Reviewer Clinical (Prelims) PDF

CHAPTER 1: Clinical Psychology: Definition and “The field of Clinical Psychology integrates Training science, theory, and practice to understand, predict,...

CHAPTER 1: Clinical Psychology: Definition and “The field of Clinical Psychology integrates Training science, theory, and practice to understand, predict, and alleviate maladjustment, What Is Clinical Psychology? disability, and discomfort as well as to promote human adaptation, adjustment, and personal Original Definition development. Clinical Psychology focuses on the intellectual, emotional, biological, Lightner Witmer psychological, social, and behavioral aspects Clinical psychology – the term was first used of human functioning across the life span, in in print by Lightner Witmer in 1907 varying cultures, and at all socioeconomic First to operate a psychological clinic levels.” Envisioned clinical psychology as a discipline ○ Defined by the Division of Clinical with similarities to a variety of other fields, Psychology (Division 12) of the specifically medicine, education, and American Psychological sociology. Association (APA). Clinical psychologist – a person whose work ○ An accurate, comprehensive, with others involves aspects of treatment, contemporary definition of clinical education, and interpersonal issues. psychology that is more inclusive and While the first clients of his clinic were children descriptive. with behavioral or educational problems, ○ Reflects the rich and varied growth that Witmer foresaw clinical psychology, even in the field has seen in the century since his earliest writings, as applicable to people of Witmer originally identified it. It is all ages and with a variety of presenting observed that both the field and its problems. practitioners continue to outgrow the classic definitions. More Recent Definitions ○ Its authors do not intend to suggest that each clinical psychologist spends Defining clinical psychology is a greater challenge equal time on each component of that today than it was in Witmer’s time. The field has definition. But, collectively, the work of witnessed such tremendous growth in a wide variety clinical psychologists does indeed of directions that most simple, concise definitions fall encompass such a wide range. short of capturing the field in its entirety. As a group, “Clinical psychology involves rigorous study contemporary clinical psychologists do many different and applied practice directed toward things, with many different goals, for many different understanding and improving the people. psychological facets of the human experience, “Clinical psychology is essentially the branch including but not limited to issues or problems of psychology that studies, assesses, and of behavior, emotions, or intellect.” treats people with psychological problems or ○ A broad but somewhat more succinct disorders.” definition according to Pomerantz. ○ A “quick” definition according to various introductory psychology Education and Training in Clinical Psychology textbooks and dictionaries of psychology. Basic components of clinical psychology training ○ This definition sounds reasonable common and well-established across programs: enough, however, it doesn’t portray all Must obtain a doctoral degree in clinical that clinical psychologists do, how they psychology. do it, or who they do it for.  Most students enter a doctoral program with The multitude of specialty tracks within clinical only a bachelor’s degree, some enter with a psychology doctoral programs. More than half master’s degree. of APA-accredited doctoral programs in ○ Often, the master’s degree was earned clinical psychology offer (but may not require) from a “terminal” master’s program in training within a specialty track. clinical psychology, meaning that their ○ The most common specialty areas are program ends at the master’s level. clinical child, clinical health, forensic, ○ Some graduates of such master’s family, and clinical neuropsychology. programs go on to earn doctoral Coexistence of three distinct models of degrees, while others enter the training currently used by various graduate workforce in some capacity. programs: ○ The scientist-practitioner (Boulder) For those entering with a bachelor’s degree, training model typically consists of: ○ The practitioner-scholar (Vail) model At least 4 years of intensive, full-time ○ The clinical scientist model coursework ○ Required coursework includes courses Balancing Practice and Science: The Scientist- on: Practitioner (Boulder) Model Psychotherapy In 1949, the first conference on graduate Assessment training in clinical psychology was held in Statistics Boulder, Colorado. Research design and Training directors from around the country methodology reached an important consensus where Biological bases of behavior training in clinical psychology should jointly Cognitive-affective bases of emphasize both practice and research. behavior To become a clinical psychologist, graduate Social bases of behavior students would need to receive training and Individual differences display competence in: And other subjects ○ The application of clinical methods ○ A master’s thesis and doctoral (assessment, psychotherapy, etc.) dissertation are also commonly ○ The research methods necessary to required. study and evaluate the field ○ Also, a practicum in which students scientifically start to accumulate supervised Coursework should reflect this dual emphasis, experience doing clinical work. with classes in: Followed by a 1-year, full-time predoctoral ○ Statistics and research methods internship ○ Psychotherapy and assessment ○ They take on greater clinical Expectations for the more independent responsibilities and obtain supervised aspects of graduate training would also reflect experience on a full-time basis. the dual emphasis. Graduate students under Lastly, a postdoctoral internship occurs after supervision would conduct both: the degree is obtained. ○ Clinical work ○ Their own empirical research: thesis, Beyond these basic requirements, especially in recent and dissertation. decades, there is no single way by which someone These graduate programs would continue to becomes a clinical psychologist. Instead, there are be housed in departments of psychology at many paths to the profession. This is indicated by: universities, and graduates would be awarded the PhD degree.  