Introduction to Clinical Psychology (PDF)

introduction to Clinical Psychology An Evidence-Based Approach third edition introduction to Clinical Psychology An Evidence-Based Approach third edition j o h n h un s l e y | c at h e r i n e m. l e e Copyright © 2014, 2009, 2005 by John Wiley & Sons Canada, Ltd. All rights reserved. No part of this work covered by the copyrights herein may be reproduced or used in any form or by any means—graphic, electronic, or mechanical—without the prior written permission of the publisher. Any request for photocopying, recording, taping or inclusion in information storage and retrieval systems of any part of this book shall be directed to the Canadian copyright licensing agency, Access Copyright. For an Access Copyright licence, visit www.accesscopyright.ca or call toll-free, 1-800-893-5777. Care has been taken to trace ownership of copyright material contained in this text. The publishers will gladly receive any information that will enable them to rectify any erroneous reference or credit line in subsequent editions. Care has been taken to ensure that the web links recommended in this text were active and accessible at the time of publication. However, the publishers acknowledge that web addresses are subject to change. Library and Archives Canada Cataloguing in Publication Hunsley, John, 1959- [Introduction to clinical psychology] Clinical psychology : an evidence-based approach / John Hunsley, Catherine M. Lee. — Third edition. Revision of: Introduction to clinical psychology : an evidence-based approach. Includes bibliographical references and index. ISBN 978-1-118-62461-6 (pbk.) 1. Clinical psychology—Textbooks. I. Lee, Catherine M. (Catherine Mary), 1955-, author II. Title. III. Title: Introduction to clinical psychology. RC467.2.H86 2014 616.89 C2013-906979-8 Production Credits Acquisitions Editor: Rodney Burke Vice President & Publisher: Veronica Visentin Senior Marketing Manager: Patty Maher Editorial Manager: Karen Staudinger Editorial Assistant: Luisa Begani Production Manager: Tegan Wallace Production Editor: Yee Lyn Song Media Editor: Channade Fenandoe Typesetting: Thomson Digital Cover Design and Interior Design: Joanna Vieira Cover Image: Top row: Left, ©istockphoto.com/carterdayne; Middle, ©istockphoto.com/yellowcrestmedia; Right, ©istockphoto.com/Kangah Bottom row: Left, ©istockphoto.com/RBFried; Middle, ©istockphoto.com/RushOnPhotography; Right, ©istockphoto.com/Plougmann Printing & Binding: Webcom Printed and bound in Canada. John Wiley & Sons Canada, Ltd. 5353 Dundas Street West, Suite 400 Etobicoke, ON M9B 6H8 Visit our website at: www.wiley.ca To Rob and Nick PREFACE Between us, we have well over half a century of experience in clinical psychology. We share a passion for a profession that has the potential to make an important contribution to the understanding of human nature and to the alleviation of human suffering. We have written this book to introduce to students the theories and practices of clinical psychology and convey the important work done by clinical psychologists. The book is designed to be helpful not only to those who will go on to careers in clinical psychology, but also to those who will choose other career paths. KEY FEATURES Clinical psychology has evolved greatly in recent decades. In order to convey the nature of the contemporary practice of clinical psychology, we have incorporated three distinct features through all of the chapters. Evidence-Based Approach Concerns about health care costs, together with growing demands from well-informed health care consumers, have highlighted the need for clinical psychology to adopt evidence-based assessments and interventions. Unfortunately, many popular theories that have guided clinical practice for decades do not have supporting evidence. Throughout the text, we present theories and practices and examine the extent to which they are supported by research. If a technique or strategy is used frequently in practice but has not been supported empirically, we say so. We believe that our approach reflects the new realities in clinical psychology and the ongoing commitment of psychologists to deliver services that are the best science has to offer. Diversity Clinical psychology must address the needs of a diverse population. We highlight the need for sensitivity to gender, age, culture, ethnicity, sexual orientation, socioeconomic status, family type, and geographic location. Throughout the text, we include relevant assessment and treatment examples to illustrate the importance and the challenges of professional sensitivity to diversity issues in research and practice. Lifespan Perspective We have adopted a lifespan perspective throughout the text. We include examples illustrating issues with respect to children, adolescents, adults, and older adults. As many undergraduate students taking an introduc- tory course in clinical psychology are unlikely to have decided on the age of clients with whom they eventually wish to work, it will be appealing to learn about clinical psychology across the lifespan. It is important for students to appreciate that assessment and treatment plans can vary depending on the age of the individual. TEXT ORGANIZATION The text can be divided into three sections. The first section provides an overview of issues that set the stage for the second section, which is on assessment; and that section, in turn, is the foundation for the third section on intervention in clinical psychology. In Chapter 1, we provide a definition of clinical psychology, viii PREFACE describing its history and explaining similarities and differences between clinical psychology and other mental health professions. Chapter 2 addresses the diverse roles of clinical psychologists, all of which are based on the pillars of science and ethics. The importance of attention to ethical issues is highlighted not just in this chapter but throughout the text. The third chapter is an overview of issues related to classification and diagnosis. In this chapter, we introduce two individuals, an adult (Melissa) and an adolescent (Noah), whose psychological services we describe in subsequent chapters. Chapter 4 presents key issues on research methods, underlining the ways these methods are employed to address clinically meaningful questions. In the second section, Chapters 5 to 9 address assessment issues in clinical psychology, highlighting ethical issues that must guide psychological practice. Chapter 5 provides an overview of the purposes of psychological assessment, a review of key concepts in psychological testing, and an examination of the distinction between testing and assessment. Chapter 6 presents information on clinical interviews and clinical observation, emphasizing developmental considerations relevant to these commonly used assessment methods. Intellectual and cognitive assessments are discussed in Chapter 7. Chapter 8 covers self-report and projective assessment, with in-depth examination of the usefulness of different assessment strategies. The challenges of integrating assessment data and making clinical decisions are illustrated in Chapter 9, with reference to services for Melissa (who was introduced in Chapter 3). The third section, on intervention, covers both prevention and treatment. Chapter 10 highlights issues in prevention, describing programs designed for at-risk children and youth. In Chapter 11, we provide a brief overview of approaches to psychological intervention, describing the theoretical foundations of current evidence-based approaches and presenting data on the nature and course of psychotherapy. Chapters 12 and 13 present an overview of current evidence-based treatments for adults (Chapter 12) and for children and adolescents (Chapter 13). The case of Noah (who was introduced in Chapter 3) is used to illustrate issues in developing treatment plans. Chapter 14 provides information on evidence-based treatment elements derived from the therapy process and therapy process-outcome research. Finally, in Chapter 15, we examine issues in the practice of clinical psychology in the areas of health psychology, clinical neuropsychology, and forensic psychology. Two appendices are included. The first lists journals in clinical psychology and should help students as they research topics in greater depth. The second appendix, entitled Applications to Graduate School, is designed to help students make decisions about graduate school applications as well as plan an application. FEATURES OF INTEREST TO THE STUDENT Within each chapter, many features have been incorporated to aid student learning. This text is designed to introduce clinical psychology in a reader-friendly and accessible manner, highlighting the varied and dynamic areas of the discipline. Chapter Outline Each chapter begins with an outline that prepares the student for the material to be covered. Case Examples In courses in clinical psychology, case examples are the tool through which abstract material is brought to life. In addition to the extended case presentations in Chapters 3, 9, and 13, case material is embedded throughout the text to illustrate issues in different PREFACE ix developmental periods and with a diverse clientele. Reflecting the terminology in current practice, we alter- nate our use of the terms “patient” and “client.” All the case examples we describe are based on our clinical experience. We have blended details about different people into composites to illustrate clinical issues. The case examples do not, therefore, represent specific individuals and all the names are fictitious. Viewpoint Boxes In each chapter, controversial issues and new directions in the field are highlighted in Viewpoint Boxes. Topics include: historically important themes, such as in Distress in Clinical Psychologists and How They Deal with It and IQ and Its Correlates new directions in clinical psychology, such as in Psychological Resilience in the Face of Potential Trauma, Options for Increasing Psychotherapy Attendance, and Dissemination of Evidence-Based Treatments controversies, such as in What Do Psychologists Need to Know about Psychopharmacology?, The Trials and Tribulations of DSM-5, and How Reliable Are the Findings Reported in Research Studies? issues with a lifespan perspective, such as in Issues in Interviewing Older Adults and Treatment of Childhood