WHAT IS CLINICAL PSYCHOLOGY?, Study notes of Clinical Psychology

Download WHAT IS CLINICAL PSYCHOLOGY? and more Study notes Clinical Psychology in PDF only on Docsity! 1 Chapter Preview In this chapter we introduce the field of clinical psychology. We first outline the requirements for becoming a clinical psychologist and discuss the profession’s popularity. Next we describe how clinical psychology relates to other mental health professions. We describe the work activities of most clinical psychologists and the rewards of the profession, financial and otherwise. Finally, we introduce some of the key issues shaping the field today. These issues include how to (a) strike a balance between science and practice, (b) train new clinicians, (c) combine divergent theoretical approaches, and (d) adapt clinical practice to a changing health care environment. What Is ClInICal PsyChology?1 A Clinical Case Bonnie, a 15-year-old European American girl in 9th grade, asked her parents to get her some help to deal with her fear and anxiety. They did so, and as part of the intake evaluation at her first appointment, Bonnie was interviewed by a clinical psychologist specializing in treatment of childhood anxiety disor- ders. At the beginning of the interview, Bonnie said her problem was that she would “get nervous about everything,” particularly about things at school and doing anything new. When asked to give an example, Bonnie mentioned that her father wanted her to go to camp during the coming summer, but she did not want to go to camp because of her “nerves.” It soon became clear that Bonnie’s anxiety stemmed from a persistent fear of social situations in which she might be the focus of other people’s attention. She said she felt very self-conscious in the local mall and constantly worried about what others might be thinking of her. She was also fearful of eating in public, using public restrooms, being in crowded places, and meeting new people. She almost always tried to avoid such situations. She experienced anxiety when talking to her teachers and was even more afraid of talking to store clerks and other unfamiliar adults. Bonnie would not even answer the telephone in her own home. In most of these situations, Bonnie said that her fear and avoidance related to worry about pos- sibly saying the wrong thing or not knowing what to say or do, which would lead others to think badly of her. Quite often, her fear in these situations became so intense that she experienced a full-blown panic attack, complete with rapid heart rate, chest pain, shortness of breath, hot flashes, sweating, trembling, dizziness, and difficulty swallowing. To get a clearer picture of the nature of Bonnie’s difficulties, the psychologist conducted a separate interview with Bonnie’s parents. While confirming what their daughter had said, they reported that Bonnie’s social anxiety was even more severe than she had described it. (Based on Brown & Barlow, 2001, pp. 37–38.) How can we best understand Bonnie’s fears and anxieties? How did her problems develop, and what can be done to help her overcome them? These questions are important to Bonnie, her loved ones, and anyone interested in her condition, but the questions are especially important to clinical psychologists. In this book you will learn how clinical psychologists address problems such as those faced by Bonnie. You will learn how clinicians assess and treat persons with psychological problems, how they conduct research into the causes and treatments for psychological disorders, and how they are trained. You will learn how clinical psychologists have become key providers of health care in the United States and in other countries, and how clinical psychology continues to evolve and adapt to the social, political, and cultural climate in which it is practiced. M01_KRAM1858_08_SE_C01.indd 1 10/06/13 2:50 PM 2 Section I • Basic Concepts An Overview Of CliniCAl PsyChOlOgy seCtiOn Preview Here we define clinical psychology and identify the essential requirements satisfied by its practitioners. We also discuss the continued appeal of clinical psychology, popular concep- tions of clinical psychologists, and how clinical psychology overlaps with, and differs from, other mental health professions. As its name implies, clinical psychology is a subfield of the larger discipline of psychology. Like all psychologists, clinical psychologists are interested in behavior and mental processes. Like some other psychologists, clinical psychologists generate research about human behavior, seek to apply the results of that research, and engage in individual assessment. Like the members of some other professions, clinical psychologists provide assistance to those who need help with psychological problems. It is difficult to capture in a sentence or two the ever-expanding scope and shifting directions of clinical psychology. Nevertheless, we can outline the central features of the discipline as well as its many variations. Definition of Clinical Psychology The definition of clinical psychology adopted by the American Psychological Association’s Divi- sion of Clinical Psychology reads as follows: “The field of Clinical Psychology integrates science, theory, and practice to understand, predict, and alleviate maladjustment, disability, and discom- fort as well to promote human adaptation, adjustment, and personal development. Clinical Psy- chology focuses on the intellectual, emotional, biological, social, and behavioral aspects of human functioning across the life span, in varying cultures, and at all socioeconomic levels” (American Psychological Association, Division 12, 2012). As you can see, the definition focuses on the inte- gration of science and practice, the application of this integrated knowledge across diverse human populations, and the purpose of alleviating human suffering and promoting health. But what are the requirements to become a clinical psychologist? Personal requirements to Be a Clinical Psychologist Certain requirements for those wishing to be clinical psychologists have more to do with attitudes and character than with training and credentialing. Perhaps the most notable distinguishing fea- ture of clinical psychologists has been called the clinical attitude or the clinical approach (Korchin, 1976), which is the tendency to combine knowledge from research on human behavior and men- tal processes with efforts at individual assessment in order to understand and help a particular Clinical psychology’s purpose is to alleviate human suffering and promote health. Those wishing to become clinical psychologists must satisfy rigorous personal, legal, and educational requirements. Source: Alina Solovyova-Vincent/E+/Getty Images. M01_KRAM1858_08_SE_C01.indd 2 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 5 Popularity of Clinical Psychology Clinical psychology is the largest subfield of psychology. Graduate programs in clinical psychol- ogy attract more applicants than do graduate programs in any other area of psychology (see Figure 1.1), and far more doctoral-level degrees are awarded