Uncertainty work as ontological negotiation: adjudicating access to therapy in clinical psychology

Abstract

Across the UK, wide‐ranging efforts have been made to enhance citizen access to psychological therapy. Clinical psychologists are key providers of and gatekeepers for therapy. This article is concerned with how clinical psychologists foster access (or not) to psychological care. More specifically, it interrogates how psychologists manage, and make decisions around, patient referrals. Following a referral, psychologists must resolve an uncertain situation: should they accept a referral and continue with an assessment? Thereafter, they must decide whether a patient is suitable for their service – and for therapy more generally. Certainty is synthesised against a backdrop of sometimes powerful pressures to meet service targets. Taking cues from medical sociology and science and technology studies (STS), this article interrogates some of the uncertainties around access to psychological therapy, and how decisions made by clinical psychologists involve negotiations of patient, service and professional ontologies. To do so, it draws on interviews with 40 psychologists across England and Scotland. The paper spotlights a professional group that is often absent from or only dimly lit within sociological observation and analysis: clinical psychology. Through attending to the discourses of psychologists, I extend conversations about uncertainty through a distinctive case study.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

“…2017). Sociological approaches tend to broaden the lens to attend to co‐dependencies between ‘the affective state of individuals’ and ‘socio‐political and clinico‐epistemic infrastructures’ (Pickersgill 2019). We highlight dimensions of uncertainty across the papers: (i) epistemological and ontological uncertainty, and (ii) moral or normative dimensions.…”

“…Within clinical psychology services, the Psychological Mindedness Scale (Shill and Lumley 2002) provides epistemic authority for gaining insight into the self (Pickersgill 2019). The scoring system helps psychologists navigate uncertainty and provides a framework for considering who should receive therapy and why (Pickersgill 2019).…”

“…Within clinical psychology services, the Psychological Mindedness Scale (Shill and Lumley 2002) provides epistemic authority for gaining insight into the self (Pickersgill 2019). The scoring system helps psychologists navigate uncertainty and provides a framework for considering who should receive therapy and why (Pickersgill 2019). Pre‐assessments largely occur in the absence of patients; as a result, the ontology of a patient is negotiated at a distance via a multifaceted biopsychosocial matrix involving demographic data, psychological identifiers, and social and behavioural indicators and networks (Pickersgill 2019).…”

“…Preservation of the clinical and moral identity of a psychologist as ‘good’ links to constructs of patients’ readiness for therapy and psychological mindedness which legitimises exclusion from therapy as a form of care (i.e. protecting patients from failure if patient/service misaligned) (Pickersgill 2019). Normative bias (Kugelmass 2016) features ‘as a constitutive element of clinical experience that shapes and directs the management of uncertainty and therapeutic (in)action’ (Pickersgill 2019, p. 13).…”

“…protecting patients from failure if patient/service misaligned) (Pickersgill 2019). Normative bias (Kugelmass 2016) features ‘as a constitutive element of clinical experience that shapes and directs the management of uncertainty and therapeutic (in)action’ (Pickersgill 2019, p. 13). Even within structural constraints, psychologists have the power to ‘stretch or shrink’ a service remit, and facilitate or deny access to particular patients.…”