Attention-Deficit/Hyperactivity Disorder debates around evidence-based assessment, such as in Child Custody Evaluations, Risk Assessment, and Why Do Questionable Psychological Tests Remain Popular with Some Clinical Psychologists? expansion of the practice of clinical psychology to health, such as in Health Promotion and Prevention Programs for Older Adults and Insomnia: No Need to Lose Sleep Over It! current issues in treatment research, such as in Multiple Perspectives on Treatment Goals and Sudden Gains in Therapy. Profile Boxes To bring to life the reality of being a clinical psychologist, we have featured 24 individuals in Profile Boxes. We invited Canadian clinical psychologists at different stages of their careers to answer questions about being a clinical psychologist. In addition, to give students a sense of the varied activities in which psychologists engage, we asked three psychologists who work in different types of settings to describe a typical work week. We invited colleagues whom we consider fine examples of clinical psychologists, and we chose people whom we hope students will find inspiring. Students reading the Profile Boxes will better appreciate the wide range of activities in which clinical psychologists engage, the range of challenges they address in their work, and the creativity with which psychological principles are applied to reduce human suffering and improve psychosocial functioning. We have also included a profile about a graduate student in clinical psychology, to give students a sense of the life of a clinical psychology graduate student. Critical Thinking Questions Key questions have been designed to promote discussion and debate on both traditional and emerging issues in clinical psychology. These questions appear in the margins marked with a head with a question mark icon. x PREFACE Think About It! Throughout each chapter, we have also included questions that encourage students to consider specific text material more deeply and more personally. These questions, which are marked with a thought bubble icon, usually ask the reader to consider the impact that a certain professional or empirical issue could have on someone’s life. There are also questions that encourage students to consider how the manner in which clinical psychologists make decisions about professional services is similar to and different from the manner in which people make routine decisions. Summary and Conclusions At the end of each chapter, a section draws together the material discussed in the chapter. Key Terms and Key Names Throughout each chapter, important names and key terms are highlighted in bold. In addition, key term definitions are included in the margin. These are important study aids to highlight the most salient points of each chapter. Additional Resources For students who wish to explore an issue in greater depth, additional resources have been cited for various journals and books. The Check It Out! feature provides website links that allow readers to find out more about important issues raised in the chapter. CHANGES IN THE THIRD EDITION As clinical psychology is a rapidly evolving profession, in this third edition we have updated the scientific and professional literature we review to highlight recent changes in the field. In Chapter 1, this involved providing new estimates about the economic costs of mental disorders and the numbers of mental health care specialists (including clinical psychologists). Chapter 2 has updated information about the professional activities and theoretical orientations of clinical psychologists, characteristics of training programs and their graduates, accreditation standards, and registration/licensure. A new profile on a “week in the life of a graduate student” has also been added. Information on both DSM-5 and ICD-10 diagnostic systems is included in Chapter 3, along with updated information on the epidemiology of mental disorders. To encourage the critical evaluation of scientific research, Chapter 4 has new Viewpoint Boxes addressing media reporting of research and the reliability of research results. New assessment-related information has been included in Chapters 5 to 9. This includes a discussion of the continuing growth of evidence-based assessment, information on the updated Wechsler scales, and details of updated versions of frequently used self-report measures. Also, Chapter 6 has been reorganized to help readers be better prepared for learning about the challenges in assessing clients across the lifespan. The chapters on prevention and treatment (Chapters 10 to 14) include new evidence of the impact of a number of prevention programs, information on the American Psychological Association resolution about the effectiveness of psychotherapy, an expanded listing of evidence-based treatments, details on a range of clinical practice guidelines, and results from a task force on evidence-based psychotherapy relationships. PREFACE xi Chapters 12 and 13 have been revised to provide updated information on evidence-based treatments and the results of treatment efficacy and effectiveness research for clients across the lifespan. In Chapter 15, we have expanded information on the management of both chronic pain and insomnia, added information on the use of neuropsychological assessment to evaluate the capacity of older adults to live independently and manage their lives, and updated details on forensic risk assessment tools and challenges in their interpretation. Overall, 7 new Viewpoint Boxes and 20 new Profile Boxes have been added. We have also increased the use of clinical case material to illustrate important points discussed in the text, and focused increased attention on diversity issues. Furthermore, to improve the readability and comprehensibility of the material, we have enhanced the cross-referencing across chapters. ACKNOWLEDGEMENTS We have appreciated the support and guidance of many people during the preparation of the third edition of this book. Thanks are due to Rodney Burke, the acquisitions editor, who championed the importance of a written-in-Canada text on contemporary clinical psychology. We are grateful to Georgina Montgomery, our copy editor for this edition, and production editor Yee Lyn Song who coordinated the phases of production with efficiency. We are grateful for the helpful feedback provided by Robert Hunsley and Majeeda Khan and the capable research assistance provided by Robert Hunsley and Kathryn LaRoche. The book is enriched by the contributions of the psychologists who agreed to be profiled. We appreciate their cooperation and willing- ness to talk about their careers, and special thanks go to them. They are Drs. Melanie Barwick, Peter Bieling, Christopher Bowie, Clarissa Bush, Christine Chambers, David A. Clark, Karen Dyck, Jennifer Frain, Heather Hadjistavropoulos, David Hodgins, Charlotte Johnston, Martin Lalumière, Christopher Mushquash, Randy Paterson, Martin D. Provencher, Adam Radomsky, Graham Reid, Don Saklofske, Katreena Scott, Colette Smart, Michael Sullivan, Henny Westra, Jonathan Weiss, and Sheila Woody. We deeply appreciate the contribution of graduate student Emma MacDonald. Last, but not least, we are grateful for the ongoing support of friends and family. ABOUT THE AUTHORS John Hunsley received a Ph.D. from the University of Waterloo in 1985. He is a full professor in the clinical psychology program at the University of Ottawa and is the director of the program. Dr. Hunsley teaches graduate courses in clinical research methods and psychological assessment. Dr. Hunsley’s research interests focus on evidence-based psychological practice, the delivery of psychological services, and the scientific basis of psychological assessment. He has authored over 110 articles, chapters, and books on these topics. Dr. Hunsley is a Fellow of the Association of State and Provincial Psychology Boards, the Canadian Psychological Association (CPA), and the CPA Clinical Psychology Section. He has received the CPA Award for Distinguished Contributions to Education and Training in Psychology. From 2007 to 2011, he served as the editor of Canadian Psychology. He has also served on the editorial board of Assessment, Journal of Personality Assessment, Professional Psychology: Research and Practice, and Scientific Review of Mental Health Practice. Catherine M. Lee earned a Ph.D. from the University of Western Ontario in 1988. She is a full professor of psychology at the University of Ottawa. Dr. Lee teaches graduate courses in evidence-based services for children and families and an undergraduate course on Clinical Psychology, as well as supervising practicum students and interns at the Centre for Psychological Services and Research. Her research interests focus on the provision of evidence-based services to promote positive parenting. She has authored over 70 articles, chapters, and books on this and related topics. Dr. Lee is a Fellow of the Canadian Psychological Association (CPA) and the CPA Clinical Psychology Section. She is an ad hoc reviewer for many granting agencies and scholarly journals and she serves on the editorial boards of Clinical Child and Family Psychology Review and Cognitive and Behavioral Practice. She is the former chair of the Clinical Psychology Section of the CPA and was President of the CPA in 2008–2009. She is a site visitor for the Canadian Psychological Association Accreditation Panel. BRIEF TABLE OF CONTENTS CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY 1 CHAPTER 2 CONTEMPORARY CLINICAL PSYCHOLOGY 45 CHAPTER 3 CLASSIFICATION AND DIAGNOSIS 87 CHAPTER 4 RESEARCH METHODS IN CLINICAL PSYCHOLOGY 125 CHAPTER 5 ASSESSMENT: OVERVIEW 167 CHAPTER 6 ASSESSMENT: INTERVIEWING AND OBSERVATION 205 CHAPTER 7 ASSESSMENT: INTELLECTUAL AND COGNITIVE MEASURES 243 CHAPTER 8 ASSESSMENT: SELF-REPORT AND PROJECTIVE MEASURES 279 CHAPTER 9 ASSESSMENT: INTEGRATION AND CLINICAL DECISION-MAKING 321 CHAPTER 10 PREVENTION 355 CHAPTER 11 INTERVENTION: OVERVIEW 391 CHAPTER 12 INTERVENTION: ADULTS AND COUPLES 429 CHAPTER 13 INTERVENTION: CHILDREN AND ADOLESCENTS 469 CHAPTER 14 INTERVENTION: IDENTIFYING KEY ELEMENTS OF CHANGE 505 CHAPTER 15 CLINICAL HEALTH PSYCHOLOGY, CLINICAL NEUROPSYCHOLOGY, AND FORENSIC PSYCHOLOGY 539 APPENDIX 1 MAJOR JOURNALS RELEVANT TO CLINICAL PSYCHOLOGY 573 APPENDIX 2 APPLICATIONS TO GRADUATE SCHOOL 579 REFERENCES 589 NAME INDEX 613 SUBJECT INDEX 627 TABLE OF CONTENTS CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY 1 Introduction 1 Defining the Nature and Scope of Clinical Psychology 4 Viewpoint Box 1.1 Mental Health Commission of Canada 5 Profile Box 1.1 Dr. Jennifer Frain 6 Evidence-Based Practice in Psychology 10 Mental Health Professions 13 Counselling Psychology 14 School Psychology 16 Psychiatry 17 Clinical Social Work 19 Other Mental Health Professions 20 Availability of Mental Health Service Providers 22 A Brief History of Clinical Psychology 23 The Roots of Clinical Psychology 24 The History of Assessment in Clinical Psychology 25 The History of Intervention in Clinical Psychology 34 The History of Prevention in Clinical Psychology 41 The Future 41 Summary and Conclusions 42 CHAPTER 2 CONTEMPORARY CLINICAL PSYCHOLOGY 45 Introduction 45 Activities of Clinical Psychologists 46 Assessment and Diagnosis 48 Profile Box 2.1 Dr. Clarissa Bush 48 Profile Box 2.2 Dr. Sheila Woody 51 Intervention 52 Viewpoint Box 2.1 What Do Psychologists Need to Know about Psychopharmacology? 