The term scientist-practitioner model was fewer courses related to research and used to label this two-pronged approach to statistics. training. Since the 1970s, graduate programs offering For decades, the scientist-practitioner—or the the PsyD degree have proliferated. Between Boulder model—approach to clinical 1988 to 2001 time period alone, the number of psychology training unquestionably PsyD degrees awarded increased by more dominated the field. In fact, more programs than 160%. The growth of the PsyD (or still subscribe to the Boulder model than to any practitioner-scholar or Vail model) approach other. However, as time passed, to training in clinical psychology has developments took place that produced a influenced the field tremendously. Currently, wider range of options in clinical psychology more than half the doctoral degrees being training. The pendulum did not remain awarded in the field are PsyD degrees. stationary at its midpoint between practice and There are only 80 PsyD programs compared research; instead, it swung toward one to 250 PhD programs, but PsyD program extreme and then toward the other. accepts and graduates a much larger number of students than does the PhD program. So, Leaning Toward Practice: The Practitioner- the number of graduates with each degree is Scholar (Vail) Model about the same. In 1973, another conference on clinical psychology training was held in Vail, Colorado. Comparing PhD Programs With PsyD Programs In the years preceding this conference, some discontent has arisen regarding the Boulder, In general, compared with PhD programs, PsyD or scientist-practitioner, model of training. programs tend to: ○ In effect, many current and aspiring Place less emphasis on research-related clinical psychologists question the aspects of training and more emphasis on importance of extensive training as a clinically relevant aspects of training. scientist in their goal of clinical Accept and enroll a much larger percentage practice. It was then that only a and number of applicants. minority of clinical psychologists were Be housed in freestanding, independent (or entering academia or research as a university-affiliated) “professional schools,” as primary professional task. opposed to departments of psychology in ○ Clinical practice was the more popular universities. career choice, and many would-be Accept students with lower Graduate Record clinical psychologists sought a Examination (GRE) scores and undergraduate doctoral-level degree with less grade point averages (GPAs). extensive training in research and Offer significantly less funding to enrolled more extensive training in the students in the form of graduate development of applied clinical skills. assistantships, fellowships, tuition remission, ○ Additionally, some within the and so on. profession were questioning whether Accept and enroll a higher percentage of the quality and quantity of practitioners students who have already earned a master’s was sufficient to serve the population. degree. So the practitioner-scholar model of training Have lower rates of success placing their was born, along with a new type of doctoral students in APA-accredited predoctoral degree, the PsyD. Compared with PhD internships. programs, these programs typically offer more Produce graduates who score lower on the coursework directly related to practice and national licensing exam (EPPP).  Graduate students in a briefer time period emphasis on the scientific method and (about 1.5 years sooner). evidence-based clinical methods. Graduate students who pursue practice- There are two defining events highlight the related careers rather than academic or initial steps of this movement: research-related careers. ○ In 1991, Richard McFall, at the time a Have at least a slightly higher percentage of professor of psychology at Indiana faculty members who subscribe to University, published an article that psychodynamic approaches, as opposed to served as a rallying call for the clinical cognitive-behavioral approaches. scientist movement. In this article, “Manifesto for a Science of Clinical Leaning Toward Science: The Clinical Scientist Psychology,” McFall argued that Model “scientific clinical psychology is the After the advent of the balanced Boulder only legitimate and acceptable form of model in the late 1940s and the subsequent clinical psychology... after all, what is emergence of the practice-focused Vail model the alternative?... Does anyone in the 1970s, the more empirically minded seriously believe that a reliance on members of the clinical psychology profession intuition and other unscientific methods began a campaign for a strongly research- is going to hasten advances in oriented model of training. knowledge?” ○ A few years later, a conference of prominent leaders of select clinical psychology graduate programs took place at Indiana University which purpose was to unite in an effort to promote clinical science. From this, Academy of Psychological Clinical Science was founded in which McFall served as its president for the first several years. As time has passed, an increasing number of graduate programs and internships have In the 1990s, a movement toward increased become members. The programs in empiricism took place among numerous this academy still represent a minority graduate programs and prominent individuals of all graduate programs in clinical involved in clinical psychology training. psychology, but among the members ○ The leaders of this movement argued are many prominent and influential that science should be the bedrock of programs and individuals. clinical psychology. They sought and Considering the discrepancies between the created a model of training—the three models of training, the experience of clinical scientist model—that clinical psychology graduate students varies stressed the scientific side of clinical widely from one program to the next. Insider’s psychology more strongly than did the Guide to Graduate Programs in Clinical Boulder model. and Counseling Psychology, a valuable ○ Unlike the Vail model in the 1970s, resource used by many applicants to learn their program still awards the PhD, just about specific graduate programs in clinical as Boulder model graduate programs psychology, the first piece of information listed do. However, a PhD from a clinical about each program is that program’s