed in, for instance, how, in what sense, and with what effects a given object, practice, or institution comes to be feted as novel (a disposition which perhaps also takes some inspiration from Foucault). More generally, I find myself in alignment with historians of psychology (e.g. Smith, Reference Smith1988; Thomson, Reference Thomson2006) who have implicitly or explicitly cautioned against embracing too tightly or interpreting too literally theorists like Foucault. Such practices can constrain analyses and reproduce their own form of scholarly conservatism.

The arguments set out in these pages, then, are informed by a range of histories and sociologies of psychology specifically, and – as will become evident over the chapters that follow – of clinical knowledge and healthcare practice more generally (most notably from traditions like the sociology of the professions and the sociology of science). Such scholarship collectively demonstrates the significance of psychology to societies while also showing that the psychological does not pre-exist the social in straightforward ways. Rather, what we take to be the psyche, and what counts as expert knowledge about it, is accomplished via a range of social and technical operations (Byford, Reference Byford2016; Hayward, Reference Hayward2014; Miller and Rose, Reference Miller and Rose1988; Young, Reference Young1995). These can be regarded as forming what Rose (Reference Rose1985, p. 9) terms the ‘psychological complex’: an intersecting matrix of ‘discourses, practices, agents and techniques’ through which the psychological is known and understood to be. Clinical psychology and the provision of psychological therapy more broadly are vital to understand, then, not only because they are key yet often understudied elements of healthcare. They also require our attention because they have ramifications in turn for how the subjects of therapy – which, partly because of an ethic of access, are very many of us – might be configured.

What Lies Ahead

This book draws on a range of texts and interviews (predominantly with clinical psychologists) to examine the dynamic relationships between policy and law, norms and categorisation, and knowledge and expertise within psychology vis-à-vis the enhancement of access to therapy. I show how health research, professional politics, governmental pressures, and everyday exigencies reciprocally configure the contexts of psychological care and the experiences of healthcare workers. In doing so, I also demonstrate the troubling ambivalence of an ethic of access. First, this entails a reconfiguration of praxis in ways that create professional and affective challenges even as policy to enhance the accessibility of therapy is deemed broadly desirable. Second, it creates the conditions of possibility for an increase in care for some while curtailing it for others, in part through giving clinical psychologists both more and less power.

Clinical psychologists often play senior roles in mental health services, managing different kinds of staff. This includes within NHS Talking Therapies services, formerly the Improving Access to Psychology Therapy (IAPT) initiative, one of the key programmes to expand the numbers of people receiving therapy in England. Within these and other services based in primary care settings across the United Kingdom (i.e. places generally serving as the ‘first port of call’ for accessing healthcare, such as a local general medical practice), therapy is very often delivered by other, less well-paid professionals. This is part of the broader logic of cost effectiveness that configured the initial instantiation of IAPT. However, clinical psychologists also contribute significant amounts of therapy, especially within secondary care (i.e. more specialist services which generally require a referral and are commonly located in hospitals). Given the prestige the profession has worked so hard to attain, clinical psychology also shapes the psychological complex more widely through its epistemic practices, ontological assertations, and strategic activities. As such, the narrative of the book moves, in the earlier chapters, from an exploration of clinical psychology as a profession to a broader consideration of psychological therapy, before refocusing later on the experiences and accounts of clinical psychologists specifically.

Accordingly, this book is divided into two parts. Part I focuses on national shifts and debates. It is grounded primarily in textual sources: scientific articles, policy documents, and charity campaigns materials as well as blogs, newsletters, and other, more informal media. The analysis is also undergirded by a small number of interviews (conducted over 2012–2014) and informal conversation with various policy actors including civil servants, policy advisors, and charity leads. It is additionally informed by scores of encounters with different kinds of mental health professionals and discussions with a range of people who have lived experience of mental ill-health. I have been engaged to varying degrees for around 20 years now with different constituents of the psychological complex – including people receiving or/and contesting healthcare, as well as advocacy and campaign groups – through formal research interviews and focus groups as well as more everyday and personal interactions. Some of the people closest to me also work within the NHS delivering therapy, including as clinical and health psychologists. Further, alongside undertaking the sociology of the psychological complex I am also increasingly an actor within it through active research collaborations with psy-practitioners. The arguments made in this book are deeply impacted by all those engagements.