53 Profile Box 2.3 Dr. Randy Paterson 56 Prevention 58 Consultation 59 Profile Box 2.4 Emma MacDonald 60 Research 61 Teaching and Supervision 62 Administration 65 Employment Settings 65 The Two Pillars of Clinical Psychology: Science and Ethics 66 Viewpoint Box 2.2 Distress in Clinical Psychologists and How They Deal with It 71 xviii TABLE OF CONTENTS Training in Clinical Psychology 73 Models of Training in Clinical Psychology 74 Accreditation of Clinical Psychology Programs 76 Licensure in Clinical Psychology 80 Summary and Conclusions 83 CHAPTER 3 CLASSIFICATION AND DIAGNOSIS 87 Introduction 87 Defining Abnormal Behaviour and Mental Disorders 90 Developmental Psychopathology 92 Diagnosis 92 Defining Disorder 94 Profile Box 3.1 Dr. Christopher Bowie 95 Prevalence of Mental Disorders 97 Understanding the Development of Mental Disorders 101 Viewpoint Box 3.1 Psychological Responses to Natural Disasters 103 The Diagnostic and Statistical Manual of Mental Disorders (DSM) System 106 The Evolution of the DSM 106 Viewpoint Box 3.2 The Trials and Tribulations of DSM-5 108 The DSM-5 109 The International Statistical Classification of Diseases and Related Health Problems (ICD) System 112 Limitations of Diagnostic Systems 114 Defining Abnormality (Revisited) 114 Diagnostic Reliability 115 Heterogeneity of Symptom Profiles 116 Diagnostic Validity 117 Comorbidity 118 Viewpoint Box 3.3 Psychological Resilience in the Face of Potential Trauma 119 Categorical versus Dimensional Classification 120 Summary and Conclusions 122 CHAPTER 4 RESEARCH METHODS IN CLINICAL PSYCHOLOGY 125 Introduction 125 Profile Box 4.1 Dr. Adam Radomsky 129 Generating Research Hypotheses 130 Ethics in Research 134 Research Designs 139 Viewpoint Box 4.1 If It Is Reported in the Media, It Must Be True—Right? 140 Case Studies 144 Single Case Designs 145 Correlational Designs 147 Quasi-Experimental Designs 150 Experimental Designs 151 Profile Box 4.2 Dr. David Hodgins 152 Meta-Analysis 154 TABLE OF CONTENTS xix Selecting Research Participants and Measures 155 Selecting the Sample 155 Selecting the Sampling Strategy 156 Setting the Sample Size 157 Measurement Options and the Importance of Psychometric Properties 158 Analyzing the Data 160 Viewpoint Box 4.2 How Reliable Are the Findings Reported in Research Studies? 161 Statistical and Clinical Significance 162 Summary and Conclusions 163 CHAPTER 5 ASSESSMENT: OVERVIEW 167 Introduction 167 Psychological Assessment 168 The Purposes of Psychological Assessment 171 Viewpoint Box 5.1 Child Custody Evaluations 173 Psychological Testing 184 Viewpoint Box 5.2 Psychological Testing on the Internet 186 Assessment versus Testing 187 Profile Box 5.1 Dr. Michael Sullivan 189 Psychometric Considerations 191 Testing Practices in Clinical Psychology 196 Evidence-Based Assessment 199 Ethical Considerations 200 Summary and Conclusions 202 CHAPTER 6 ASSESSMENT: INTERVIEWING AND OBSERVATION 205 Introduction 205 Ethical Issues: Limits of Confidentiality 207 Unstructured Assessment Interviews 209 Structured Diagnostic Interviews 212 General Issues in Interviewing 216 Attending Skills 216 Contextual Information 219 Viewpoint Box 6.1 Screening for Exposure to Violence 219 Culturally Sensitive Interviewing 220 Defining Problems and Goals 222 Assessing Suicide Risk 224 Interviewing Couples 225 Interviewing Families 226 Viewpoint Box 6.2 Issues in Interviewing Older Adults 227 Interviewing Children and Adolescents 228 Observations 231 Profile Box 6.1 Dr. Charlotte Johnston 232 xx TABLE OF CONTENTS Self-Monitoring 235 Viewpoint Box 6.3 Ecological Momentary Assessment 239 Summary and Conclusions 239 CHAPTER 7 ASSESSMENT: INTELLECTUAL AND COGNITIVE MEASURES 243 Introduction 243 Defining Intelligence 245 Theories of Intelligence 245 Assessing Intelligence: The Clinical Context 248 The Wechsler Intelligence Scales 251 Background Issues 252 Viewpoint Box 7.1 IQ and Its Correlates 253 Viewpoint Box 7.2 Emotional Intelligence and Its Correlates 257 Administration, Scoring, and Interpretation Issues 258 Canadian Normative Data 260 Profile Box 7.1 Dr. Don Saklofske 261 Wechsler Adult Intelligence Scale —Fourth Edition (WAIS-IV) 263 Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV) 266 Wechsler Preschool and Primary Scale of Intelligence —Fourth Edition (WPPSI-IV) 268 Viewpoint Box 7.3 The Flynn Effect 268 Other Intelligence Scales 270 Selected Cognitive Assessment Scales 271 Wechsler Memory Scale —Fourth Edition (WMS-IV) 271 Wechsler Individual Achievement Test—Third Edition (WIAT-III) 273 Summary and Conclusions 275 CHAPTER 8 ASSESSMENT: SELF-REPORT AND PROJECTIVE MEASURES 279 Introduction 279 The Person-Situation Debate 280 Viewpoint Box 8.1 How Well Do We (and Can We) Know Ourselves? 282 Self-Presentation Biases 283 Developing Culturally Appropriate Measures 285 The Clinical Utility of Self-Report and Projective Measures 288 Self-Report Personality Measures 292 MMPI-2 and MMPI-A 293 Other Clinical Measures of Personality Functioning 300 Self-Report Checklists of Behaviours and Symptoms 304 Profile Box 8.1 Dr. David A. Clark 305 Achenbach System of Empirically Based Assessment 307 Viewpoint Box 8.2 Top Problems: An Option for Tracking and Evaluating Treatment Effects 308 SCL-90-R 309 Outcome Questionnaire 45 309 Beck Depression Inventory-II 310 Children’s Depression Inventory 2 311 TABLE OF CONTENTS xxi Projective Measures of Personality 312 Rorschach Inkblot Test 313 Viewpoint Box 8.3 Why Do Questionable Psychological Tests Remain Popular with Some Clinical Psychologists? 316 Thematic Apperception Test 317 Summary and Conclusions 318 CHAPTER 9 ASSESSMENT: INTEGRATION AND CLINICAL DECISION-MAKING 321 Integrating Assessment Data 324 Viewpoint Box 9.1 Integrating Data from Multiple Informants 326 Case Formulation 327 Profile Box 9.1 Dr. Heather Hadjistavropoulos 333 Threats to the Validity of Assessments and Case Formulations 335 Patient/Client Factors 335 Clinician Factors 337 Improving the Accuracy of Clinical Judgment 341 Psychological Assessment Reports and Treatment Plans 343 Assessment Feedback 346 Viewpoint Box 9.2 Multiple Perspectives on Treatment Goals 347 Summary and Conclusions 350 CHAPTER 10 PREVENTION 355 Introduction 355 Viewpoint Box 10.1 Poverty 357 Approaches to Prevention 360 Promoting Evidence-Based Parenting 366 Home Visiting Programs 367 Incredible Years 368 Triple P 369 Prevention of Violence 370 Physical Abuse of Children 370 Profile Box 10.1 Dr. Katreena Scott 371 Youth Violence: Bullying and Conduct Disorder 373 Prevention of Internalizing Disorders 377 Anxiety Disorders 377 Depression 378 Prevention of Substance Abuse 379 Viewpoint Box 10.2 Health Promotion and Prevention Programs for Older Adults 382 Prevention of Problems in Those Exposed to Trauma or Loss 383 Profile Box 10.2 Dr. Jonathan Weiss 385 Viewpoint Box 10.3 Unsung Heroes 386 Summary and Conclusions 387 xxii TABLE OF CONTENTS CHAPTER 11 INTERVENTION: OVERVIEW 391 Introduction 391 The Ethics of Intervention 394 Profile Box 11.1 Dr. Christopher Mushquash 398 Theoretical Approaches 399 Short-Term Psychodynamic Psychotherapies 400 Interpersonal Psychotherapy for Depression 403 Process-Experiential Therapies 406 Cognitive-Behavioural Therapies 408 Viewpoint Box 11.1 The Case of Michael 411 Seeking Psychological Treatment 412 Profile Box 11.2 Dr. Karen Dyck 415 The Duration and Impact of Psychotherapy 417 Viewpoint Box 11.2 Options for Increasing Psychotherapy Attendance 418 Alternative Modes of Service Delivery 420 Summary and Conclusions 426 CHAPTER 12 INTERVENTION: ADULTS AND COUPLES 429 Introduction 429 Does Psychotherapy Work? A Controversy and Its Impact 430 Meta-Analysis and Psychotherapy Research 431 Evidence-Based Treatments: Initiatives and Controversies 436 Profile Box 12.1 Dr. Martin D. Provencher 437 Viewpoint Box 12.1 Searching for Evidence 447 Clinical Practice Guidelines 448 Examples of Evidence-Based Treatments 451 CBT for Depression 451 Profile Box 12.2 Dr. Peter Bieling 454 Prolonged Exposure CBT for PTSD 455 EFT for Couple Distress 457 Effectiveness Trials 458 Viewpoint Box 12.2 Dissemination of Evidence-Based Treatments 460 Adoption of Evidence-Based Treatments 461 Summary and Conclusions 465 CHAPTER 13 INTERVENTION: CHILDREN AND ADOLESCENTS 469 Introduction 469 Who Is the Client in Psychological Services for Children and Adolescents? 469 Profile Box 13.1 Dr. Graham Reid 472 Landmarks in the Evolution of Evidence-Based Psychological Services for Children and Adolescents 474 Do Psychological Treatments for Children and Adolescents Work? 475 Which Treatments Work for Specific Disorders? 