in clinical and related health service provider areas than in other areas of psychology (Kohout & Wicherski, 2011). The prominence of clinical psychology helps explain why the terms psychologist and clinical psychologist are practically synonymous in public discourse. The appeal of clinical psychology is also reflected in the composition of the largest orga- nization of psychologists in the United States: the American Psychological Association. Of the 56 divisions in APA, the largest divisions relate to clinical psychology (Division 12—Clinical Psychology, Division 40—Clinical Neuropsychology, and Division 42—Psychologists in Inde- pendent Practice). Of course, for students interested in clinical psychology, popularity means competition, especially for spots in graduate schools. Indeed, the stronger, research-oriented PhD programs, whose students typically score the highest on the Examination for Professional Practice in Psychology, accept as few as 7% of applicants, while some freestanding PsyD programs accept closer to 50% (Norcross, Ellis, & Sayette, 2010). Despite the competition, the outlook for clinical psychologists looks promising. The U.S. Department of Labor’s Occupational Outlook Handbook (2011) projects that job prospects for doctoral-level applied psychologists are best, while master’s degree holders will face keen competition and bachelor’s degree holders will find limited opportunities. CNN’s Money.com (2012) rates clinical psychologist as 23rd among the top 50 jobs in America, with personal satisfaction, job security, future growth, and benefit to society at high levels. The field’s popularity is also shown by the numerous portrayals of clinical psychologists and their distressed clients in movies, television, and other media. This kind of popularity is a double-edged sword. On the one hand, accurate portrayals can contribute to the public’s mental health literacy—accurate understanding of psychological disorders and their treatments (Jorm, 2000). On the other hand, inaccurate portrayals can decrease mental health literacy and create inaccurate, stereotyped views of the profession. Unfortunately, the latter outcome seems to be more common. Clinical psychologists are often portrayed as oracles, agents of social compliance, or wounded healers, and the techniques by which they help clients are seldom portrayed accurately (Orchowski, Spickard, & McNamara, 2006). Inaccurate portrayals might make for good drama, but they don’t reveal what clinical psychology is really like. We hope that this book does a much better job. Clinical Psychology and the related mental health Professions As noted earlier, clinical psychologists are considered health service providers. Other subfields within psychology belonging to this category include behavioral and cognitive psychology, clinical psy- chology, clinical child psychology, clinical health psychology, clinical neuropsychology, counseling psychology, family psychology, forensic psychology, professional geropsychology, psychoanalytic psychology, and school psychology (Nelson, 2013). Clinical services are also offered by professionals trained outside psychology in professions such as social work, psychiatry, and nursing. Like clinical figure 1.1 Applicants to U.S. Psychology Programs, 2009–2010. Source: Adapted from Kohout and Wicherski (2011). Clinical Counseling School Neuroscience Developmental Experimental Social/Personality Cognitive 0 10,000 20,000 30,000 40,000 50,000 M01_KRAM1858_08_SE_C01.indd 5 10/06/13 2:50 PM 6 Section I • Basic Concepts psychology, each of the professions mentioned above has one or more national or international organizations, networks of accredited training programs, well-established research traditions, and specific licensing or certification requirements. Each group also has its own unique history and traditions. Practitioners from each group offer mental health services in one form or another. How then are clinical psychologists similar to, and different from, these other professionals? COunseling PsyChOlOgy Counseling psychologists are the most similar to clinical psycholo- gists in their training and in the types of services that they offer. Much of their course work and supervised training overlaps with that of clinical psychologists—practitioners are trained in psycho- pathology, interviewing, assessment, counseling and psychotherapy, research, and the like. Students in the two fields apply to the same list of accredited internship sites, and graduates from the two subfields are eligible for the same licensure, practice opportunities, and insurance reimbursement. These two subfields are similar enough in their training, research interests, professional activities, and licensure requirements that calls to merge the two fields are often heard (Norcross, 2011). Neverthe- less, there are a few salient differences between clinical and counseling psychology. Clinical psychology programs are invariably housed in psychology departments, while counseling psychology programs are sometimes housed in psychology departments, but are often located in education departments or other departments or divisions. Counseling psychologists can earn a PhD, PsyD, or EdD degree, all doctoral-level degrees but differing in emphasis (discussed later in this chapter and in Chapter 15). Counseling psychology was founded to promote personal, educational, vocational, and group adjustment (American Psychological Association Division 17, 2012). Accordingly, coun- seling psychologists are more likely to deal also with normal transitions and adjustments that people may face. Besides offering psychotherapy, counseling psychologists might, for instance, do career counseling or other forms of counseling related to life changes or developmental problems. Clinical psychology, on the other hand, was founded primarily to assess and treat persons with psychological disorders (see Chapter 2). Therefore, clinical psychologists focus more specifically on prevention, diagnosis, and treatment of psychological problems and on research related to these issues, and they generally deal with more severe pathology than counseling psychologists do. So the differences between clinical psychology and counseling psychology are largely a mat- ter of emphasis. Despite these differences, there is considerable overlap between the professions. sChOOl PsyChOlOgy School psychologists also have much in common with clinical and counseling psychologists: they generally share a scientist-practitioner model of training, move through similar internship and licensure requirements, conduct assessments, design interven- tions at the individual and system levels, and evaluate programs. The obvious difference is that school psychologists typically receive more training in education and child development, and they focus their interventions on children, adolescents, adults, and their families in school and other educational settings. Despite the differences in emphasis, the similarities to clinical, especially to clinical child psychology, and to counseling psychology are greater than