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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.
1 What Is ClInICal PsyChology?
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.
2 Section I • Basic Concepts
An Overview Of CliniCAl PsyChOlOgy
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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.
4 Section I • Basic Concepts
At the subdoctoral level, practitioners have titles such as limited license psychologist, mar- riage and family therapist, psychological assistant, mental health counselor , and similar terms. To obtain a limited license, one usually needs a master’s degree and a specific period of postgraduate supervised experience. Some states regulate the limited license much as they regulate the doctoral- level license, but other states provide less oversight, or no oversight, for subdoctoral practitioners (Sales, Miller, & Hall, 2005). Many states place limits on the practice of clinicians who are not fully licensed. An example would be requiring that the subdoctoral-level clinician always practices under the supervision of a fully licensed psychologist. Unfortunately, subdoctoral degrees are too often accompanied by restricted or lesser levels of reimbursement from insurance companies, lower salaries, and higher job turnover (Rajecki & Borden, 2011). This is not to say that quali- fied master’s-level clinicians provide inferior services—well-trained masters level clinicians have helped millions of people—but rather, as in medicine, law, or any other profession, higher levels of training are usually associated with higher levels of skill in those areas and greater financial rewards. Given that clinical psychology is such a popular and competitive field, the best advice for students contemplating entry into this field is to resolve to work very hard and to seek the highest levels of training available.
exPerienCe Some term of supervised practice in the field, often embodied in successful com- pletion of an approved practicum, internship, or period of supervision is also a critical part of a clinical psychologist’s required training. The duration of supervised practice varies, but one-year and two-year internships are common. Students are typically paid a modest stipend during their internships. As the number of persons applying for internships has recently outpaced the number available in a given year, internship placement has become more competitive (Vasquez, 2011). The APA annually publishes a list of accredited clinical psychology programs and approved internship sites in its flagship journal, the American Psychologist.
testing Of COmPetenCe To be licensed as a clinical psychologist, candidates must declare to licensing boards their areas of competence, and they must pass a comprehensive examination, often called a licensing board exam , which may include both written and oral components. The written national licensing test used in the United States and Canada is called the Examination for Professional Practice in Psychology (EPPP). Passing this examination also makes it easier for clini- cians to have their licenses recognized in a state other than the one where they were first licensed, a process called reciprocity. Some states require other examinations, particularly if candidates want to declare certain areas of competency.
gOOD ChArACter Prospective clinical psychologists must show the physical, mental, and moral capability to engage in the competent practice of the profession. This characteristic is often denoted by letters of recommendations and by the absence of ethical or legal violations. Practi- tioners of clinical psychology should also know the ethical codes that guide practice: the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2010). Referred to hereafter as the Ethics Code , this publication offers guidance on ethical concerns related to competence, human relations, privacy and confidentiality, record keeping, education and train- ing, therapy, and many other situations. It is especially useful in navigating the gray areas that invariably come up in the practice of clinical psychology. Of course, all practitioners should know the obligations, freedoms, and limitations that go with practice under their level of licensure and in their state. Familiarity with the Ethics Code, as well as with state and federal laws, is necessary for these psychologists to be effective and to avoid professional mistakes that could have serious consequences. Most clinical psychologists hold professional licenses and provide psychotherapy treatment, but as suggested earlier, not all do. Rather than specialize in assessment and treatment, some choose to engage primarily in some combination of teaching, research, consulting, or adminis- tration, while doing little or no direct service delivery. But non practicing clinical psychologists, too, must complete formal educational requirements and follow professional codes of conduct and regulations. For instance, clinical researchers must follow sections of the Ethics Code dealing with research in psychology, and their studies are overseen by Institutional Review Boards , which are established under federal guidelines to protect the rights and well-being of human participants in research.
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,
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).
8 Section I • Basic Concepts
seCtiOn summAry
Clinical psychology involves the application of principles, methods, and procedures to reduce or alleviate maladjustment, disability, and discomfort in a wide range of client popula- tions. Its title and practices are regulated by professional organizations and by state licensing boards. Specific kinds of training are required for the different types of licensure, and certain personal traits, such as a clinical attitude, sound judgment, and emotional stability, are needed to practice the profession effectively. As one of the health service provider professions, clinical psychology overlaps with other mental health professions but is distinguished by psy- chological training that is both research oriented and practical. It remains the most popular specialty within psychology, one of the most popular majors among undergraduates, and a profession, the practice of which is a source of considerable curiosity and interest in the public.
CliniCAl PsyChOlOgists At wOrk
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Here we describe the various professional activities of clinical psychologists and how clini- cians distribute their work time among those activities. We also describe the various employ- ment settings and general salary ranges of clinical psychologists.
Activities of Clinical Psychologists Let’s consider in more detail some of the activities that clinical psychologists pursue, the variety of places in which they are employed, the array of clients and problems on which they focus their attention, and the rewards of the job. Not all clinicians are equally involved with all the activities we will describe, but our review should provide a better understanding of the wide range of options open to those who enter the field. It might also help explain why the field remains attractive to so many students. About 95% of all clinical psychologists spend their working lives engaged in some combina- tion of six activities: assessment, treatment, research, teaching (including supervision), consulta- tion, and administration. Figure 1.2 shows the results of surveys taken over the last few decades examining how clinical psychologists spend their time. Keep in mind that the percentages vary considerably across work settings—psychologists in university settings will spend more time engaged in teaching and research, and those in private practice will spend more time conducting psychotherapy and assessment.