477 Clinical Practice Guidelines 481 TABLE OF CONTENTS xxiii Examples of Evidence-Based Treatments 483 Disruptive Behaviour Disorders 483 Viewpoint Box 13.1 Treatment of Childhood Attention-Deficit/Hyperactivity Disorder 492 Adolescent Depression 493 Coping with Depression in Adolescence 494 Efficacy, Effectiveness, and the Dissemination of Evidence-Based Treatments 496 Profile Box 13.2 Dr. Melanie Barwick 498 Viewpoint Box 13.2 Psychological Treatment for Noah 501 Summary and Conclusions 503 CHAPTER 14 INTERVENTION: IDENTIFYING KEY ELEMENTS OF CHANGE 505 Introduction 505 Psychotherapy Process and Process-Outcome Research 506 Viewpoint Box 14.1 Sudden Gains in Therapy 508 Examining Client Factors 509 Examining Therapist Factors 512 Examining Treatment Factors 515 Profile Box 14.1 Dr. Henny Westra 519 Some Methodological Cautions 521 Common Factors in Psychotherapy 522 Research Perspectives on Common Factors: The Therapeutic Alliance 524 Research Perspectives on Common Factors: Psychotherapy Equivalence 526 Evidence-Based Psychotherapy Relationships 530 Task Force Recommendations 532 Empirically Based Principles of Therapeutic Change 533 Summary and Conclusions 535 CHAPTER 15 CLINICAL HEALTH PSYCHOLOGY, CLINICAL NEUROPSYCHOLOGY, AND FORENSIC PSYCHOLOGY 539 Introduction 539 Clinical Health Psychology 541 Definitions of Health and Disability 541 Activities of Clinical Health Psychologists 543 Assessment and Intervention Related to Pain 546 Profile Box 15.1 Dr. Christine Chambers 548 Viewpoint Box 15.1 Insomnia: No Need to Lose Sleep over It! 551 Clinical Neuropsychology 552 Activities of Clinical Neuropsychologists 553 Profile Box 15.2 Dr. Colette Smart 554 Assessment 556 Intervention 559 Viewpoint Box 15.2 Neuropsychological Assessment to Aid in Differential Diagnosis and Treatment Planning 560 xxiv TABLE OF CONTENTS Forensic Psychology 562 Activities of Forensic Psychologists 563 Profile Box 15.3 Dr. Martin Lalumière 564 Assessment 566 Viewpoint Box 15.3 Risk Assessment 568 Intervention 569 Summary and Conclusions 570 APPENDIX I 573 Major Journals Relevant to Clinical Psychology 573 APPENDIX 2 579 Applications to Graduate School 579 REFERENCES 589 NAME INDEX 613 SUBJECT INDEX 627 THE EVOLUTION OF CLINICAL PSYCHOLOGY 1 CHAPTER INTRODUCTION Introduction Mental health is a state of well-being in which every individual Defining the Nature and Scope of realizes his or her own potential, can cope with the normal Clinical Psychology stresses of life, can work productively and fruitfully, and is able Evidence-Based Practice in to make a contribution to his or her community. Psychology World Health Organization (2007) Mental Health Professions Counselling Psychology More than 450 million people have mental disorders. Many more have mental health problems. School Psychology About half of all mental disorders begin before people reach age 14. Psychiatry Worldwide, 877,000 people commit suicide every year. Clinical Social Work In emergencies, the number of people of mental disorders is esti- Other Mental Health Professions mated to increase by 6–11%. Mental disorders increase the risk for physical disorders. Availability of Mental Health Service Providers Many health conditions increase the risk of mental disorders. Stigma prevents many people from seeking mental health care. A Brief History of Clinical Psychology There are great inequities in the availability of mental health pro- The Roots of Clinical Psychology fessionals around the world. The History of Assessment in Clinical Adapted from World Health Organization (2007) Psychology The History of Intervention in Clinical In the second decade of the 21st century, the potential for clinical Psychology psychology to make important contributions to the health of individu- The History of Prevention in Clinical als, families, and society is abundantly clear. In this opening chapter, Psychology we introduce you to the profession of clinical psychology, its scope, The Future and its remarkable history. Throughout this text, we will illustrate with compelling evidence that clinical psychologists have developed assess- Summary and Conclusions ments that are helpful in understanding problems and interventions 2 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY that are effective in preventing, treating, and even eliminating a broad range of health problems and disorders. To fully appreciate the importance of such health services, it is necessary to understand the scope of the public health problem facing health care systems in North America and other parts of the world. A national survey of the mental health and well-being of Canadians aged 15 years and older found that as many people suffered from clinical depression as from common chronic health conditions such as heart disease and diabetes (Statistics Canada, 2003). Furthermore, 1 out of every 10 Canadian adolescents and adults reported symptoms consis- tent with a diagnosis of a mental disorder such as alcohol or illicit drug dependence, a mood disorder (i.e., major depressive disorder or bipolar disorder), or a serious anxiety disorder (i.e., social phobia, panic disorder, or panic disorder with agoraphobia). It is estimated that the cost of mental illness to Canadian society—including absenteeism, under- employment, unemployment, disability costs, health care services and supports, and premature death—may be as high as $63 billion annually (Wilkerson, 2012). Perhaps due to the stressfulness of living and/or working conditions, the rate of mental health problems is even higher among certain groups than in the general population. For example, a health survey of members of active Canadian military personnel found that 15% reported a mental disorder in the previous year and 23% believed they required mental health services (Sareen et al., 2007). Being deployed to combat operations and witnessing atrocities were associated with increased risk of disorder and need for services. Participation in peace- keeping operations was not associated with increased risk, unless such assignments were associated with exposure to combat and witnessing atrocities. Similar results have been reported for American troops deployed to Iraq and Afghanistan (Smith et al., 2008). In 1999, the Surgeon General of the United States released a report on the mental health of Americans (U.S. Department of Health and Human Services, 1999). Using data from national epidemiological studies, he estimated that, over a one-year period, 21% of Americans suffered from anxiety disorders, mood disorders, schizophrenia and other psychotic conditions, antisocial personality disorder, anorexia nervosa, or severe cognitive impairments. The estimate that one in five people suffers from a mental disorder applied to all age groups, including children, adolescents, adults, and older adults. The report also presented data showing that, in countries with established market economies (such as Canada, the United States, the United Kingdom, Australia, and New Zealand), the economic burden of mental disorders, mental illness, and suicide in terms of health care costs and lost productivity is second only to that of cardiovascular conditions. THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 3 The Depression Report, released in 2006 by the London School of Economics, translated epidemiological data into economic terms (London School of Economics Centre for Economic Performance, Mental Health Policy Group, 2006). Despite the estimate that one family in three is affected by depression or anxiety, only 2% of the expendi- tures of the National Health Service (NHS) in the United Kingdom (UK) are allocated to the treatment of these disorders. Lost output due to depression and anxiety is estimated to cost the UK economy £12 billion a year—representing 1% of the total national income. A million people in the UK receive disability benefits because of mental disorders, at a cost of £750 a month (about $1,500 Canadian) per person. The UK National Institute for Health and Care Excellence (NICE) is an independent interdisciplinary organization with the mandate to provide national guidance on promoting good health and preventing and treating ill health. Systematic literature reviews by NICE concluded that evidence-based psychological therapies, which cost approximately £750 per person, are effective for at least half the people with anxiety and depression and are at least as effective as medication in tackling these mental health problems. The UK government therefore decided to improve access to psychological therapies by training mental health professionals, including, but not limited to, psychologists. Policy-makers predict that this investment will, in addition to offering enormous potential human benefits in reduced suffering and increased well-being, yield significant economic benefits in terms of both reduced claims for disability and increased productivity. Data from the World Health Organization (presented in Exhibit 1.1) illustrate the scope of mental health problems in different countries. Worldwide, hundreds of millions of people suffer from mental disorders. However, most mental disorders are overlooked or misdiagnosed, and only a small percentage of those individuals who suffer from a mental disorder ever receive treatment. Even if they do receive treatment for other health concerns, in most cases—regardless of the wealth or level of development of the country in which these people live—mental health problems are neglected. This is particularly troubling because effective, relatively inexpensive treatments (psychological and/or pharmacologi- cal) exist for most of these conditions. Viewpoint Box 1.1 describes the Are mental health initiatives undertaken by the Mental Health Commission of Canada to problems as serious as enhance the health and well-being of Canadians. physical health problems? In addition to the pressing problems posed by mental disorders, there is mounting evidence that lifestyle and psychosocial factors are related to many of the causes of death in Western countries. As you will learn in Chapters 10 and 15, there is evidence that psychological services can dramatically reduce the negative health impact of these lifestyle and psychosocial risk factors. A large-scale study of the causes 4 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY of mortality in the United States reached startling conclusions (Mokdad, Marks, Stroup, & Gerberding, 2004). Although dramatic causes such as motor vehicle accidents accounted for 2% of deaths, and shooting fatalities accounted for 1% of deaths, the leading causes of death were related to tobacco smoking (18.1%), poor diet and physical inactiv- ity (16.6%), and alcohol consumption (3.5%). Adding the numbers together, these data demonstrate that at least 40% of fatalities were attributable to entirely preventable—or treatable—factors. Exhibit 1.1 World Health Organization Mental Health: The Bare Facts At any given time, there are 450 million people worldwide suffering from mental, neurological, and behavioural problems. It is predicted that the number of people suffering from these problems will increase