the differences (American Psychological Association Division 16, 2012; Cobb et al., 2004). sOCiAl wOrk As the nation’s largest group of mental health service providers, social workers are employed in a variety of settings, including hospitals, businesses, community mental health centers, courts, schools, prisons, and family service agencies. Students in social work programs may choose to specialize in direct services to clients, or they may specialize in community services (Ambrosino, Heffernan, Shuttlesworth, & Ambrosino, 2012). About half of the National Association of Social Workers members are engaged in offering direct clinical services, including various forms of therapy; the rest work in areas such as administration, public policy, research, and community organizing. Social workers can earn a bachelor’s degree (Bachelor of Social Work, or BSW), master’s degree (Master of Social Work, or MSW), or doctoral degree (Doctorate in Social Work, or DSW or PhD). As in clinical psychology, licensing and certification laws vary by state. Typically, the minimum degree required to provide psychotherapy services is an MSW (National Association of Social Workers, 2012). Social workers may be trained in various psychotherapy techniques, but as a general rule, they focus more on how social/situational variables, rather than intrapersonal and interpersonal variables, affect functioning. Social workers, like clinical psychologists, spend much of their time in direct client contact, helping clients cope with problems and navigate a world that has become complex and difficult because of those problems. M01_KRAM1858_08_SE_C01.indd 6 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 7 PsyChiAtry One of the first questions students ask when they begin studying psychology is “What’s the difference between a psychologist and a psychiatrist?” The most entertaining answer is: “about $80,000 per year,” but the more comprehensive answer involves the differences in train- ing and practice between the two professions. Psychiatry is a specialty within the medical field. So, just as pediatrics focuses on children, ophthalmologists specialize in eyes, and neurologists focus on the brain and nervous system, psychiatrists are medical doctors who specialize in treating psy- chological disorders. Persons training to be psychiatrists typically complete a psychiatric residency in which they take course work in psychology and undergo supervision by qualified psychiatrists as they work with patients. This residency often occurs in a hospital setting and therefore generally involves exposure to more serious psychopathology, but it may also occur in outpatient settings. Many psychiatrists offer psychotherapy, but not all do. According to recent surveys, the majority see patients for less than 25 minutes at a time, often for medication reviews (Kane, 2011). In addi- tion to doing therapy and prescribing medication, psychiatrists order or conduct other medical tests, teach, do research, work in administration, and perform other tasks commensurate with their level of training. Though psychiatrists generally have more medical training than clinical psychologists, clinical psychologists typically have more formal training in psychological assess- ment and a broader exposure to a variety of approaches to psychology. The historical distinction between psychiatrists and clinical psychologists has been under- stood as reflecting the difference between a more biological (psychiatrists) and a more psychologi- cal (clinical psychologists) view of the causes of mental disorders. Recent years, however, have seen increased collaboration between the professions. Much of the change can be attributed to the growing realization that psychological disorders are seldom either biological or psychological in origin but typically a complex interaction of both. As a result, clinical psychologists are increas- ingly employed in medical settings, where their psychological and research expertise are valued. Psychiatrists and psychologists often work cooperatively on task forces devoted to issues of valid diagnoses and effective treatments. This is consistent with a broader shift toward psychology becoming a health profession rather than strictly a mental health profession (Rozensky, 2011). Other sPeCiAlties relAteD tO CliniCAl PsyChOlOgy Mental health services are also offered by a variety of other specialists and caregivers. We have already mentioned counseling psychology and school psychology as two subfields that are closely related to clinical psychology. In Chapters 11–14, we detail four other specialties related to clinical psychology: clinical child psy- chology, health psychology, clinical neuropsychology, and forensic psychology. Other psychology programs that train health service providers include sport psychology, rehabilitation psychology, marriage and family therapy, humanistic psychology, and community counseling. Still other specialists are trained outside psychology in programs specifically devoted to that specialty. For instance, as specialists within the nursing profession, psychiatric nurses usually work in hospital settings and operate as part of a treatment team that is headed by a psychiatrist and includes one or more clinical psychologists. They may be trained in some forms of therapy, often those specific to the populations they encounter. Pastoral counselors typically get train- ing in counseling from a faith-based perspective. For clients whose religious faith is central to their identity and outlook on life, the availability of a counselor who affirms this faith can be important. Paraprofessionals, psychological assistants, and others who go by similar names, are usually bachelor’s-level or associate-level personnel trained to administer a specific form of treatment to a specific population. They generally work as part of a treatment team, and their activities are supervised by professionals. Their training varies, but many come from disciplines that have some or all of the following indicators of professional quality: well-articulated standards of practice, national organizations that promote and oversee the profession, course offerings in colleges and universities, empirical research traditions, and peer-reviewed journals. Others specialties, such as aromatherapy, reflexology, homeopathy, and spiritual healing techniques, have few or none of the indicators of professional quality just listed and might be described as further from the mainstream of mental health treatment. Often classified as alterna- tive treatments or alternative medicine, many of these further-from-the-mainstream treatments combine somatic or sensual experiences with variants on psychological, social, or spiritual inter- vention. Some of these practices derive from ancient traditions; some are new inventions. Persons who practice alternative treatments often describe their work as falling within a holistic tradition that emphasizes the integration of mind, body, and spirit (Feltham, 2000). M01_KRAM1858_08_SE_C01.indd 7 10/06/13 2:50 PM 10 Section I • Basic