self- scientist program implies a very strong rating on a 7-point scale from “practice  oriented” to “research oriented.” Applicants can find programs at both extremes and everywhere in between. Broad Trends in Training in Clinical Psychology Since the Early 1990s A shift in the theoretical orientation of faculty toward cognitive/cognitive behavioral and away from psychodynamic/psychoanalytic. Increase in the percentage of doctoral students who are: ○ Female ○ Members of racial or ethnic minorities. Technology is increasingly influential in the training of clinical psychologists. For an increasing number of students, learning psychotherapy or assessment techniques involves the use of webcams and other computer-based methods that allow supervisors to view, either live or recorded, students trying to apply what they have learned in class. Growing emphasis on specific competencies, or outcome-based skills the students must be able to demonstrate. ○ This ensures that students who graduate from clinical psychology programs will be able to apply what they have learned aside from earning good grades on exams, papers, and other academic tasks. ○ Specific competencies that may be required of students could center on: Intervention (therapy) Assessment Research Consultation/collaboration Supervision/ teaching Ethics Cultural diversity Management/administration  Personality ○ Choose electives carefully, too— classes that have direct clinical relevance. Including field studies or internships Get to know your professors. ○ Letters of recommendation are among Getting In: What Do Graduate Programs Prefer? the most important factors in clinical psychology graduate admissions Resources for Aspiring Clinical Psychology decisions. Professors (and, to some Graduate Students extent, supervisors in clinical or Insider’s Guide to Graduate Programs in research positions) can be ideal writers Clinical and Counseling Psychology of such letters—assuming the Graduate Study in Psychology professor actually knows the student. Getting In: A Step-by-Step Plan for Gaining ○ The better you know the professor, the Admission to Graduate School in Psychology more substantial your professor’s letter Admission and Application in Graduate Programs can be. Admission rates are competitive, and the For example, a professor may application process is demanding. be able to write a brief, vaguely ○ APA-accredited PhD programs admit complimentary letter for a quiet only 7% to 16% of their applicants. student who earned an A in a ○ APA-accredited PsyD programs admit large lecture course. But the about 40% to 50% of their applicants. professor would be able to write a much more meaningful, Suggestions Offered by Indicated Resouces: persuasive, and effective letter Know your professional options for the same student if the two ○ Numerous roads lead to the clinical of them had developed a strong psychologist title; moreover, numerous working relationship through professions overlap with clinical research, advising, or other psychology in terms of professional professional activities. activities. Get research experience. ○ Researching these options will allow ○ Your experience in a research for more informed decisions and better methods class is valuable, but it won’t matches between applicants and distinguish you from most other graduate programs. applicants. Take, and earn high grades in, the ○ Conducting research with a professor appropriate undergraduate courses. affords you additional experience with ○ Graduate programs want trainees the empirical process, as well as a whose undergraduate programs chance to learn about a specialized maximize their chances of succeeding body of knowledge and develop a at the graduate level. working relationship with the professor. ○ Among the most commonly required or In some cases, professors recommended courses are: seek assistants for ongoing Statistics, projects they have designed. research/experimental In others, the undergraduate methods student may approach the Psychopathology Biopsychology  faculty member with an original ○ Along with undergraduate GPA, scores idea for an independent study. on the GRE are key determinants of If your contribution is significant admission to graduate programs. enough, this research Appropriately preparing for this test experience could also yield a can boost your odds of admission. publication or presentation on ○ By learning what scores your preferred which you are listed as an programs seek author, which will further ○ Studying for the test either informally or enhance your application file. through a review course ○ Regardless of the arrangement, ○ Taking practice exams, and retaking it conducting research at the as necessary. undergraduate level improves an Select graduate programs wisely. applicant’s chances of getting into and ○ Getting in is certainly important, but succeeding in a graduate program. getting into a program that proves to be Get clinically relevant experience. a bad match benefits neither the ○ For undergraduates, the options for student nor the program. It is best to direct clinical experience (therapy, learn as much as possible about counseling, interviewing, testing, etc.) potential programs: are understandably limited. Even for What is the model of training those who have earned a bachelor’s (Boulder, Vail, or clinical degree and are considering returning scientist)? to school at the graduate level, clinical To what clinical orientations positions may be hard to find. does the faculty subscribe? ○ However, quite a few settings may What areas of specialization do offer exposure to the kinds of clients, the faculty members professionals, and issues that are represent? central to clinical psychology. These What clinical opportunities are settings include: available? Community mental health Your own preferences or centers constraints—geography, Inpatient psychiatric centers, finances, family—deserve crisis hotlines consideration as well. Alternative schools Write effective personal statements. Camps for children with ○ In addition to the many other items in behavioral or emotional issues your application file, graduate And others programs will require you to write a ○ Whether the clinical experience takes personal statement (or goal the form of an internship or practicum statement). (for which course credit is earned), a ○ This is your opportunity