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

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

The narrative then turns to explore and historicise attempts to review the 1983 Mental Health Act of England and Wales. In Chapter 3, I focus on the traffic between clinical affirmations about the need to enhance access to treatment – increasingly understood to be psychological therapy – for people diagnosed with a personality disorder and political aims to detain criminal offenders living under this diagnosis for longer periods. The rewriting of the Act and the significance of personality disorder among these represent a key yet underacknowledged moment in the unfolding story of access to psychological care, while also demonstrating how improved access is not necessarily an unproblematic social good. The chapter demonstrates how legal and professional discourses contoured each other such that an understanding of personality disorder as treatable through psychological intervention was produced. Doing so improved the accessibility of therapy for some people; however, this was often as a consequence of their involuntary confinement.

Part II of this book returns to focus specifically on clinical psychology and how the activities of its practitioners have been configured though an ethic of access. It attends to clinical psychologists’ negotiations of patient access to their care, including via the management of waiting lists and the rejection of referrals. I draw primarily on 40 interviews conducted over 2013–2015 with clinical psychologists who worked across a range of services in both rural and urban localities in both England and Scotland. These are interpreted against a backdrop of an assortment of conferences and professional events held by or convened for mental health professionals in general or clinical psychologists in particular. I took part in these on and off for more than a decade (with some respite during and following the COVID-19 pandemic). Some I arranged myself, with the explicit aims of bringing activists, clinicians, patients, and policymakers into conversation. The interview data are further contextualised by the materials and data that informed Part I. Again, the arguments advanced are additionally shaped by my ongoing research into, and increasing participation within, the psychological complex. Unfortunately, these continuing engagements confirm that many of the concerns discussed in Part II – such as long waiting lists and associated challenges – have only worsened since the interviews were conducted.

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

In Chapter 5 I move to consider some of the challenges of waiting lists and associated targets that configure clinical psychology. Taking the position that targets operate as a technology of government (Rose, Reference Rose1996), the chapter indicates some of the affective and material consequences of their instantiation. In particular, I show how clinical psychologists rework processes of entry into therapy, and the aims and character of care, to meet – and sometimes accommodate – targets. While professional autonomy is often regarded as being constrained through these technologies of government, practitioners nevertheless find ways of performing autonomous action in a manner that can advantage some patients over others. I illuminate how shifts in psychological care in response to targets might recast clinical psychologists’ relationships with their work and with people seeking therapy. In so doing, implications arise for the subjectivities that are (not) assembled through therapy.

Chapter 6 centres clinical psychologists’ perspectives on and responses to ‘did not attend’ (DNA) policies. Patient non-attendance at clinical appointments has long been regarded as troubling within healthcare, particularly so in light of pressures and targets to see more people for therapy and more quickly. DNA policies are also an object of often latent concern by professionals and patients in relation to how they ostensibly improve access for some people through the potentially strategic exclusion of others. I analyse how clinical psychologists account for and navigate such policies, exploring how (in)formal rules around attendance can prompt the involuntary discharge of patients. DNA policies often provide space for clinical discretion and are even sometimes elided by practitioners. Their negotiations can involve highly moralised configurations of both patient and professional subjectivities. These contribute to legitimising exclusion from services, as well as the expertise leveraged to do so.

Finally, I conclude with a short coda. In it, I describe some of the ambivalences that come with an ethic of access. I reflect on the procedural and ethical challenges that can be propelled by ostensibly progressive healthcare initiatives, and consider what could perhaps be done about these. In light of the arguments made throughout the preceding chapters, I decline to advance discrete recommendations in what is already a crowded policy space. Rather, I urge an ethos of reconfiguration within mental healthcare that fosters variability and mutability in services through direct and ongoing engagement with communities. In so doing, psychological practitioners might be enabled to better comprehend, articulate, and serve the needs of those with whom they undertake therapeutic work.