Concepts There are at least four reasons. First, it is important that all clinicians be able to critically evaluate published research so that they can determine which assessment procedures and thera- peutic interventions are likely to be effective. Second, clinicians who work in academia must often supervise and evaluate research projects conducted by their students. Third, when psychologists who work in community mental health centers or other service agencies are asked to assist admin- istrators in evaluating the effectiveness of the agency’s programs, their research training can be very valuable. Finally, research training can help clinicians objectively evaluate the effectiveness of their own clinical work. Tracking client change can signal the need to change treatment plans, reveal the need for additional clinical training, and contribute to third party (e.g., insurance companies, clinical researchers) efforts to document and understand factors affecting clinical effectiveness (Hatfield & Ogles, 2004). teAChing A considerable portion of many clinical psychologists’ time is spent in educational activities. Clinicians who hold full- or part-time academic positions typically teach undergradu- ate and graduate courses in areas such as personality, abnormal psychology, introductory clinical psychology, psychotherapy, behavior modification, interviewing, psychological testing, research design, and clinical assessment. They conduct specialized graduate seminars on advanced topics, and they supervise the work of graduate students who are learning assessment and therapy skills in practicum courses. A good deal of clinical psychologists’ teaching takes the form of research supervision. This kind of teaching begins when students and professors discuss research topics of mutual interest that are within the professor’s area of expertise. Most research supervisors help the student frame appropriate research questions, apply basic principles of research design to address those ques- tions, and introduce the student to the research skills relevant to the problem at hand. Clinical psychologists also do a lot of teaching in the context of in-service (i.e., on-the-job) training of psychological, medical, or other interns, social workers, nurses, institutional aides, ministers, police officers, prison guards, teachers, administrators, business executives, day-care workers, lawyers, probation officers, and many other groups whose vocational skills might be enhanced by increased psychological sophistication. Clinicians even teach while doing therapy— particularly if they adopt a behavioral approach in which treatment includes helping people learn more adaptive ways of behaving (see Chapter 8). Finally, many full-time clinicians teach part time in colleges, universities, and professional schools. Working as an adjunct faculty member provides another source of income, but clinicians often teach because it offers an enjoyable way to share their professional expertise and to remain abreast of new developments in their field. COnsultAtiOn Clinical psychologists often provide advice to organizations about a variety of problems. This activity, known as consultation, combines aspects of research, assessment, treat- ment, and teaching. Perhaps this combination of activities is why some clinicians find consulta- tion satisfying and lucrative enough that they engage in it full time. Organizations that benefit from consultants’ expertise range in size and scope from one-person medical or law practices to huge government agencies and multinational corporations. The consultant may also work with neighborhood associations, walk-in treatment centers, and many other community-based organizations. Consultants perform many kinds of tasks, including education (e.g., familiarizing staff with research relevant to their work), advice (e.g., about cases or programs), direct service (e.g., assessment, treatment, and evaluation), and reduction of intraorganizational conflict (e.g., eliminating sources of trouble by altering personnel assignments). When consulting is case oriented, the clinician focuses attention on a particular client or organizational problem and either deals with it directly or offers advice on how it might best be handled. When consultation is program or administration oriented, the clinician focuses on those aspects of organizational function or structure that are causing trouble. For example, the consul- tant may suggest and develop new procedures for screening candidates for various jobs within an organization, set up criteria for identifying promotable personnel, or reduce staff turnover rates by increasing administrators’ awareness of the psychological impact of their decisions on employees. ADministrAtiOn Many clinical psychologists find themselves engaged in managing or run- ning the daily operations of organizations. Examples of the administrative posts held by clini- cal psychologists include head of a college or university psychology department, director of a graduate training program in clinical psychology, director of a student counseling center, head M01_KRAM1858_08_SE_C01.indd 10 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 11 of a consulting firm or testing center, superintendent of a school system, chief psychologist at a hospital or clinic, director of a mental hospital, director of a community mental health center, manager of a government agency, and director of the psychology service at a Veterans Adminis- tration (VA) hospital. Administrative duties tend to become more common as clinicians move through their professional careers. Although some clinical psychologists spend their time at only one or two of the six activi- ties we have described, most engage in more, and some perform all six. To many clinicians, the potential for distributing their time among several functions is one of the most attractive aspects of their field. employment settings of Clinical Psychologists At one time, most clinical psychologists worked in a single type of facility: child clinics or guidance centers. Today, however, the settings in which clinicians function are much more diverse. You will find clinical psychologists in the following as well as many other settings: college and university psychology departments law schools institutions for the intellectually disabled police departments public and private medical and prisons psychiatric hospitals juvenile offender facilities city, county, and private mental health clinics business and industrial firms probation departments community mental health centers rehabilitation centers for the student health and counseling centers handicapped medical schools nursing homes and other geriatric facilities the military university psychological clinics orphanages alcoholism treatment centers child treatment centers health maintenance public and private schools organizations (HMOs) The work settings that clinical psychologists choose strongly influence how they distribute their time across professional activities. But so do their training, individual interests, and