to discuss paid job, or a volunteer position, it can career aspirations as well as your provide firsthand knowledge about research and clinical interests—all of selected aspects of the field, and it which should fit well with the program demonstrates to admissions to which you are applying. committees that you are serious and ○ It is also a chance to explain in more well informed about clinical detail information that may have psychology. appeared only briefly on a résumé or Maximize your GRE score. vita, such as clinical experiences or  research with an undergraduate Down the road, do you see professor. yourself as a clinician or a ○ Make sure your writing ability appears researcher? strong and that you don’t make the Have you firmly determined statement overly personal or revealing. your own theoretical orientation Prepare well for admissions interviews. already, or do you seek a ○ Most doctoral programs invite high- program that will expose you to ranking applicants for an in-person a variety? interview. What specific areas of clinical ○ These interviews are a wonderful or scientific work are most opportunity for professors in the interesting to you? program to get to know you and for you How much financial debt are to get to know the program. you willing to incur? ○ Arrive (professionally dressed, of Search the literature for studies on how course) with a strong understanding of graduate programs handle their the program and your interest in it. The admissions processes. more specific, the better: Interest in ○ For example, one study surveyed the particular professors’ research directors of clinical psychology concentrations, for example, makes a doctoral programs about the better impression than the fact that the importance they place on various program has a strong reputation. components of the application ○ And don’t forget to develop a list of process. These researchers found that your own questions—good questions both PhD and PsyD programs placed can solicit more detailed information high value on several core elements: than you were able to find on the Undergraduate GPA program’s website and can impress GRE scores interviewers in the process. Some Letters of recommendation common interview questions are: Personal statement Why do you want to be a Curriculum vitae clinical psychologist? Interview performance. What attracts you to our ○ There were some differences between graduate program specifically? PhD and PsyD programs: What are your research PhD programs placed much interests? greater importance on the What approach(es) to student–mentor research psychotherapy do you prefer? match (making sure that an Which of our faculty members incoming student has research would you like to work with? interests that closely What are your long-term career correspond to those of a faculty goals? If you were a student in member) and research our program, what would you assistance experience. like to do after you graduated? PsyD programs were more Consider your long-term goals. likely to offer admission to ○ Thinking ahead about these and other applicants who already had a questions can increase the likelihood master’s degree. that you will find yourself at a graduate program at which you thrive and that Internships: Predoc and Postdoc sets you up for a fulfilling career. Predoctoral Internship per year. That number has since All clinical psychology doctoral programs decreased, but the issue remains, at culminate in predoctoral internship. least to some extent. Typically consists of a full year of supervised ○ Numerous causes have been clinical experience in an applied setting. proposed, but the factor receiving the ○ Such as in a psychiatric hospital, a most attention is the drastic increase in Veterans Affairs medical center, a the number of PsyD applicants without university counseling center, a a corresponding increase in the total community mental health center, a number of internship placements. medical school, or another agency Now, numerous strategies to improve where clinical psychologists work. the current situation are under Along with the completion of the dissertation, consideration. this takes place before the PhD or the PsyD is ○ Applicants are generally successful in awarded. finding an internship position— Generally considered a year of transition, a especially if they don’t overly restrict sort of advanced apprenticeship in which the themselves in terms of the number of individual begins to outgrow the role of applications or geographic range. “student” and grow into the role of “professional.” Postdoctoral Internship An opportunity to gain more specialized Beyond the predoctoral internship and the training than may have been available in doctoral degree that follows, most states graduate school so far. require a postdoctoral internship for Many internships are accredited by the APA; licensure as a psychologist. those that are not may be looked on less The postdoc typically lasts 1 to 2 years. favorably by state licensing boards. ○ Postdocs take on more responsibilities than they did as predoctoral interns, Process of Applying for a Predoctoral Internship but they remain under supervision. Similar to the process of applying to graduate ○ Like the predoctoral internship, the school, it often involves: postdoc often provides an opportunity ○ Researching various internships for specialized training. ○ Applying to many, traveling for ○ Some clinical psychologists obtain interviews postdoc positions that are explicitly ○ Ranking preferences designed from the start to meet ○ Anxiously awaiting feedback licensing requirements for a particular ○ Relocating to a new geographic area. state; sometimes, such positions are Some apply to 20 or more, but 10 to 15 continuations of predoctoral internship internship sites may be more reasonable and experiences. equally effective. ○ Other clinical psychologists may obtain Internship Shortage an entry-level position with an agency ○ The number of graduate students and tailor it to meet postdoctoral seeking predoctoral internships has requirements for licensure. either approached or exceeded the After postdoctoral interns accumulate the number of available slots required number of supervised hours, and ○ The shortage worsened considerably pass the applicable licensing exams, they can after roughly 2002, as the number of become licensed to practice