Clinical Psychology PDF

8 Section I Basic Concepts Section Summary Clinical psychology involves the application of principles, methods, and procedures to reduce or alleviate...

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 Section Preview 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 13% 15% Administration Assessment 7% Psychotherapy 6% Research 35% 10% Teaching Supervision Consultation 14% 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. M01_KRAM1858_08_SE_C01.indd 8 10/06/13 2:50 PM  Chapter 1 What Is Clinical Psychology? 9 in psychological research projects, to establish pretreatment baseline levels of behavior against which to measure posttreatment improvement, and for literally hundreds of other purposes. Most clinical assessment instruments fall into one of three categories: tests, interviews, and observations. We cover each of these in detail in the chapters devoted to assessment. Clinicians today have an array of assessment options not formerly available to them. For instance, computers can administer assessment items, analyze results, and generate entire written reports. Another frontier of psychological assessment is developing from research on a variety of biological factors associated with human functioning. During the last two decades, research focusing on genetic, neurochemical, hormonal, and neurological factors in the brain has led to the development of new neurobiological assessments. These changes, too, have the potential to greatly enhance the assessment efforts of clinicians, but as with computer-based assessment, they raise a number of procedural, practical, and ethical questions (Gazzaniga, 2011; Popma & Raine, 2006). Treatment Clinical psychologists offer treatments designed to help people better understand and solve distressing psychological problems. These interventions are known as psychotherapy, behavior modification, psychological counseling, or other terms, depending on the theoretical orientation of the clinician. Treatment sessions may include client or therapist monologues, pains- taking construction of new behavioral skills, episodes of intense emotional drama, or many other activities that range from the highly structured to the utterly spontaneous. Individual psychotherapy has long been the single most frequent activity of clinicians (Kazdin, 2011), but psychologists may also treat two or more clients together in couple, family, or group therapy. Sometimes, two or more clinicians work in therapy teams to help their clients. Treatment may be as brief as one session or may extend over several years. Some psychologists, known as community psychologists, focus on preventing psychological problems by altering the institutions, environmental stressors, or behavioral skills of people at risk for disorder (e.g., t­ eenage parents) or of an entire community. The results of psychological treatments are usually posi- tive, though in some cases the change may be small, nonexistent, or even negative (­Castonguay, Boswell, Constantino, Goldfried, & Hill, 2010; Lilienfeld, 2007). Of course, increasing the effec- tiveness of ­treatments offered to the public is a key goal of research. (Treatment outcomes are discussed in several later chapters, especially Chapter 10, “Research on Clinical Intervention.”) Research By training and by tradition, clinical psychologists are research oriented. For most of the first half of its existence, the field was strongly dominated by research rather than by applica- tion (see Chapter 2). Although that balance has changed, research continues to play a vital role in clinical psychology. Research activity makes clinicians stand out among other helping professions, and we believe it is in this area that they may make their greatest contribution. In the realm of psycho- therapy, for example, theory and practice were once based mainly on case study evidence, subjec- tive impressions of treatment efficacy, and rather poorly designed research. This “prescientific” era (Paul, 1969) in the history of psychotherapy research has evolved into an “experimental” era in which the quality of research has improved greatly and the conclusions we can draw about the effects of therapy are much stronger. This development is due in large measure to the research of clinical psychologists. Clinical research varies greatly with respect to its setting and scope. Some studies are con- ducted in research laboratories, while others are conducted in the more natural, but less control- lable, conditions outside the lab. Some projects are supported by governmental or private grants that pay for research assistants, computers and other costs, but a great deal of clinical research is performed by investigators whose budgets are limited and who depend on volunteer help and their own ability to obtain space, equipment, and participants. Clinical psychology’s tradition of research is reflected in graduate school admission criteria, which often emphasize applicants’ grades in statistics or research methods over grades in abnor- mal psychology or personality theory. Many graduate departments in psychology in the United States regard research experience as among the three most important criteria for admission, and graduates of research-oriented clinical psychology programs typically outperform graduates of programs that don’t emphasize research as much (Norcross, Ellis, & Sayette, 2010; Pate, 2001). Even though most clinical psychologists do not end up pursuing a research career—many never publish a single piece of research—most graduate programs in clinical psychology still devote a significant amount of time to training in empirical research. Why? M01_KRAM1858_08_SE_C01.indd 9 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 institutions for the intellectually disabled law schools police departments public and private medical and prisons psychiatric hospitals juvenile offender facilities city, county, and private mental business and industrial firms probation health clinics 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 orphanages university psychological clinics 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. Table 1.1 P  rimary and Secondary Work Settings of APA-Affiliated Health Service Providers 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). 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). Table 1.2 Salaries of Licensed Doctoral-Level Clinical Psychologists in Direct Human Service Positions 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) M01_KRAM1858_08_SE_C01.indd 12 10/06/13 2:50 PM  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 100 80 Percentage 60 40 20 0 1950 1976 2000 2010 Year 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. M01_KRAM1858_08_SE_C01.indd 13 10/06/13 2:50 PM  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 Section Preview 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. M01_KRAM1858_08_SE_C01.indd 14 10/06/13 2:50 PM