areas of expertise. Work activities are also influenced by larger social factors. For example, a clinician could not work in a Veterans Administration hospital today if federal legislation had not been passed in the 1940s creating such hospitals. (The role played by sociocultural forces in shaping clinical psychology is more fully detailed in Chapter 2.) In short, what clinicians do and where they do it has always depended—and always will depend—on situational demands, cultural values, changing political climates, and the pressing needs of the society in which they function. Table 1.1 shows the primary and secondary work settings of health service providers in psychology, the majority of which are clinical psychologists. Setting Primary Setting (%) Secondary Setting (%) Independent private practice Individual 36 37 Group 10 9 Hospitals 12 6 Other human service settings 11 11 Managed care 5 3 Business and government 7 9 Academic 19 25 Source: Michalski and Kahout (2011). tABle 1.1 Primary and Secondary Work Settings of APA-Affiliated Health Service Providers M01_KRAM1858_08_SE_C01.indd 11 10/06/13 2:50 PM 12 Section I • Basic Concepts salaries of Clinical Psychologists The financial rewards for employment as a clinical psychologist are significant. A 2010 report by the APA Center for Workforce Studies showed that the overall 11–12-month median salary for licensed doctoral-level clinical psychologists was $87,015. As you no doubt have guessed, salary levels vary according to employment setting, years of experience, and economic conditions. Table 1.2 presents the median as well as the 25th and 75th percentile (Q1 and Q3, respectively) salaries for clinical psychologists in a variety of settings. These figures should give you an idea of salary ranges for clinical psychologists. The APA periodically surveys its members concerning salaries, demographics, practice con- cerns, and many other topics, and then makes the results public. Much of that information can be accessed at APA’s Web site: http://www.apa.org (though some information is available only to APA members). Median, 25th, and 75th Percentile Salaries Setting and Years of Experience Median Q1 Q3 Individual Private Practice 10–14 years 82,733 64,028 125,000 20–24 years 89,000 65,000 120,000 Group Psychological Practice 10–14 years 90,000 68,000 120,000 20–24 years 95,000 75,000 130,000 Primary Care Group Practice 15–19 years 88,000 40,000 159,000 20–24 years 96,500 79,900 129,715 VA Medical Center 15–19 years 102,000 91,000 112,228 20–24 years 104,000 85,500 114,500 Public General Hospital 10–14 years 80,500 65,000 87,125 20–24 years 85,000 65,000 97,000 University Student Counseling Center 10–14 years 58,900 50,000 67,250 20–24 years 63,500 52,145 79,000 Elementary or Secondary School 10–14 years NA NA NA 20–24 years 94,278 74,250 128,639 Community Mental Health Center 15–19 years 69,950 60,500 90,750 25–29 years 72,500 69,196 103,250 Criminal Justice System 15–19 years 80,000 51,000 107,160 20–24 years 80,500 75,000 103,000 Federal Government Agency 10–14 years 99,000 94,750 99,833 15–19 years 99,050 82,375 112,500 Note: NA = not available. Source: Finno, Michalski, Hart, Wicherski, and Kohout (2010) tABle 1.2 Salaries of Licensed Doctoral-Level Clinical Psychologists in Direct Human Service Positions M01_KRAM1858_08_SE_C01.indd 12 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 15 science and Practice Some of the liveliest discussions within clinical psychology involve the extent to which the field should reflect the concerns of its scientists and its practitioners. If scientists/researchers hold one viewpoint but practitioners hold another, whose view should prevail? There is a long history to this topic, and here we introduce only the broad outlines and suggest some of its major implications. Later, especially in Chapters 2, 10, and 15, we detail the various positions and work through their implications for the field. We have already noted that the official definition of clinical psychology incorporates both science and practice. The question is: how should science and practice be combined? This seem- ingly simple question goes well beyond mere philosophical or academic debate. It affects how clinicians are trained, how clients are treated, how research is conducted, and how others view psychological interventions. eviDenCe-BAseD PrACtiCe Imagine going to a physician who was unaware of, or who chose to disregard, the last two decades of medical research results and relied instead on intuition, outdated training, and folklore to decide what treatments to provide. If you wanted state-of-the- art treatment, you probably would not go back to that doctor. Basing professional practice on solid, up-to-date research is referred to as evidence-based practice (EBP). The idea is that rather than rely on the best guesses of individuals or on “the way it’s always been done,” practitioners should use those diagnostic and therapeutic practices that the best scientific evidence finds most effective. Clearly, evidence-based practice is an idea whose time has come, and no reasonable person doubts that clinical psychologists should base their practice on the results of high-quality scientific research. The problem is that the field lacks a clear consensus on which research is of the highest quality, what it shows, and exactly how it should guide practice. In short, different groups within the APA have different understandings of what evidence-based practice means. Our own perspec- tive, which we detail in Chapter 10, is that both empirical evidence and clinical experience are crucial for evaluating the usefulness of different psychological interventions. Clinical experience is invaluable as a starting point for generating hypotheses about what makes psychotherapy effective, but if certain therapy techniques underperform in repeated clinical trials, those techniques should be abandoned in favor of techniques that perform better. There is some urgency in the field’s reaching consensus about what constitutes the best evi- dence and how to train and update clinicians in the best practices. Some local and state agencies and some insurance providers have constructed lists of the psychotherapies for which they will provide reimbursement to patients (Norcross, Beutler, & Levant, 2006). They do so on the basis of their understanding of the research and of their needs, not on the basis of official positions taken by clinical psychologists. Presumably, clinical researchers and practitioners should have more expertise in these matters, and many believe that they and their official organizations should be more active in listing which psychotherapies are most effective. Fortunately, the urgency of establishing best practices (while recognizing that research and practice are continually evolving) is being recognized. Indeed, the term “evidence-based” has become a rallying cry that is widely shared, even among people who may disagree about exactly what it means. Consider, for example, that a search of APA’s PsychScan clinical psychology data- base (which surveys