independently. students who applied but were not Since 2008, a small but growing number of successfully placed at an internship states have decided to drop the requirement of increased dramatically, to hundreds  a postdoc for licensure. The rationale behind education units (CEUs) to renew the license this decision involves several factors: from year to year. ○ Current graduate training (including ○ In various states, psychologists can the predoctoral internship) provides far meet these ongoing requirements in a more clinical experience than it did number of ways by: years ago when postdoc requirements Attending workshops were put into place. Taking courses ○ Employers often have difficulties Undergoing additional funding postdoc positions because specialized training third-party payers (e.g., health Passing exams on selected insurance companies) who pay the professional reading material, bills for many clients can refuse to pay and the like. for services by someone who is not yet ○ The purpose of requiring CEUs is to licensed. ensure that clinical psychologists stay ○ Postdoc positions can be difficult to up to date on developments in the field, find, especially in rural areas. with the intention of maintaining or ○ Some states have a shortage of clinical improving the standard of care they psychologists to serve their residents, can provide to clients. so making licensure easier to obtain is a win-win for the psychologists and the Professional Activities and Employment Settings public. Where Do Clinical Psychologists Work? Getting Licensed Works in a wide variety of settings but private Becoming licensed gives professionals the practice is the most common. right to identify as members of the According to the surveys conducted since profession—to present themselves as 1980s: psychologists (or clinical psychologists—the ○ Private practice has been the primary terminology, as well as licensing requirements employment site of 30% to 41% of in general, differs from state to state). It also clinical psychologists. authorizes the psychologist to practice ○ University psychology departments independently. came in second, but that number has Requires passing licensure exams—typically, not exceeded 19%. the Examination for Professional Practice ○ Came in third is the “other” category. in Psychology (EPPP) and a state-specific Between 2% and 9% of clinical exam on laws and ethics. psychologists have listed each ○ The EPPP is a standardized multiple- of the following as their primary choice exam on a broad range of work setting: psychiatric psychology topics; all U.S. states and hospitals, general hospitals, most provinces of Canada establish a community mental health minimum score for licensure. The state centers, medical schools, and exams vary, of course, according to Veterans Affairs medical state regulations but tend to center on centers. legal issues relevant to the practice of In 2003, 15% of psychologists psychology in the state in question. listed “other,” writing in diverse The state exams may be written or settings such as government oral. agency, public schools, Once licensed, clinical psychologists in many substance abuse center, states must accumulate continuing  corporation, and university counseling center. ○ It is clear that although private practice remains a common destination, clinical psychologists are finding employment across an expanding range of settings. What Do Clinical Psychologists Do? They are engaged in an enormous range of professional activities, but psychotherapy is foremost. ○ Since 1973, the number of clinical psychologists reporting that they are involved in psychotherapy has always outranked that of any other Counseling Psychologists professional activity and has ranged Historically, clinical psychologists were more from 76% to 87%. likely to work with seriously disturbed ○ Clinical psychologists have reported individuals, whereas counseling psychologists that they spend between 31% and 37% were more likely to work with or counsel less of their time conducting pathological clients. psychotherapy—a percentage more Today, many clinical and counseling than double that of any other activity. psychologists see the same types of clients, ○ Of those who practice psychotherapy, sometimes as colleagues working side by individual therapy occupies the largest side. Another similarity is that their graduate percentage of their therapy time (76%), students occupy the same internship sites, with group, family, and couples therapy often earn the a PhD degree, and obtain the far behind 6% to 9% each. same licensure status. A sizable number of psychologists—more than While two professions share so much common half—have also reported that they are at least ground, a few meaningful differences remain. somewhat involved in each of the following ○ Clinical psychologists: activities: diagnosis/ assessment, teaching, Work with more seriously supervision, research/writing, consultation, disturbed populations and administration. Of these, diagnosis and Work and complete internships assessment generally occupy more of clinical more often in settings such as psychologists’ time than do the others. hospitals and inpatient Overall, it is evident that “clinical psychologists psychiatric units are involved in multiple professional pursuits Theoretical orientation across varied employment sites”. In fact, more endorses behaviorism more than half of clinical psychologists hold at least strongly two professional positions. More interested in applications of psychology to medical How Are Clinical Psychologists Different From... settings ○ Counseling psychologists: Work with less seriously disturbed populations Work and complete internships more often in university counseling centers  Theoretical orientation Traditionally, social workers have focused endorses humanistic/client- their work on the interaction between an centered approaches more individual and the components of society that strongly. may contribute to or alleviate the individual’s More interested in vocational problems. They saw many of their clients’ testing and career counseling problems as products of social ills— racism, oppressive gender roles, poverty, abuse, and Psychiatrists so on. Psychiatrists go to medical school and are ○ They also helped their clients by licensed as physicians. Their first several connecting them with