in the future. Mental health problems are found in all countries. Mental health problems cause suffering, social exclusion, disability, and poor quality of life. Mental health problems increase mortality. Mental health problems have staggering economic costs. One in every four people seeking other health services has a diagnosable mental, neurological, or behavioural problem that is unlikely to be diagnosed or treated. Mental health problems are associated with poor compliance with medical regimens for other disorders. Cost-effective treatments exist for most disorders and, if applied properly, could enable people to function better in their communities. There is greater stigma associated with mental health problems than with physical health problems. Most countries do not allocate sufficient funds to address mental, neurological, and behavioural problems. Adapted from World Health Organization (2004b). DEFINING THE NATURE AND SCOPE OF CLINICAL PSYCHOLOGY As we consider the pain and suffering experienced by people with mental and physical health problems, the interpersonal effects of their distress on their family, friends, and co-workers, and the tragedy of untimely death, the need for effective services to identify and address these problems is evident. It is inevitable that, at many points in our lives, each of us will be affected, either directly or indirectly, by the emotional distress of psychological disorders. The first experience may be helping a friend through confusion and anger stemming from a loved one’s suicide. As a university student, you may be faced with the challenges of helping a roommate with an eating disorder who binges and purges. Young parents may provide support to another young parent who is desperate to find appropriate services for a child with autistic disorder. In mid-life, you may be faced with the burden of caring for THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 5 an elderly parent suffering from dementia, or you may be attempting to support a partner who is chronically anxious and avoids social gather- ings. As you age, you may face the death of your partner and friends, and may have to cope with your own increasing infirmity and pain. Clinical psychology is the branch of psychology that focuses on developing assessment strategies and interventions to deal with these painful experiences that touch everyone’s life. VIEWPOINT BOX 1.1 MENTAL HEALTH COMMISSION OF CANADA In Canada, although health services are provided by the prov- inces, federal initiatives have underlined the need for a national strategy with respect to mental health. Out of the Shadows at Last, published in 2006, reported on the Senate Commission on Mental Health, chaired by Senator Michael Kirby. Testimony from people with mental disorders, their families, service providers, and researchers drew attention to the urgent need for increased government investment to address the needs of the high numbers of Canadians suffering from a mental disorder. The incomplete and patchwork nature of mental health services available across the country was emphasized in the report. Following one of the key recommendations of the report, the federal government established the Mental Health Commission of Canada (MHCC). The MHCC is a national non-profit organization designed to enhance the health and well-being of those living with a mental disorder by focusing national attention on mental health issues. The MHCC is designed to foster col- laboration among different levels of government, service providers, researchers, people with mental disorders, and the families of those individuals. The MHCC has two clear messages about people living with a mental disorder: They have the right to receive the services and supports they need. They have the right to be treated with the same dignity and respect as those struggling to recover from any kind of illness. The MHCC currently has six initiatives and projects: 1. Opening Minds: a campaign to reduce the stigma associated with mental disorders and to eradicate discrimination faced by those living with mental health problems 2. Mental Health First Aid: a program for training members of the public to assist a person developing a mental health problem or experiencing a mental health crisis 3. Mental Health Strategy for Canada: an initiative for developing a national mental health strategy (over two-thirds of countries already have one; Canada lags behind the rest of the world in this regard) 4. Knowledge Exchange Centre: an initiative designed to make evidence-based information about mental health widely available to both service providers and the public 5. Housing First: a program for providing people with housing and support services tailored to meet their needs 6. Peer Project: a project designed to enhance the use of peer support by creating and applying national guidelines of practice 6 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY Think about the challenges and stressors that you have faced and those faced by those you care about. Can you identify the things that made your distress worse? On the other hand, what helped you in dealing with difficulties? Throughout the text, to give you a clear sense of who clinical psychologists are and the variety of things they do in their work, we introduce you to a number of Canadian clinical psychologists. In our first example in the text, Profile Box 1.1, you will meet psychologist Dr. Jennifer Frain, who is the executive director of a social service agency in Winnipeg, Manitoba. PROFILE BOX 1.1 DR. JENNIFER FRAIN I did my undergraduate degree in psychology in my hometown at the University of Winnipeg. My master’s degree in clinical psychology was completed at the University of Saskatchewan, followed by my Ph.D. in clinical psychology at Concordia University in Montreal. I completed my internship/ residency at the Clarke Institute of Psychiatry in Toronto (which is now part of the Centre for Addictions and Mental Health). I returned to Winnipeg to begin my career and have now worked for over 15 years in social services. In 2006, I became the executive director of New Directions for Children, Youth, Adults and Families, Inc., the largest social service agency in Winnipeg, serving the Winnipeg community since 1885. I joined the board of directors of the Manitoba Psychological Society (MPS) in 2000, as I wanted to connect with colleagues in the psychology community. I became president of MPS for the first time in 2002 and was re-elected in 2005. During my time on the MPS board of directors, I had the Courtesy of Jennifer Frain great fortune to work with other psychology advocates from across Canada, and in 2005 I became the chair of the Council of Professional Psychologists. It was in this role that I joined the board of directors of the Canadian Psychological Association (CPA). It was my privilege to serve as the president of the CPA in 2012–2013. HOW DID YOU CHOOSE TO BECOME A CLINICAL PSYCHOLOGIST? I was actually heading toward medical school (follow- very interesting, I was most affected by the profes- ing a long tradition of MDs in my family) when, in my sor and the way she interacted with others, the way second year of undergraduate study, I took a Psychol- she approached questions, and the way she thought. ogy of Sex Differences course with a well-known and She was a dynamic teacher and, for the first time in my brilliant psychologist. Although the course content was life, I became totally fascinated with course material. CONTINUED... THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 7 Other psychology courses followed and I veered away clinical psychology. I have never once regretted this from a medical career and into graduate training in decision. WHAT IS THE MOST REWARDING PART OF YOUR JOB AS A CLINICAL PSYCHOLOGIST? The breadth of skill development in clinical psychology forward positively in his or her life. In my work, I am training has been essential to my success in social ser- required to supervise staff at all levels of my organiza- vices. I was trained to conduct interviews and perform tion and to engage at a systems level with civil servants, assessments that require the distillation, analysis, and elected officials, other organizations, and community synthesis of diverse sources of information. Gradu- and family stakeholders. It is incredibly rewarding and ate training also helped me learn to use my reactions, stimulating to be able to use my scientist and practitio- empathic abilities, and problem-solving skills to provide ner skills as a clinical psychologist working in a com- therapeutic interventions to help an individual move munity setting. WHAT IS THE GREATEST CHALLENGE YOU FACE AS A CLINICAL PSYCHOLOGIST? The greatest challenge that I face as a clinical psycholo- the intervention with youth who are heavily involved in gist is my relative isolation in the area of social services. street culture, the provision of programs and services Although my training provided ideal preparation for for persons with cognitive disabilities living in the com- what I do, few clinical psychologists consider a career munity). The significance of the work, the high stakes, in the social services. This is highly unfortunate, as and the miserable outcomes for people when service is many of the day-to-day issues dealt with are of serious not available or not done right are huge, both for the consequence (e.g., the care and protection of children, individuals and for society at large. WHAT DO YOU SEE AS THE MOST EXCITING CHANGES IN THE FIELD OF CLINICAL PSYCHOLOGY? We are witnessing the participation of clinical psy- and institute policies that address population-level con- chologists throughout the health care system and cerns, such as modifying poor behavioural choices and I am very excited about that, as clinical psychologists strategies to help people make better choices to ward can be providers of both health and mental care. It is off future problems (e.g., positive parenting strategies, encouraging to see a growing number of psychologists healthy eating, active lifestyle adoption). So, for me, working in primary care clinics, oncology clinics, pain the most exciting changes I see are that psychologists clinics, and cardiology units. The increased employ- are now working in diverse roles, which is enabling ment of psychologists in government is also