journals related to clinical psychology) from the years 1990 to 2000 yielded a total of eight articles with the term “evidence-based” in the titles. Between 2000 and 2011 there were 206 hits. Lately, numerous authors have suggested ways to better align research and practice (see Goodheart, 2011; Kazdin, 2011). And in 2010, the American Psychological Association initiated a process to develop evidence-based treatment guidelines, the first time that organization has sought to develop recommendations for treatments for specific disorders (Kurtzman & Bufka, 2011). CliniCAl PsyChOlOgy trAining Decisions about the most desirable mix of science and practice also affect how students are trained in clinical psychology (and how textbooks such as this one are written!). There are two general models upon which clinical psychology training is based. Both are named after Colorado cities that hosted conferences where those models were developed. The Boulder model came out of clinical psychology’s first major training conference, held in 1949 (Raimy, 1950). Often referred to as the scientist-practitioner model, the Boulder model recommended that clinical psychologists be proficient in research and professional practice, earn M01_KRAM1858_08_SE_C01.indd 15 10/06/13 2:50 PM 16 Section I • Basic Concepts a PhD in psychology from a university-based graduate program, and complete a supervised, year- long internship. In 1973, the National Conference on Levels and Patterns of Professional Training in Psy- chology was held at Vail, Colorado. The resulting Vail model recommended alternative training that placed proportionately less emphasis on scientific training and more on preparation for the delivery of clinical services (Korman, 1976). The Vail delegates also proposed that when training emphasis is on the delivery and evaluation of professional services, the PsyD would be the appro- priate degree. They suggested, too, that clinical psychology training programs could be housed not only in universities but also in medical schools or in free-standing schools of professional psychol- ogy (such as those in California, Illinois, and other states), and that these independent schools should have status equal to that of more traditional scientist-professional training venues. We discuss these models of clinical training in more detail in Chapter 15. For now, perhaps the most important thing to remember about the differences among the various types of clinical psychology training is that programs vary widely in their application processes, costs, training orientations, and outcomes (Ameen & El-Ghoroury, 2013; Norcross, Ellis, & Sayette, 2010; Sayette Norcross, & Dimoff, 2011). We do not yet know for certain which of these, if any, affect outcomes for clients, but it is vital that we learn. eclecticism and integration Most of the clinical psychologists engaged in practice, research, and teaching today were trained in programs that emphasized one main theoretical orientation, such as psychodynamic, cogni- tive-behavioral, humanistic, family/systems, and the like. Is this the best way to organize clinical psychology training? Some have expressed concerns that a theory-based approach to clinical edu- cation has created such divisiveness within the field that those who have pledged allegiance to one orientation too often reflexively dismiss research and theory supporting other approaches (Gold & Strickler, 2006). This reaction is problematic because there is seldom a compelling empirical rea- son to adhere to only one theoretical approach; they all have their strengths and weaknesses. As a result, many clinical psychologists now favor eclecticism, an approach in which it is acceptable, and even desirable, to employ techniques from a variety of “schools” rather than sticking to just one. Eclecticism is closely related to the idea of psychotherapy integration, the systematic combin- ing of elements of various clinical psychology theories. In our view, it makes sense to combine approaches in reasonable ways rather than to strictly segregate them. If assessment and therapy techniques are tools, it is easy to see that possessing a wide range of tools, and knowledge of when and how to use them makes for an effective psychotherapist. Indeed, most therapists now identify themselves as eclectic (Santoro, Kister, Karpiak, & Norcross, 2004), and there is now a journal—the Journal of Psychotherapy Integration—devoted to integrating various therapy approaches. But integration and eclecticism are not as easy to achieve in practice as they are in the- ory. How should theories and practices be combined? Might clinicians be better off trying to understand clients’ problems within one reasonably coherent theoretical orientation rather than with a multitude of orientations, some of which may feature conflicting assumptions? Chapter 9 describes some of the answers to these questions. the health Care environment Like all other professions, clinical psychology is shaped partly by the culture in which it operates. Popular beliefs and attitudes affect how mental health concerns are perceived, how problems are treated, and how treatment is funded. The last few years have seen significant changes in the health care laws affecting clinical psychology practice. mentAl heAlth PArity In 2008, the Mental Health Parity and Addiction Act (MHPAA) became law. Mental health parity requires that health insurers provide the same level of coverage for mental illness as they do for physical illness. Prior to 2008, parity had been the exception rather than the norm in U.S. health care. In other words, mental health problems have been regarded as less deserving than other health problems, and people were seen as more responsible for their psychological problems than for their medical problems. This belief might have been easier to maintain a century ago when the most severe physical ailments were infectious diseases—smallpox, typhoid, diphtheria, for example—and when theo- ries about the causes of mental illness did not incorporate interactions of biological, psychological, and social factors. But few people knowledgeable about psychological disorders today argue that M01_KRAM1858_08_SE_C01.indd 16 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 17 persons simply choose to have a psychological problem. At the same time, many of today’s most urgent physical problems—heart disease, obesity, diabetes, for example—are related to lifestyle choices that people make. In short, people probably do not choose to be psychologically ill any more, or any less, than they choose to be physically ill, but disparities in health coverage can suggest that they do. Fortunately, there are signs that this pattern is changing, though negative attitudes toward mental health treatment have certainly not disappeared. mAnAgeD CAre Clinical psychology training, practice, and research are all affected by how health care is structured. Whereas clients once paid providers directly for services, now most health care, including mental health care, involves three parties: client, clinician, and