social services, years are often identical to that of other types such as welfare agencies, disability of physicians, only then they receive offices, or job-training sites. specialized training in psychiatry. ○ They were likely to get into the “nitty- The two professions fundamentally differ in gritty” of their clients’ worlds by visiting their understanding of and approach to their homes or workplaces, or by behavioral or emotional problems. making contacts on their behalf with ○ Clinical psychologists: organizations that might prove Trained to appreciate the beneficial. biological aspects of their ○ When they worked together with clients’ problems psychologists and psychiatrists (e.g., Clinical psychologists view in institutions), they usually focused on clients’ problems as behavioral, issues such as arranging for clients to cognitive, emotional—still transition successfully to the stemming from brain activity, of community after leaving an inpatient course, but amenable to unit by making sure that needs such as change via those for housing, employment, and nonpharmacological methods. outpatient mental health services were It was only recently that being met. psychologists have rallied and In more recent years, the social work obtained prescription privileges profession has grown to encompass a wider in small number of states. range of activities, and the similarity of some ○ Psychiatrists: social workers, especially those conducting Psychiatrists’ training therapy, to clinical psychologists has emphasizes biology to such an increased. extent that disorders— The training of social workers, however, depression, anxiety disorders, remains quite different from the training of attention-deficit/hyperactivity clinical psychologists. disorder (ADHD), borderline ○ Typically earn a master’s degree rather personality disorder, and so than a doctorate. on—are viewed first and ○ Their training includes a strong foremost as physiological emphasis on supervised fieldwork, abnormalities of the brain. however, it includes very little on To fix the problem, research methods, psychological psychiatrists tend to fix the testing, or physiological psychology. brain by prescribing ○ Their theories of psychopathology and medication. therapy continue to emphasize social and environmental factors. Social Workers School Psychologists ○ They attend graduate programs in School psychologists usually work in schools, counseling or professional counseling, but some may work in other settings such as which should not be confused with day-care centers or correctional facilities. doctoral programs in counseling Their primary function is to enhance the psychology. These programs typically intellectual, emotional, social, and have rather high acceptance rates developmental lives of students. compared with programs in many ○ They frequently conduct psychological similar professions. testing (especially intelligence and Every state has some version of professional achievement tests) to determine counselor licensure, but the name may vary diagnoses such as learning disorders slightly, with common alternatives including and ADHD. mental health counselor, licensed professional ○ They use or develop programs mental health counselor, licensed clinical designed to meet the educational and professional counselor, and licensed emotional needs of students. counselor of mental health. ○ They also consult with adults involved in students’ lives—teachers, school Marriage and Family Therapists administrators, school staff, parents— Marriage and family therapists, or MFTs, earn and are involved, to a limited degree, master’s degrees. in direct counseling with students. Their training focuses on working with couples In many states, the title of school psychologist and families, but sometimes they also see requires only a master’s degree rather than a individuals struggling with issues related to doctorate. their partners or families. About half of MFTs work in private practice, Professional Counselors and most of the others practice in other types Often called licensed professional counselors, of work settings like clinics or agencies. or LPCs Compared to the training of clinical Professional counselors’ work generally psychologists, the training of MFTs places involves counseling of people with problems in relatively little emphasis on research and living or mild mental illness (as opposed to assessment. serious mental illness). Professional counselors are among the clinicians who serve wide varieties of clients in community agencies, and they often enter private practice as well. They often specialize in such areas as career, school, addiction, couple/ family, or college counseling. Their training typically includes: ○ Very little emphasis on psychological testing or conducting research. Correspondingly, their training programs include few if any courses on these topics, focusing instead on providing services to clients. ○ Earn a master’s rather than a doctoral degree and often complete their training within 2 years. CHAPTER 2: EVOLUTION OF CLINICAL dungeons. He championed the idea that mental illness was not due PSYCHOLOGY to demonic possession and advocated for compassionate, evidence-based treatment. Pinel also introduced the practice of ORIGINS OF THE FIELD maintaining case histories and treatment records, which marked a Foundational Context: While the roots of psychology can be significant step toward modern clinical practices. traced back to ancient philosophers like Socrates, Plato, and Aristotle, the specific field of clinical psychology is a much more Eli Todd (1769–1833): An American physician inspired by recent development, emerging in the early 20th century. Prior to Pinel’s work, Todd established The Retreat in Connecticut, where this, the mentally ill were often viewed with fear and treated patients were treated with respect and allowed to participate in inhumanely, believed to be possessed or deserving of their their treatment decisions. His work helped spread the principles of suffering. They were frequently housed in institutions more akin humane treatment throughout the United States. to prisons than hospitals. Dorothea Dix (1802–1887): A reformer who observed the poor EARLY PIONEERS treatment of mentally ill individuals in American jails, Dix In the 1700s and 1800s, the mentally ill were generally viewed dedicated her