terrific, as them to bring their breadth of knowledge and skills to psychologists are being sought out to develop, identify, bear on a wide range of challenges in society. Let’s consider some definitions of clinical psychology. Exhibit 1.2 provides examples of definitions and descriptions of clinical psychology from the United States, Britain, and New Zealand. Despite some differences in emphasis, a common theme running through these definitions is that clinical psychology is based firmly on scientifically supported psychological theories and principles. Clinical psychology is a science-based profession. Furthermore, the development of effective assessment, prevention, and intervention services relies on basic 8 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY research into the nature of emotional distress and well-being. The practice of clinical psychology uses scientifically based methods to reli- ably and validly assess both normal and abnormal human functioning. Clinical psychology involves gathering evidence about optimal strategies for delivering health care services. Exhibit 1.2 International Definitions of Clinical Psychology AMERICAN PSYCHOLOGICAL ASSOCIATION, SOCIETY OF CLINICAL PSYCHOLOGY The field of Clinical Psychology involves research, teaching and services relevant to the applications of principles, methods, and procedures for understanding, predicting, and alleviating intellectual, emotional, biological, psychological, social and behavioral maladjustment, disability and discomfort, applied to a wide range of client populations. In theory, training, and practice, Clinical Psychology strives to recognize the importance of diversity and strives to understand the roles of gender, culture, ethnicity, race, sexual orientation, and other dimensions of diversity. (www.div12.org/about-us/) BRITISH PSYCHOLOGICAL SOCIETY, DIVISION OF CLINICAL PSYCHOLOGY Clinical psychology applies the scientific knowledge base of psychology to ‘clinical’ problems. After completing a psychology undergraduate degree, postgraduate training is undertaken in the application of psychology to a variety of human difficulties. Clinical psychologists aim to reduce psychological distress and to enhance and promote psychological well-being. A wide range of psychological difficulties may be dealt with, including anxiety, depression, relationship problems, learning disabilities, child and family problems and serious mental illness. (dcp.bps.org.uk/dcp/clinical_psychology/role_home$.cfm) NEW ZEALAND PSYCHOLOGSTS BOARD Clinical Psychologists apply psychological knowledge and theory derived from research to the area of mental health and development, to assist children, young persons, adults and their families with emotional, mental, developmental or behavioural problems by using psychological assessment, formulation and diagnosis based on biological, social and psychological factors, and applying therapeutic interventions using a scientist-practitioner approach. (www.psychologistsboard.org.nz/scopes-of-practice2) Over the decades, the nature and definition of clinical psychology has shifted, expanded, and evolved. From an initial primary focus on assessment, evaluation, and diagnosis, the scope of clinical psychology has grown. Clinical psychology now also includes numerous approaches to intervention and prevention services that are provided to individuals, couples, and families. The practice of clinical psychology also covers indirect services that do not involve contact with those suffering from a mental disorder, such as consultation activities, research, program development, program evaluation, supervision of other mental health professionals, and administration of health care services. Given the ever-changing THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 9 nature of the field, the only certainty about clinical psychology is that it will continue to evolve. Only time will tell whether this evolution ulti- mately leads to a decreasing focus on traditional activities of assessment and treatment (as predicted by some experts), to an increasing focus on the use of psychopharmacological agents to treat mental illness and mental health problems (as promoted by some psychologists and some psychological associations), or to the adoption of universal prevention programs designed to enhance our protection from risk. The changing nature of clinical psychology does, however, require that any definition of the field be treated as temporary, to be maintained only as long as it accurately reflects the field. The definition of clinical psychology must be altered and updated as innovations and new directions emerge. The Canadian Psychological Association’s Section on Clinical Psychology developed an excellent document that defines the current nature of clinical psychology, provides general principles intended to apply to future changes in the field, and firmly grounds the practice of clinical psychology in the context of professional ethics and responsibility. An excerpt of this definition is presented in Exhibit 1.3. In developing this Exhibit 1.3 Canadian Definition of Clinical Psychology APPROVED BY THE CLINICAL SECTION AND THE BOARD OF DIRECTORS OF THE CANADIAN PSYCHOLOGICAL ASSOCIATION, MAY 1993 Clinical psychology is a broad field of practice and research within the discipline of psychology, which applies psychological principles to the assessment, prevention, amelioration, and rehabilitation of psychological distress, disability, dysfunctional behaviour, and health-risk behaviour, and to the enhancement of psychological and physical well-being. Clinical psychology includes both scientific research, focusing on the search for general principles, and clinical service, focusing on the study and care of clients, and information gathered from each of these activities influences practice and research. Clinical psychology is a broad approach to human problems (both individual and interpersonal), consisting of assessment, diagnosis, consultation, treatment, program development, administration, and research with regard to numerous populations, including children, adolescents, adults, the elderly, families, groups, and dis- advantaged persons. There is overlap between some areas of clinical psychology and other professional fields of psychology, such as counselling psychology and clinical neuropsychology, as well as some professional fields outside of psychology, such as psychiatry and social work. Clinical psychology is devoted to the principles of human welfare and professional conduct as outlined in the Canadian Psychological Association’s Canadian Code of Ethics for Psychologists. According to this code, the activities of clinical psychologists are directed toward: respect for the dignity of persons; responsible caring; integrity in relationships; and responsibility to society. Copyright 1993, Canadian Psychological Association. Permission granted for use of material. 10 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY definition, the Section on Clinical Psychology sought input from numerous sources, including the members of the section, the executive committees of other sections within the Canadian Psychological Association, and the executive committees of several national organizations in Canada for which the definition might be relevant, such as the Canadian Council of Clinical Psychology Programs, the Council of Provincial Associations of Psychology, and the Canadian Register of Health Service Providers in Psychology (Vallis & Howes, 1996). Throughout this textbook you may notice other examples that illustrate the importance of conducting wide- ranging consultation in order to achieve consensus on important issues in the profession. Consultation is a hallmark of successful initiatives in clinical psychology. EVIDENCE-BASED PRACTICE IN PSYCHOLOGY Despite the apparent overlap in the various definitions of clinical psychology that we presented in Exhibit 1.2, there is still very active debate about the extent to which clinical psychology can or should be based solely on the science of psychology. Some psychologists doubt that clinical psychology can ever be effectively guided by scientific knowledge. Critics of a science-based approach to clinical psychology express the following concerns: Group-based data cannot be used in working with an individual— Critics argue that because a great deal of psychological research is based on research designs that involve the study of groups of individuals, it is difficult to determine the relevance of research results to any specific individual. Clients have problems now and we cannot afford to wait for the research—Critics argue that developing, conducting, and rep- licating research findings takes substantial time and thus the information provided by researchers inevitably lags behind the needs of clinicians to provide services to people in distress. Each individual’s unique constellation of life experience, culture, and societal context makes it unlikely that general psychological principles can ever provide much useful guidance in alleviating emotional distress or interpersonal conflict. There is simply no research evidence on how to understand or treat many of the human problems confronted by clinical psychologists on a daily basis. Although these kinds of concerns sound reasonable enough, they lead to the suggestion of basing clinical practice on the individual THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 11 psychologist’s gut feelings, intuition, or experience. The idea that clinical psychology is primarily a healing art rather than primarily a science- based practice is extremely problematic. As we discuss in subsequent chapters, there is ample evidence that people are prone to a host of decision-making errors and biases. Because clinicians are not immune from these errors and biases, they risk making serious mistakes in evaluating and treating clients. Thus, over-reliance on the clinician’s professional experience and general orientation to understanding human functioning can be risky if it is not balanced with the application of scientifically based knowledge and with a scientific approach to developing and testing clinical hypotheses. At the other end of the spectrum, there are clinical psychologists for whom the current definitions of clinical psychology do not go far enough in ensuring that science is at the heart of all clinical services offered to the public. A passionate proponent of this position is Richard McFall, who, in his 1991 presidential address to the Society for a Science of Clinical Psychology (a section of the American Psychological Association’s Society of Clinical Psychology), chal- lenged the field to provide only psychological services that research has shown to be effective and safe (McFall, 1991). The key elements of his Manifesto for a Science of Clinical Psychology are presented in Exhibit 1.4. Exhibit 1.4 McFall’s Manifesto for a Science of Clinical Psychology CARDINAL PRINCIPLE Scientific clinical psychology is the only legitimate and acceptable form of clinical psychology. First Corollary Psychological services should not be administered to the public (except under strict experimental conditions) until they have met the following four minimal criteria: Criterion 1 The exact nature of the service must be described clearly. Criterion 2 The claimed benefits of the service must be stated explicitly. Criterion 3 These claimed benefits must be validated scientifically. Criterion 4 Possible negative side effects that might outweigh any benefits must be ruled out empirically. Second Corollary The primary and overriding objective of doctoral programs in clinical psychology must be to produce the most competent clinical scientists possible. Adapted from McFall (1991). 