an insur- ance company, HMO, or similar organization. When the third-party organization influences who provides service, which treatments are used, how long treatments last, how much providers are paid, what records are kept, and so on, it is called managed care. Managed care systems use business principles, not just clinicians’ judgments, to make decisions about treatment. As managed care systems in the United States have grown and exerted their influence over psychological treatments, clinicians have had to adapt. In one study, clinicians reported a culture clash between themselves and the managed care companies, complaining that they sometimes had to violate standards of care or ethical standards in order to be paid (Cohen, Marecek, & Gillham, 2006). Managed care’s influence helps explain why the salary discrepancy between private practice and other areas of clinical work is now smaller than it used to be. No wonder, then, that in general, clinicians dislike managed care. Although the relationship between managed care and clinical psychology has sometimes been rocky, as it has between managed care and other health professions, it is not entirely negative (Bobbitt, 2006; Wilson, 2011). One positive effect of health care changes has been to stimulate research into which treatments are most effective for which problems; another is to put more emphasis on prevention (Silverman, 2013). It is in the interest of clients, clinicians, and insurers to know which interventions have the most positive and lasting impact on health, because that information, correctly applied, will ultimately lower costs and improve client well-being. The influence of managed care is also partly responsible for the pressure on clinicians to more precisely measure the outcome of the treatments they provide. Clinical psychologists are continuing to adapt, often changing services to better match those for which managed care systems will pay. This adaptability makes sense, but it can lead to prob- lems if psychologists simply allow managed care personnel to make decisions about clinical prac- tice. Those with the most training and expertise should be in the best position to provide empirical evidence about what works best and what should be reimbursed. PresCriPtiOn Privileges fOr CliniCAl PsyChOlOgists A final aspect of the health care environment is the movement for clinical psychologists to be able to prescribe drugs. In 2002, New Mexico became the first state to pass legislation that permitted licensed psychologists with special- ized training to prescribe psychotropic medications. In 2004, Louisiana followed, and prescription privileges now exist and in the military and Indian Health Services. There are several reasons that many think this trend will continue. One is the increasing public acceptance of medications for psychological problems, fueled in part by pervasive television and print advertising by drug com- panies. Another is that clinical psychologists deal extensively with persons taking certain medi- cations. As a result, those psychologists are sometimes as knowledgeable, if not more so, about the effects of these drugs as the general practice physicians who referred the clients. Prescription privileges make sense also because psychologists see clients regularly, so they are often in a better position to monitor the effectiveness of the medications. However, there are also arguments against prescription privileges, some coming from clini- cal psychologists themselves. One concern is that as prescription privileges expand, clinicians may prescribe drugs more and offer psychotherapy less. If this happens, and there is some evidence that it might, then clients would receive less of the services for which clinical psychology is best known, services that help clients develop coping and problem-solving skills that they can apply in the future (Nordal, 2010). Suffice it to say that the prescription privileges debate continues, and we discuss the pros and cons in Chapter 15. mODels Of treAtment Delivery As the previous discussion indicates, clinical psychologists have worked hard to identify the most effective treatments, and they have promoted the prefer- ential use of these evidence-based treatments, for instance, via publication of practice guidelines. M01_KRAM1858_08_SE_C01.indd 17 10/06/13 2:50 PM 20 Section I • Basic Concepts Epstein, R. (2007). Sexual orientation lies smoothly on a continuum: Verification and extension of Kinsey’s hypothesis in a large-scale internet study. Scientific American, October, 6. Feltham, C. (2000). What are counselling and psychotherapy? In C. Feltham & I. Horton (Eds.), Handbook of counselling and psychotherapy. London, United Kingdom: Sage. Finno, A. A., Michalski, M., Hart, B., Wicherski, M., & Kohout, J. L. (2010). Report of the 2009 APA Salary Survey. Retrieved Dec, 28, 2011 from http://www.apa.org/workforce/publications/09-salaries/ index.aspx?tab=4. Gazzaniga, M. (2011) Who’s in charge: Free will and the science of brain. New York, NY: Harper Collins. Gold, J., & Strickler, G. (2006). Introduction: An overview of psycho- therapy integration. In G. Strickler & J. Gold (Eds.), A casebook of psychotherapy integration. Washington, DC: American Psychological Association. Goodheart, C. D. (2011). Design for tomorrow. American Psychologist, 66, 339–347. Hall, G. C. N. (2005). Introduction to the special section on multicul- tural and community psychology: Clinical psychology in context. Journal of Consulting and Clinical Psychology, 73, 787–789. Harwood, T. M., Pratt, D., Beutler, L. E., Bongar, B. M., Lenore, S., & Forrester, B. T. (2011). Technology, telehealth, treatment enhance- ment, and selection. Professional Psychology: Research and Practice, 42, 448–454. Hatfield, D. R., & Ogles, B. M. (2004). The use of outcome measures by psychologists in clinical practice. Professional Psychology: Research and Practice, 35, 485–491. Hays, P. A., & Iwamasa, G. Y. (Eds.). (2006). Culturally respon- sive cognitive-behavioral therapy. Washington, DC: American Psychological Association. Jameson, J. P., Blank, M. B., & Chambless, D. L. (2009). If we built it, they will come: An empirical investigation of supply and demand in the recruitment of rural psychologists. Journal of Clinical Psychology, 65, 723–735. Johnson, B. W., & Campbell, C. D. (2004). Character and fitness requirements for professional psychologists: Training directors’ per- spectives. Professional Psychology: Research and Practice, 35, 405–411. Jorm, A. F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396–401. Kane, L. (2011). Medscape psychiatry compensation report: 2011 results. Retrieved Dec 27, 2011 from http://www.medscape.com/ features/slideshow/compensation/2011/psychiatry. Kazdin, A. E. (2011). Evidence-based treatment research: Advancements, limitations, and next steps. American Psychologist, 66, 685–698. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., et al. (2005). Prevalence and treatment of mental disorders 1990 to 2003. New England Journal of Medicine, 352, 2515–2523. Kessler, R. C., & Wang, P. S. (2008). The descriptive epidemiology of commonly occurring mental disorders in the United States. Annual Review of Public Health, 29, 115–129. Kohout, J., & Wicherski, M. (2011). 