Assessment Assessment involves collecting information about people: their behavior, prob- lems, unique characteristics, abilities, and intellectual functioning. This information may be used to diagnose problematic behavior, to guide a client toward an optimal vocational choice, to facilitate selection of job candidates, to describe a client’s personality characteristics, to select treatment techniques, to guide legal decisions regarding the commitment of individuals to institu- tions, to provide a more complete picture of a client’s problems, to screen potential participants
figure 1.2 Percentage of Time Licensed Psychologists Spend in Professional Activities. Source : Based on Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psychologists across the years: The Division of Clinical Psychology from 1960 to 2003. Journal of Clinical Psychology, 61, 1467–1483.
35%
14%
10%
6%
7%
13% 15% (^) Administration
Assessment Psychotherapy Research Teaching Supervision Consultation
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
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
Chapter 1 • What Is Clinical Psychology? 13
Diversity Among Clinical Psychologists
The workforce in clinical psychology has become more diverse over the years. In 1950, for instance, women earned only 15% of the doctoral degrees awarded in psychology, but since that time, there has been a dramatic reversal in the gender distribution. As illustrated in Figure 1.3, women made up a third of new clinical doctoral degrees in 1976, but by 2010 they made up over 70% of earned clinical doctorates (Michalski, 2009; National Center for Education Statistics, 2000; Pate, 2001; Rozell et al., 2011; Sayette et al. 2011). This percentage is quite similar in both more practice- oriented and more research-oriented programs. A survey of student gender distribution in clinical psychology programs showed that in European countries, too, women outnumber men, often by wide margins (Olos & Hoff, 2006). Of course, there is a lag of several years between enrollment in a degree program and the attainment of senior status within a profession. As a result, there are still more men than women among senior clinical psychology faculty in colleges and universities and more men than women among the higher-salary private practitioners of clinical psychology. But at all levels, there is a clear trend toward greater representation of women, and there are now more women than men in the health service provider workforce (58% versus 42%; Michalski & Kohout, 2011). Ethnic minorities currently make up approximately 20% of the new doctoral degrees in clinical psychology, up from about 8% in 1977. While this is a positive trend, the overall pace of change in minority representation has been slow, with percentages of minorities hovering around 20% for nearly a decade (Michalski, 2009; Rozell et al., 2011). African Americans represent the highest percentage of minorities in all psychology graduate programs, followed by persons of Hispanic and Asian origin and Native Americans. Many colleges and universities have specific recruitment plans for targeting persons of color, and many psychology departments have their own department-level strategies for recruiting minorities. Examples of such efforts include out- reach programs to “feeder” undergraduate schools, financial assistance to minorities, brochures or other materials geared toward persons of color, and involvement of more persons of color in the recruitment and screening process. The median age of recent doctorates in clinical psychology is 32. That may seem old (or per- haps “mature” is a better word) to students approaching or just finishing their bachelor’s degrees, but it can be accounted for by a couple of factors. First, many people enter doctoral programs after having worked in the field for several years with a master’s or bachelor’s degree. Second, it takes years to complete a doctoral degree. While most students complete a clinical doctorate in 5–6 years, some take 7 or 8 years or more. Keep in mind that during a significant portion of this time, most students are working, at least part time, and earning a wage, and this invariably slows down progress toward completion (but it helps to pay the bills). Finally, clinical psychologists vary in terms of their sexual orientation. In the most recent survey of the workforce, about 91% of health service providers identified themselves as hetero- sexual, while 7% identified themselves as gay, lesbian, bisexual, or transgendered (a small percent did not respond to this part of the survey). These percentages are close to the percentages research- ers typically find in surveys of sexual orientation in the general population (Weiten, 2011), though
figure 1.3 Percent of Women Earning Doctorates in Clinical Psychology. Sources : National Center for Education Statistics, 2000; Pate, 2001; Rozell, Berke, Norcross, and Karpiak, 2011; Sayette, Norcross, and Dimoff, 2011.
0
20
40
60
80
100
1950 1976 Year
Percentage
2000 2010
14 Section I • Basic Concepts
such percentages vary according to how questions are asked and whether responses are simply categorized or measured on a scale that allows variation across a continuum (see Epstein, 2007).
