Clinical Psychology PDF

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...

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of, or who chose to disregard, the last two decades of medical research results and relied instead on intuition, outdated training, and folklore to decide what treatments to provide.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  18 Section I Basic Concepts Compared with a decade ago, the evidence base for psychological interventions is much stronger. However, the primary method of delivering psychological services to clients is still individual, face- to-face psychotherapy. Some have questioned whether this should change. For example, Kazdin (2011) argues that in-person one-on-one psychotherapy may not be the most effective model. He advocates models of treatment delivery that optimize the benefits of psychological interventions across broader segments of the population. This is especially pressing because in any given year, approximately 25% of the population meets the criteria for one or more psychological disorders and the majority of people in need of psychological services still do not receive them (Kessler & Wang, 2008). More effective treatment delivery would still include one-on-one psychotherapy, but also other approaches. Those less likely to use in-person one-on-one psychotherapy would especially benefit from interventions delivered via technologies. For instance, television and telephone-based interventions, interactive computer-based or cellphone-based interactions, computer-based virtual reality treatments, and social media interventions have all been used to expand how clinical psy- chologists provide services (Harwood et al., 2011; Kazdin, 2011; Miller, 2013). Greater attention to supply and demand could also improve public psychological health. For example, psychologi- cal services are typically clustered in metropolitan areas, so greater attention to the needs of rural areas might also help underserved populations (Jameson, Blank, & Chambliss, 2009). We discuss alternate modes of clinical intervention, along with their ethical and clinical implications, more in Chapter 9. Section Summary Clinical psychology combines science and practice, but the appropriate mix of the two is a matter of a debate that has intensified as the need to establish clear evidence-based practices in clinical psychology has grown. That need comes both from within the profession and from outside organizations that fund and pay for clinical services. In light of changes within the profession and within the broader society, clinical psychologists continue to examine their training models, particularly the dominant models that lead to PhD and PsyD degrees. They have also had to think more carefully about ways to integrate and combine vari- ous approaches to psychotherapy and assessment, as well as ways to deliver services. It has become clear that the turf wars among adherents of different approaches do not benefit the profession. Managed care organizations have influenced clinical practice and will continue to do so. Cultural and legal factors affect the field as well, as exemplified by the fate of legislation requiring mental health parity and that permitting prescription privileges for clinicians. Chapter Summary Clinical psychology is the largest single subfield within the the increasing diversity of clinical psychologists themselves, and larger discipline of psychology. It involves research, teaching, in the diversity of the population in need of mental health care. and other services designed to understand, predict, and allevi- Clinical psychologists are employed in many different settings, ate maladjustment and disability. To become a licensed clini- from university psychology departments and medical clinics to cal psychologist, one must meet certain educational, legal, and community mental health centers and prisons. Many are self- personal qualifications. As one of the core health service pro- employed private practitioners. vider professions, clinical psychology is distinguished from other Clinical psychology faces numerous challenges, not the helping professions by the clinical attitude: the tendency to use least of which is that most people with psychological problems the results of research on human behavior in general to assess, still do not receive treatment. Other factors shaping the dis- understand, and assist particular individuals. The discipline is cipline involve, among other issues, decisions about how sci- also distinguished by its emphasis on empirical research and by ence and practice should be combined, how training of new its diversity in training and practice. psychologists should be conducted, how the various theoretical That diversity can be seen in how clinicians distribute their approaches can be integrated, and how the current (and future) time among six main functions: assessment, treatment, research, systems of health care delivery affect the practice of clinical teaching, consultation, and administration. It can also be seen in psychology. M01_KRAM1858_08_SE_C01.indd 18 10/06/13 2:50 PM  Chapter 1 What Is Clinical Psychology? 19 Study Questions 1. Define clinical psychology. 9. How have differing opinions about the balance of science and prac- 2. What are the general licensure or certification requirements to be tice influenced the way psychotherapists operate and how graduate a clinical psychologist? schools educate? 3. What educational and degree options are available for someone 10. What is the eclectic approach to psychopathology and treatment? who wants to go into clinical psychology? 11. How might integration of different theoretical approaches be 4. What personal and ethical criteria are needed to be a good clinical possible? psychologist? 12. How does cultural diversity influence approaches to psychological 5. How are clinical psychologists similar to and different from coun- treatment? seling psychologists, school psychologists, psychiatrists, social 13. How has managed care influenced clinical psychology research, workers, and other mental health professionals? training, and practice? 6. How do clinical psychologists spend most of their work time? 14. What is mental health parity? 7. How does their work setting influence the way clinicians spend 15. What are the pros and cons associated with specially trained clinical their time? psychologists being able to prescribe certain kinds of drugs? 8. What are the salary ranges for clinical psychologists? Web Sites American Psychological Association (APA): http://www.apa.org What about Bob? (1991): Amusing and apocryphal film of a client Division 12 of the APA, the Society for Clinical Psychology: http:// who seeks to be close to his therapist and his therapist’s family, while www.div12.org/ the therapist seeks to be rich and famous. Division 16 of the APA, School Psychology: http://www.apa.org/ about/division/div16.html Memoirs Division 17 of the APA, the Society for Counseling Psychology: A Piece of Cake: A Memoir by Cupcake Brown (2006; Three Rivers http://www.apa.org/about/division/div17.html Press). This memoir describes many of the issues that clinical psy- American Psychiatric Association: http://www.psych.org chologists deal with, including child abuse, sexual assault, substance National Association of Social Workers: http://www.socialworkers abuse, forensic issues, poverty, and eventual resilience to overcome.org these challenges. American Psychiatric Nurses Association: http://www.apna.org Undercurrents: A Therapist’s Reckoning With Her Own Depres- sion (1995; New York: Harper Collins). Through her own actual diary Movies entries, this clinical psychologist shows her own personal descent into Shrink (2009): Somber film about a troubled therapist who has a best- severe depression—including a moment when she was assessing a client selling self-help book and a growing drug addition, with limited abilities for depression and realized that she met the criteria herself. to help his troubled clients. References Ambrosino, R., Heffernan, J., Shuttlesworth, G., & Ambrosino, R. 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