2011 Graduate Study in Psychol- ogy: Applications, acceptances, enrollments, and degrees awarded to master’s- and doctoral-level students in the U.S. and Cana- dian graduate departments of psychology: 2009–2010. APA Cen- ter for Workforce Studies. Retrieved Dec 21, 2011 from http://www .apa.org/workforce/publications/11-grad-study/applications.aspx. Korchin, S. J. (1976). Modern clinical psychology: Principles of intervention in the clinic and community. New York, NY: Basic Books. Korman, M. (Ed.). (1976). Levels and patterns of professional training in psychology. Washington, DC: American Psychological Association. Kurtzman, H., & Bufka, L. (2011). APA moves forward on developing clinical treatment guidelines. Practice update retrieved December 21, 2011 from http://www.apapracticecentral.org/update/2011/07-14/ clinical-treatment.aspx. Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53–70. Michalski, D. (2009). Clinical workforce in psychology: Pipeline, employment, challenges, and opportunities. Presentation given at the American Psychological Association Conference, August 6, Toronto, Ontario, Canada. Michalski, D. S., & Kohout, J. L. (2011). The state of the psychology health service provider workforce. American Psychologist, 66, 825–843. Miller, A. (2013). Phone therapy works for mild to moderate disorders, study suggests. Monitor on Psychology, January, 2013, 10. National Association of Social Workers website (2012). National Center for Education Statistics (2000). Digest of Education Statistics, 1999. Retrieved Dec 13, 2001 from http://nces .ed.gov/pubs2000/Digest99/d99t298.htm. Nelson, P. D. (2013). Psychology: A science with many applications and a profession with many specialties. Retrieved March 20, 2013 from American Psychological Association Psychology Teacher Network at http://www.apa.org/ed/precollege/ptn/2013/02/psychology-specialties .aspx. Norcross, J. C. (2011). Clinical versus counseling psychology: What’s the diff? Eye on Psi Chi: Fall, 2000 Retrieved Dec 27, 2011 from http://www.psichi.org/pubs/articles/article_73.aspx. Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practices in mental health. Washington, DC: American Psychologi- cal Association. Norcross, J. C., Ellis, J. L., & Sayette, M. A. (2010). Getting in and getting money: A comparative analysis of admission standards, acceptance rates, and financial assistance across the research-practice continuum in clinical psychology programs. Training and Education in Profes- sional Psychology, 42, 99–104. Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psy- chologists across the years: The Division of Clinical Psychology from 1960 to 2003. Journal of Clinical Psychology, 61, 1467–1483. Norcross, J. C., Kohout, J. L., & Wicherski, M. (2005). Graduate study in psychology: 1971 to 2004. American Psychologist, 60, 959–975. Nordal, K. C. (2010). Where has all the psychotherapy gone? Monitor on Psychology, 41, 10. Occupational Outlook Handbook, 2010–2011 Edition. U.S. Depart- ment of Labor Bureau of Labor Statistics. Retrieved Jan 1, 2012 from http://www.bls.gov/oco/ocos056.htm. Olos, L., & Hoff, E. H. (2006). Gender ratios in European psychology. European Psychologist, 11, 1–11. Orchowski, L. M., Spickard, B. A., & McNamara, J. R. (2006). Cinema and the valuing of psychotherapy: Implications for clinical practice. Professional Psychology: Research and Practice, 37, 506–514. Pate, W. E., II. (2001). Analyses of data from graduate study in psychol- ogy: 1999–2000. Retrieved Dec 12, 2001 from APA Research office, http://research.apa.org/grad00contents.html. Paul, G. L. (1969). Behavior modification research: Design and tactics. In C. M. Franks (Ed.), Behavior therapy: Appraisal and status (pp. 29–62). New York: McGraw-Hill. Popma, A., & Raine, A. (2006). Will future forensic assessment be neurobiologic? Child and Adolescent Psychiatric clinics of North America, 15, 429–444. Prideaux, D., Roberts, C., Eva, K., Centeno, A., Maccrorie, P., et al. (2011). Assessment for selection for the health care professionals and specialty training: Consensus statement and recommendations from the Ottawa 2010 conference. Medical Teacher, 33, 215–223. M01_KRAM1858_08_SE_C01.indd 20 10/06/13 2:50 PM Chapter 1 • What Is Clinical Psychology? 21 Raimy, V. C. (1950). Training in clinical psychology. New York NY: Prentice-Hall. Rajecki, D. W., & Borden, V. M. H. (2011). Psychology degrees: Employment, wage, and career trajectory consequences. Perspectives on Psychological Science, 6, 321–335. Rozell, C. A., Berke, D. M., Norcross, J. C., & Karpiak, C. P. (2011). Clinical psychologists in the 2010s: Fifty-year trends in Division 12 membership. Presentation given at 2011 American Psychological Association Convention, August 4, 2011, Washington, DC. Rozensky, R. H. (2011). The institution of the institutional practice of psychology: Health care reform and psychology’s future workforce. American Psychologist, 66 , 797–808. Sales, B. D., Miller, M. O., & Hall, S. R. (2005). Legal credentialing and privileges to practice. In B. D. Sales, M. O. Miller, & S. R. Hall (Eds.), Laws affecting clinical practice (pp. 13–22). Washington, DC: American Psychological Association. Santoro, S. O., Kister, K. M., Karpiak, C. P., & Norcross, J. C. (2004, April). Clinical psychologists in the 2000s: A national study. Paper presented at the annual meeting of the Eastern Psychological Association, Washington, DC. Sayette, M. A., Norcross, J. C., & Dimoff, J. D. (2011). The heterogeneity of clinical psychology Ph.D. programs and the distinctiveness of APCS programs. Clinical Psychology: Science and Practice, 18, 4–11. Sehgal, R., Saules, K., Young, A., Grey, M. J., Gillem, A. R., Nabors, N. A., et al. (2011). Practicing what we know: Multicultural counseling competence among clinical psychology trainees and experienced multicultural psychologists. Cultural Diversity and Ethnic Minority Psychology, 17, 1–10. Sharpless, B. A., & Barber, J. P. (2013). Predictors of program performance on the Examination for Professional Practice in Psychology. Profes- sional Psychology: Research and Practice, Advance online publication. doi: 10.1037/a0031689. Silverman, W. H. (2013). The future of psychotherapy: One editor’s perspective. Psychotherapy. Advance online publication. doi: 10.1037/ a0030573. Swaminathan, N. (2012). What predicts grad school success? American Psychological Association gradPSYCH Magazine. Retrieved Mar 20, 2013 from http://www.apa.org/gradpsych/2012/09/cover-success .aspx. Vasquez, M. J. T. (2011). The internship crisis: Strategies and solutions. Monitor on Psychology, 42, 4. Weiten, W. (2011). Psychology: Themes and variations. New York, NY: Wadsworth/Cengage. Wilson, G. T. (2011). Clinical psychology. In P. R. Martin, F. M. Cheung, M. C., Knowles, et al. (Eds.), IAPP handbook of applied psychology. Oxford, United Kingdom: Wiley-Blackwell. M01_KRAM1858_08_SE_C01.indd 21 10/06/13 2:50 PM