12 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY McFall’s manifesto adopted a position on the role of science in clinical psychology that many clinical psychologists initially found too extreme. McFall’s demand that only scientifically supported treatments should be offered to the public met with strong opposition from many clinical psychologists. The manifesto sparked a lively debate about the appropriateness and the ethics of routine psychological service (or any health service for that matter) that does not have documented, scientifically sound evidence demonstrating its effectiveness. There is no doubt that the vast majority of people who seek psychological services are in significant distress and hope to receive treatment that will reduce their distress and improve their overall functioning. Do you think it is responsible to offer services that have no evidence of effectiveness? When effective treatments exist, is it reasonable to continue to offer services of undocumented effectiveness? If you were advising a friend to seek services, wouldn’t you suggest looking for services that have been shown to be helpful for similar problems? If not, then why not? In recent years, questions surrounding the appropriateness of adopting a science-based approach for the practice of clinical psychology have taken centre stage in discussions about the nature of clinical evidence-based practice: a psychology. Originally developed within medicine, the evidence-based practice model that involves the practice (EBP) model: synthesis of information drawn from research and systematically collected data on the patient in question, the a. requires the clinician to synthesize information drawn from re- clinician’s professional experience, search and systematically collected data on the patient in question, and the patient’s preferences when the clinician’s professional experience, and the patient’s preferences considering health care options. when considering health care options (Institute of Medicine, 2001; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996); and b. emphasizes the importance of informing patients, based on the best available research evidence, about viable options for assessment, prevention, or intervention services. The EBP model is now being integrated into many health and human service systems, including mental and behavioural health care, social work, education, and criminal justice (McHugh & Barlow, 2010; Mullen & Streiner, 2004). In order to practise in an evidence-based manner, a health care professional must be familiar with the current scientific literature and must use both the research evidence and scientifically informed decision-making skills to determine the ways in which research evidence can inform service planning for a patient. THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 13 As we describe in the next chapter, current training models in clinical psychology all emphasize the need for psychologists to be competent in the use and interpretation of scientific methods. Indeed, the EBP model has been endorsed by the both the Canadian Psychological Association (CPA Task Force on Evidence-Based Practice of Psychological Treatments, 2012) and the American Psychological Association as the basis for the professional practice of psychology (APA Presidential Task Force on Evidence-Based Practice, 2006). It is fascinating to note that the movement for evidence-based practice in health care services places demands on all health services that are remarkably similar to those expressed by McFall’s first corollary. Within two decades, a position that was originally considered extreme became mainstream in many health care systems and a goal espoused by several health care professions. Moreover, in a position paper on the implications of EBP for psychiatrists, the Canadian Psychiatric Association indicated that the single most compelling reason for prac- tising in an evidence-based manner was an ethical one (Goldner, Abass, Leverette, & Haslam, 2001). In essence, because their code of ethics obliges psychiatrists to provide those receiving their services with the best available information about service options, these authors argued that psychiatrists must adopt the EBP model. MENTAL HEALTH PROFESSIONS The definitions of clinical psychology provide an important perspective on the nature and function of modern clinical psychology. However, it In what ways is clinical is useful to describe other health care professions whose services and psychology similar to other client populations overlap those of clinical psychology. In the follow- mental health professions? ing pages, we describe several other professions, some of which also involve extensive training in psychology. Within the field of psychology, what is unique about clinical psychology? The definitions we presented emphasized that clinical psychology is primarily concerned with the application of psychological knowledge in assessment, prevention, and/or intervention in problems in thoughts, behaviours, and feelings. Of course, in addition to providing psychological services, many clinical psychologists also conduct psychological research and contribute important information to the science of psychology. Nevertheless, the objective of research in clinical psychology is to produce knowledge that can be used to guide the development and application of psychological services. Clinical psychology shares many of the research methods, approaches to statistical analysis, and measurement strategies found in other areas of psychology. Many areas of psychology, such as cognitive, 14 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY developmental, learning, personality, physiological, and social, generate research that has direct or indirect applicability to clinical psychology activities. However, the key purpose of research in these other areas of psychology is to generate basic knowledge about human functioning and to enhance, in general terms, our understanding of people. The fact that some of this knowledge can be used to assess and treat dysfunction and thereby improve human functioning is of secondary importance. Many psychologists apply their knowledge in diverse applied fields. In Chapter 15, you will learn about health psychologists, forensic psychologists, and neuropsychologists—typically these professionals are trained in clinical psychology and also have specialized training in their specific areas of research and practice. Two other areas of applied psychology, counselling psychology and school psychology, also provide important mental health services to the public. Although there is some similarity to clinical psychologists in their training and practices, these psychologists bring unique skills to the assessment, prevention, and treatment of mental health problems. Counselling Psychology It is important to distinguish between counselling psychology and counselling. Counselling is a generic term used to describe a range of mental health professions with various training and licensure requirements (Robiner, 2006). Estimates indicate that there are 49.4 counsellors per 100,000 people in the United States. The comparable figure for psychologists is 31.1 per 100,000 (Robiner, 2006). Turning specifically to counselling psychology, this profession has a great deal in common with clinical psychology. Historically, the distinction between clinical and counselling psychology was in terms of the severity of problems treated. Traditionally, the focus of clinical psychology was on the assessment and treatment of psychopathology—that is, manifestations of anxiety, depression, and other symptoms that were of sufficient severity to warrant a clinical diagnosis. On the other hand, counselling psychologists provided services to individuals who were dealing with normal challenges in life: predictable developmental transitions, such as leaving home to work or to attend university or college, dealing with changes in work or interpersonal roles, and handling the stress associated with academic or work demands. Simply put, counselling psychologists dealt with people who were, by and large, well adjusted, whereas clinical psychologists dealt with people who were experiencing significant problems in their lives and who were unable to manage the resulting emotional and behavioural symptoms. Another distinction between the two professions was the type of setting in which the practitioners worked. Counselling psychologists THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 15 were most commonly employed in educational settings (such as college or university counselling clinics) or general community clinics in which various social and psychological services are available. Clinical psychologists, in contrast, were most likely to be employed in hospital settings—both in general hospitals and in psychiatric facilities. These traditional distinctions between clinical and counselling psychologists are