life to advocating for better care. Her efforts led to and treated much more unfavorably than they are today. During the creation of over 30 state institutions across the U.S. and this time, numerous individuals of various professional inspired similar reforms in Europe and Asia. backgrounds from Europe and North America assumed the challenge of improving the way people with psychological Tuke, Pinel, Todd, and Dix did not create clinical psychology. problems were regarded and treated. Through their efforts, the Their efforts do, however, represent a movement prevalent Western world eventually adopted a new, more humane, approach through much of the Western world in the 1700s and 1800s that to the mentally ill, foretelling the emergence of clinical promoted the fundamental message that people with mental illness psychology as a formal discipline. deserve respect, understanding, and help rather than contempt, fear, and punishment. William Tuke (1732–1822): A key figure in England, Tuke was horrified by the conditions he observed in asylums. He founded LIGHTNER WITMER AND THE CREATION OF the York Retreat, a facility where the mentally ill were treated CLINICAL PSYCHOLOGY with compassion and dignity, challenging the prevailing norms. Lightner Witmer (1867-1956) His approach became a model for humane care in mental health - Was born in Philadelphia treatment across Europe and the United States. - Earned an undergraduate degree in business at the Philippe Pinel (1745–1826): In France, Pinel is renowned for University of Pennsylvania freeing the mentally ill from brutal conditions in Parisian - Received his doctorate in psychology in 1892 in first article, “Clinical Psychology.” This article Germany under Wilhelm Wundt (the founder of introduced the term "clinical psychology," providing its experimental psychology) definition and explaining the need for its establishment. - Studied under James McKeen Cattell, another pioneer Witmer described his innovation as a "psychological of experimental psychology clinic" developed at the University of Pennsylvania. He At the time Witmer received his doctorate, psychology defined clinical psychology as a field that, while related was essentially an academic discipline, a field of to medicine, education, and social work, required research. It had almost none of the applied functions that specialized training and would involve collaboration characterize the field today. In the late 1800s, with professionals from these areas. Notably, his psychologists didn’t practice psychology, they studied it definition was uninfluenced by Freud and did not (Vasquez & Kelly, 2016). address the empirical evaluation of treatments, which - 1896, he founded the first psychological clinic at the was surprising given his experimental research University of Pennsylvania, where he had returned as a background. By the late 1800s, the work of pioneers like professor. Tuke, Pinel, and Dix had set the stage for clinical The first time that the science of psychology was psychology, which Witmer described just beginning to systematically and intentionally applied to people’s emerge from the broader science of psychology. problems. At the 1896 convention of the American Psychological ASSESSMENT Association, Witmer (1897) spoke to his colleagues and Diagnostic Issues fellow members about his clinic and encouraged them to The issues mentioned above are about categorizing mental open their own—to “throw light upon the problems that illnesses centrally to CP long before Witmer entered the picture. confront humanity” (p. 116)—but they were largely unenthusiastic (Reisman, 1991). In the 1800s in Europe, labeling systems for mental illness began - 1914, there were about 20 psychological clinics in the to take shape in a very basic way. Specifically, mental illnesses United States. were often placed in one of two very broad categories: neurosis - 1935, the number had soared to more than 150. and psychosis. In his clinic, Witmer and his associates worked with Neurosis children whose problems arose in school settings and ○ Neurotic individuals were thought to suffer from were related to learning or behavior (L. T. Benjamin, some psychiatric symptoms (including what we 2007; Routh, 2015c). would now call anxiety and depression) but to In 1907, Witmer founded the first scholarly journal in maintain an intact grasp on reality. the field, The Psychological Clinic, and authored the Psychosis  ○ Psychotic individuals, on the other hand, In 1840, the U.S. Census Bureau included a single demonstrated a break from reality in the form of category—“idiocy/insanity”—for this purpose. hallucinations, delusions, or grossly disorganized In 1880, there were seven such categories, and soon the thinking. American Medical Association and the U.S. Army each made preliminary attempts at classifying mental illness Who is Emil Kraepelin? (American Psychiatric Association, 2000). Considered as the “father of descriptive psychiatry” Offers a different two-category system of mental illness DSM Revisions which are the exogenous and endogenous disorders. The original DSM was published by the American ○ Exogenous disorders (caused by external factors Psychiatric Association in 1952, representing a more and suggested that exogenous disorders were the sophisticated attempt to define and organize mental far more treatable type.) diagnoses. ○ Endogenous disorders (caused by internal A revision (DSM-II) followed in 1968, but it was not factors) considered to be significantly different from the original. However, the next revision—DSM-III, which arrived in Kraepelin also assigned names to specific examples of disorders 1980—signified an entirely new way of thinking about in the broad exogenous or endogenous categories. For example, mental disorders. Whereas DSM and DSM-II included Kraepelin put forth the term dementia praecox to describe one somewhat vague descriptions of each disorder, endogenous disorder similar to what is now known as ○ DSM-III provided specific diagnostic schizophrenia. Later, he also proposed terms such as paranoia, criteria—lists indicating exactly what symptoms manic depressive psychosis, involutional melancholia, constitute each disorder. cyclothymic personality, and autistic personality—terms that ○ DSM-III also introduced a multiaxial system, a had not yet been coined. Most of Kraepelin’s specific terms have