Diversity Among Clients Clinical psychologists in the United States and Canada can expect to see increasing diversity in their clients too. By 2050, non-Hispanic whites are expected to be 50% of the U.S. population with ethnic minorities making up the other half. A greater proportion of Americans will have been born in other countries, or will have parents who were, than has been the case for decades. How does this diversity affect clinical psychology? For one thing, persons from different backgrounds often have different ways of expressing psychological distress, so clinicians have become increasingly sensitive to cultural variations in symptoms (Hays & Iwamasa, 2006). Responses to treatments can also vary depending on clients’ backgrounds. Even willingness to seek psychological help varies by cultural and ethnic back- ground. Clinicians will therefore need additional training in order to provide culturally sensitive services to diverse groups (Hall, 2005). Clients will be diverse not only in their demographics, but also in the types of problems they bring to clinical psychologists. Which are the most common problems? The National Comorbidity Survey (1990–1992) and National Comorbidity Survey Replication (2001–2003) are among the largest studies to try to examine the general population prevalence and severity of psychological disorders. They show that anxiety disorders (e.g., panic disorders, social phobia), mood disorders (e.g., depression), impulse-control disorders (e.g., intermittent explosive disorder), and substance disorders (e.g., alcohol abuse, drug abuse) are among the most common. Yet only about half of those who receive treatment actually meet the criteria for a diagnosable mental disorder (Kessler et al., 2005). The remainder have symptoms that do not quite fit the current diagnostic criteria (discussed in Chapter 3). Such problems include difficulties in interpersonal relationships, marital problems, school difficulties, psychosomatic and physical symptoms, job-related difficulties, and so on. The prevalence and types of problems for which people seek help have remained similar over the years, suggesting that the need for clinical psychologists has not declined, even though the cultural backgrounds of clients who experience those problems have become more diverse. The bottom line is that cultural competence has become a requirement for clinical psychologists (Sehgal et al., 2011). In numerous places throughout this book, we describe how personal, ethnic, and cultural diversity affects clinical practice.
seCtiOn summAry
Clinical psychologists spend most of their professional time engaged in assessment, psy- chotherapy, research, teaching, consultation, and administration. The activities in which they engage, and the clients they see, are strongly affected by employment settings, personal preferences, training, and broader social factors. Clinicians are employed in a variety of settings, including individual and group practices, hospitals of various types, community mental health centers, college and university psychology departments and medical schools, government agencies, private corporations, and others. In those settings, they see clients from a variety of cultural backgrounds and with a variety of problems. Clinicians’ salaries vary by level of training, employment setting, and regional factors but are on par with many other professions with similar levels of training. Once dominated by white males, the field now has a higher percentage of women and ethnic minorities than in the past.
CliniCAl PsyChOlOgy in the 21st Century
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Here we outline some of the more prominent issues shaping clinical psychology today. The first of these relates to the need to balance science and practice within the field. Other key issues concern how clinicians should be trained, how the traditionally separate “schools” or theoretical orientations within clinical psychology might be brought together, and how the practice of clinical psychology has been affected by the social and cultural environment, particularly by the way managed care and legislation have changed health care delivery.
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
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.
Chapter 1 • What Is Clinical Psychology? 19
Study Questions
1. Define clinical psychology. 2. What are the general licensure or certification requirements to be a clinical psychologist? 3. What educational and degree options are available for someone who wants to go into clinical psychology? 4. What personal and ethical criteria are needed to be a good clinical psychologist? 5. How are clinical psychologists similar to and different from coun- seling psychologists, school psychologists, psychiatrists, social workers, and other mental health professionals? 6. How do clinical psychologists spend most of their work time? 7. How does their work setting influence the way clinicians spend their time? 8. What are the salary ranges for clinical psychologists? 9. How have differing opinions about the balance of science and prac- tice influenced the way psychotherapists operate and how graduate schools educate? 10. What is the eclectic approach to psychopathology and treatment? 11. How might integration of different theoretical approaches be possible? 12. How does cultural diversity influence approaches to psychological treatment? 13. How has managed care influenced clinical psychology research, training, and practice? 14. What is mental health parity? 15. What are the pros and cons associated with specially trained clinical psychologists being able to prescribe certain kinds of drugs?
Web Sites
- American Psychological Association (APA): http://www.apa.org
- Division 12 of the APA, the Society for Clinical Psychology: http:// www.div12.org/
- Division 16 of the APA, School Psychology: http://www.apa.org/ about/division/div16.html
- Division 17 of the APA, the Society for Counseling Psychology: http://www.apa.org/about/division/div17.html
- American Psychiatric Association: http://www.psych.org
- National Association of Social Workers: http://www.socialworkers .org
- American Psychiatric Nurses Association: http://www.apna.org
MovieS
Shrink (2009): Somber film about a troubled therapist who has a best- selling self-help book and a growing drug addition, with limited abilities to help his troubled clients.
What about Bob? (1991): Amusing and apocryphal film of a client who seeks to be close to his therapist and his therapist’s family, while the therapist seeks to be rich and famous.
MeMoirS A Piece of Cake: A Memoir by Cupcake Brown (2006; Three Rivers Press). This memoir describes many of the issues that clinical psy- chologists deal with, including child abuse, sexual assault, substance abuse, forensic issues, poverty, and eventual resilience to overcome these challenges. Undercurrents: A Therapist’s Reckoning With Her Own Depres- sion (1995; New York: Harper Collins). Through her own actual diary entries, this clinical psychologist shows her own personal descent into severe depression—including a moment when she was assessing a client for depression and realized that she met the criteria herself.
references
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