In Chapter 1, 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 many 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). This includes through the development of a professional body solely for clinical psychologists: the Association of Clinical Psychologists UK (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 that patients are (not) able to access.

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 patient for therapy. This decision-making process depends on far more than an ‘objective’ evaluation of the patient 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 patients, although even exclusions might themselves sometimes be accounted for by professionals as forms of care.

In this Introduction, I sketch out the rise of a transnational ethic of access to treatments for ill-health, and how it configures and is configured by mental healthcare in the UK. The instantiation of this ethic has resulted in policy and clinical attention to enhancing access to psychological therapy (often cognitive behavioural therapy, CBT, specifically). I introduce the importance of clinical psychology within this context and chart its consolidation as a profession, alongside a discussion of the role of CBT within the UK. I also discuss the wider entanglements of psychological praxis and societies, and the theoretical perspectives that propel the analysis presented in this book. I conclude with outlining the various chapters that follow.

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 a key issue of concern within healthcare, and particularly so in light of pressures and targets to see more patients 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.

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 what Nikolas Rose calls a ‘technology of government’, 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, in order 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 matter that can advantage some patients over others. I illuminate how shifts in psychological care in response to targets could recast clinical psychologists’ relationships to their work and with patients, with implications for the subjectivities that are (not) assembled through therapy.

In this short Coda, 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 an overdetermined 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.

This opening chapter provides a broad survey of the field. It describes what features define clinical psychology and what clinical psychologists do in their roles as researchers, therapists, teachers, consultants, and administrators. It describes the increasingly diverse demographic characteristics of clinicians and their clients, and the wide range of settings in which they work. The chapter also outlines the personal, educational, and experiential requirements needed to enter the field. It discusses the continued appeal of clinical psychology as a profession, popular conceptions and misconceptions about clinical psychologists held by the general public, and how clinical psychology overlaps with, and differs from, other mental health professions, including counseling, school, and educational psychology, as well as social work and psychiatry.

The applied psychology of religion takes information from the knowledge base developed by psychologists of religion and uses this information for some social, psychological, or spiritual/religious purpose. When we seek to apply research and theory in this field we must first answer questions about our objectives, and it is unlikely that we will arrive at much agreement on ultimate goals. Still, it is possible that some consensual objectives and applications can emerge among researchers and those who seek to apply what researchers have learned. This chapter lists and discusses a broad range of potential applications. One major domain of application concerns clinical psychology, counseling psychology, psychiatry, social work, and related fields. We see that in recent decades, there have been many proposals – partly driven by the findings of empirical research – to integrate religious and spiritual approaches into mainstream psychotherapy. As with nearly everything else in the psychology of religion, these proposals can be controversial. In addition, the chapter discusses proposed spiritual and religious competencies for psychologists.

Our thoughts affect our feelings and our feelings affect our thoughts. But the way to break into this cycle is through changing our thoughts. Experimental evidence shows the effectiveness of many ways of doing this. Cognitive behaviour therapy (CBT) teaches us to observe our automatic negative thoughts and make space for more positive thinking. Positive psychology builds on this, applying the lessons to all of us, and not just those in distress. It helps us all to build our emotional intelligence. The Action for Happiness movement applies these lessons through their 10 Keys to Happier Living. Mindfulness meditation, through non-judgemental and friendly engagement with the present moment, can transform our mental state and improve our immune system.

In this chapter, the author examines clinical psychological, traumatic developmental, and sociocultural perspectives of a serial murder. This includes media dynamics and feminist perspectives. The author discusses malingering, or the faking of mental illness. The case of female serial killer (FSK) Aileen Wuornos is revisited to illustrate clinical psychological issues. The cases of male serial killers (MSKs) Ronald Dominique and Dennis Rader (BTK Strangler) highlight phenomena from the chapter.

Summarizes how psychologists define psychopathology. Discusses ways in which abnormality was viewed historically, and modern mental health care. Identifies the research methods that psychologists utilize.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

In a gendered world, doctors and caretakers took for granted that making atypical bodies more typical was a humane way out of a difficult situation for child and family. Had the professionals carried out proper research, they would have learned from their young patients that the approach was physically and psychologically risky. But research on the long-term effects was not carried out, certainly not from the patients’ perspective. There was also no comparison group made up of people growing up with unaltered genital variations. Research with adults is the topic of Chapter 4 of this book. Since the 1990s, a number of outcome studies with adults have identified many problems of childhood surgery, such as multiple operations, scarring, shrinkage, sensitivity loss, unusual genital appearance and sexual difficulties.

Chapter 8 begins by pointing out the current lack of collective clarity about the role of psychological care providers (PCPs) and suggests that researchers and practitioners make collective effort to develop the role of PCPs in sex development in future. Meanwhile it outlines the psychological consultation process that is generic and familiar to most PCPs. The author provides an initial assessment template and summarizes the popular psychotherapeutic interventions. The template is visible in several of the practice vignettes in the ensuing chapters of the book. The author ends the chapter by arguing that the tertiary environment is set up for diagnostic workup and treatment and unsuitable for the kind of ongoing psychosocial input that is needed by individuals and families living in their communities. The author makes a case for PCPs in DSD centers to collaborate with peer support workers to enable nonspecialist providers in the community to contribute to ongoing support for individuals and families.

Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.