fading due to changes within both professions. Contemporary counselling psychologists provide services to individuals who are having ©iStock.com/nullplus difficulty functioning, providing, for example, treatment to university Traditionally, counselling psychologists students suffering from disorders such as major depressive disorder, were most commonly found in panic disorder, social phobia, or eating disorders (Benton, Robertson, educational settings, such as university Tseng, Newton, & Benton, 2003; Kettman et al., 2007). Both clinical and clinics. counselling psychologists are now employed in a wide range of work settings, including public institutions and private practices. In 2009, to aid in clearly defining and describing counselling psychology as a specialty within professional psychology, the Canadian Psychological Association adopted a definition of Canadian counselling psychology (Bedi et al., 2011). Over time, clinical psychologists have expanded their practice to address human problems outside the usual realm of mental health services by providing other services such as couples therapy, consultation, and treatment for people dealing with chronic illness and stress-related disorders. Thus, clinical psychologists developed services for individuals whose problem would not meet criteria for any psychopathological condition. Clinical psychologists have also begun to develop programs that are designed to prevent the development of problems. At one level, it is a rather tenuous decision to mark professional boundaries between counselling and clinical psychology on the basis of the possible differences between what constitutes “normal” range distress and abnormal levels of distress. Depending on the point in time in which someone seeks help, the same person might present with symptoms severe enough to meet diagnostic criteria for a mental disorder or with less severe, subclinical symptoms. In many countries, there is no distinction between clinical and counselling psychology. In others, the distinction is becoming less and less meaningful for any practical purpose. In Canada, for example, the regulatory body for the profession of psychology in Ontario (the College of Psychologists of Ontario) requires that both counselling and clinical psychologists have the training and expertise to diagnose mental disorders. Just like clinical psychology, counselling psychology promotes the use of scientifically based interventions. This drive to provide evidence-based services is likely to have substantial implications for both training and practice in counselling psychology (Waehler, Kalodner, 16 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY Wampold, & Lichtenberg, 2000). The source of the distinction between the two psychology professions in some countries is that clinical and counselling psychologists are usually trained in different academic settings and in different academic traditions. Counselling psychology programs are found, for the most part, in faculties of education and/or departments of educational psychology. Clinical psychology programs, on the other hand, are based in psychology departments. Data from surveys by Norcross and his colleagues indicate that clinical psychology programs attract far more applicants than do counselling psychology programs (Norcross, Kohout, & Wicherski, 2005; Norcross, Sayette, Mayne, Karg, & Turkson, 1998) and that counselling programs have a greater representation of ethnic minority students (Norcross et al., 1998). Research on clinical disorders is more commonly conducted in clinical psychology programs, and research on minority adjustment and academic/vocational issues is more frequently conducted in counselling psychology programs. School Psychology School psychologists have specialized training in both psychology and education. In the United States, school psychologists are employed in diverse organizations such as schools, clinics, and hospitals, and in private practice. In Canada, most school psychologists are employed by school boards. Given the focus on children’s functioning, there is a natural overlap between school psychology and child clinical psychology. Historically, school psychology emphasized services related specifically to the learning of children and adolescents, including the assessment of intellectual functioning; the evaluation of learning difficulties; and consultation with teachers, students, and parents about strategies for optimizing students’ learning potential. Clinical child psychology focused on the treatment of a diagnosable mental disorder. Over time, the scope of school psychology has expanded in response to the demands of parents, school systems, and governments. Because of growing awareness of the deleterious effects on learning of child and adolescent psychopathology, parental psychopathology, and stressful family circumstances, the work of school psychologists now addresses students’ mental health and life circumstances more broadly. The role of school psychologists now includes attention to social, emotional, and medical factors in a context of learning and development. These ©iStock.com/CEFutcher changes, combined with legal obligations that schools provide the most appropriate education for all children, have resulted in school psycholo- School psychologists now take into account the social, emotional, and gists diagnosing a range of disorders of childhood and adolescence, medical influences on students’ as well as developing school and/or family-based programs to assist learning and development. students to learn to the best of their abilities. School psychologists have THE EVOLUTION OF CLINICAL PSYCHOLOGY CHAPTER 1 17 also taken a leadership role in the development of school-based prevention programs designed to promote social skills, to reduce bullying, to facilitate conflict resolution, and to prevent violence (Kratochwill, 2007). These are described in detail in Chapter 10. In the United States, there are estimated to be 11.4 school psychologists per 100,000 people (Robiner, 2006). Despite the increasingly close connections between school and child clinical psychology, it is likely that the two disciplines will remain distinct, at least in the near future. A survey of American school and child clinical psychologists clearly illustrates this point. Tryon (2000) found that, in a sample of school psychologists and clinical psychologists, the majority of school psychologists endorsed the position that training programs in school and clinical psychology should merge in order to provide improved services for school-based and school-linked mental health services, whereas fewer than half of the child clinical psychologists endorsed a merger. It therefore appears likely that distinctions in training will continue. Psychiatry Although we have focused on psychology-based professions thus far, it is important to note that primary care physicians provide more mental health services than any other health care profession (Robiner, 2006). As medical generalists, these physicians are usually the first health care professionals consulted for any health condition, be it physical or mental. Psychiatrists are physicians who specialize in the diagnosis, treatment, and prevention of mental illnesses. Like all physicians, in four years of medical school training they learn about the functioning of the human body and the health services that physicians provide. As with other medical specialties, training as a psychiatrist requires five years of residency training after successful completion of basic medical training. A range of residency options are possible, including both broad training in psychiatric services and specific training in subspecialties such as child psychiatry or geropsychiatry. Once they have completed specialization in psychiatry, psychiatrists rarely examine or treat the basic health problems that were covered in their medical training. Psychiatric training differs in important ways from applied psychology training. First, psychiatric training deals extensively with physiological and biochemical systems and emphasizes biological functioning and abnormalities. Psychiatrists are well qualified to determine whether mental disorders are the result of medical problems and to unravel the possible interactions between physical illnesses and emotional disturbances. Psychiatric training provides the skills to evaluate the extent to which psychological symptoms result from or are exacerbated by medications used to treat physical ailments and 18 CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY chronic illnesses. On the other hand, compared with psychologists, psychiatrists receive relatively little training in human psychological development, cognition, learning, or psychological functioning in general. Standard psychiatric training provides only limited training in research skills such as research design and statistical analysis. Many psychiatrists have become active researchers and have contributed in important ways to the knowledge base of the neurosciences and human sciences. Nevertheless, the average psychiatry resident receives far less ©iStock.com/Squaredpixels training in research than does the average graduate student in clinical Psychiatric services often emphasize psychology. An expert panel in the United States warned that unless both psychopharmacological and psychological treatments. research training in psychiatric residency programs was dramatically strengthened, research by American psychiatrists risked dwindling to the point of “extinction” (McLellan, 2003). Another fundamental difference between training in clinical psychology and psychiatry is that psychiatric training generally emphasizes psychopharmacological treatment over psychological treatment. Accordingly, compared with psychologists, psychiatrists tend to receive less training in the use of scientifically based psychological assessment and psychotherapy. Historically, psychiatrists were trained in forms of psychoanalytic and psychodynamic treatments such as those developed by Sigmund Freud, Carl Jung, and Alfred Adler. Due in part to the proliferation of effective psychopharmacological treatments in recent decades and the growing emphasis on evidence-based practice in psychiatry, there has been a waning of emphasis on training in psy

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