way of cataloging problems of different kinds on long since been replaced, but by offering such specific different axes, which remained for multiple terminology, he set a precedent for the creation of diagnostic editions before being taken out of the most recent. terms that eventually led to the Diagnostic and Statistical Manual The DSM has been revised several more times, with of Mental Disorders (DSM). DSM-III-R, DSM-IV, and DSM-IV-TR appearing in 1987, 1994, and 2000, respectively. The current edition Primary purpose of DSM is DSM-5, which was published in May 2013 after In the United States, long before the appearance of the significant anticipation and controversy. first DSM, the original reason for categorizing mental disorders was to collect statistics on the population. Drastic change regarding DSM  Each edition varies from its predecessor to some extent, Assessment of Intelligence but the most drastic change occurred with the publication The emergence of the field of clinical psychology around the turn of DSM-III in 1980. Sheer size is certainly among the of the 20th century coincided with a dispute among psychology’s most notable differences between DSM-II and DSM-III. pioneers about the nature of intelligence. In fact, new DSMs typically include more disorders Edward Lee Thorndike was among those who promoted than the editions they replace, with the jump between the idea that each person possesses separate, independent DSM-II and DSM-III being the largest. In the time intelligences between the original DSM (in 1952) and DSM-IV (in Charles Spearman led a group of theorists who argued 1994), the number of disorders increased by more than for the existence of “g,” a general intelligence thought to 300% to a total of 368 distinct diagnoses covering an overlap with many particular abilities. increasing scope of human behavior. The first two An important development in the history of intelligence editions of the DSM were brief, spiral-bound books; the testing arose in the early 1900s, when the French current DSM is 947 pages long. government sought help in determining which public school students should qualify for special services. What are the reasons for such an increase? In response to this request, Alfred Binet (along with On one hand, it is possible that in a relatively brief period Theodore Simon) created the first Binet-Simon scale in of time, psychological science is accurately recognizing 1905. disorders that went unrecognized (or at least unlabeled) Binet-Simon scale: This test yielded a single overall for centuries before, an explanation called “scientific score, endorsing the concept of “g.” It was the first to discovery.” incorporate a comparison of mental age to chronological On the other hand, it is also possible that psychology is age as a mea- sure of intelligence. This comparison, when making disorders out of some aspects of human expressed as a division problem, yielded the “intelligence experience that had previously been considered normal, quotient,” or IQ. an explanation called “social invention”. Binet’s test grew in popularity and was eventually revised by Lewis Terman in 1937. Terman’s revision was called Debates continue about the DSM's validity and scope, including the Stanford-Binet Intelligence Scales, the name by which disorders are included or excluded. Critics argue that which the test is currently known. decisions may be influenced by factors beyond empirical data. The standardization sample and the age range of test Despite these controversies, DSM revisions are important takers improved with each new version of Binet’s test, but milestones in the history of diagnostic labeling in clinical even after Terman revised it in 1937, it was still a child- psychology. focused measure of IQ.  In 1939, David Wechsler filled the need for a test of have also established themselves as competitors in the intelligence designed specifically for adults with the marketplace of psychological assessment, and recent publication of his Wechsler- Bellevue test. revisions in one have at times represented responses to - It quickly became popular among psychologists successful strides made by the other. working with adults, and its more recent revisions remain popular today. Since its creation, Assessment of Personality Wechsler’s adult intelligence scale has been Mental Test revised and restandardized numerous times: the - James McKeen Cattell first used the term in 1890 Wechsler Adult Intelligence Scale (WAIS) in in an article titled “Mental Tests and 1955, the WAIS-R in 1981, the WAIS-III in Measurements”. 1997, and the WAIS-IV in 2008. - At that time, the term was used to refer to basic In 1949, Wechsler released a children’s version of his tests of abilities such as reaction time, memory, intelligence test (a more direct competitor for the and sensation/perception. Stanford-Binet), which he called the Wechsler Hermann Rorschach Intelligence Scale for Children (WISC). - In 1921, he published a test that had significant - WISC distinguished itself from the Stanford- impact for many years to come. Binet by the inclusion of specific subtests as well - He is a Swiss psychiatrist, released his now- as verbal and performance scales (in addition to famous set of 10 inkblots, which rose quickly in overall IQ). popularity. - The WISC has been revised and restandardized Rorschach Inkblot Method several times: the WISC-R in 1974, the WISC-III - Projective personality test in 1991, the WISC-IV in 2003, and the WISC-V - Was based on the assumption that people will in 2014. “project” their personalities onto ambiguous or In 1967, Wechsler added an intelligence test designed for vague stimuli; hence, the way individuals very young children called the Wechsler Preschool and perceive and make sense of the blots corresponds Primary Scale of Intelligence (WPPSI). to the way they perceive and make sense of the - The WPPSI was revised in 1989 (WPPSI-R), world around them. 2002 (WPPSI-III), and 2012 (WPPSI-IV). Psychodynamic Practitioners Many other measures of child and adult intelligence have - Dominated during the early and mid-1900s, appeared during the time of the Stanford-Binet and the found such tests especially compatible with their Wechsler tests, but more than any others, these two have clinical approach to clients. established themselves as standards in the field. They Thematic Apperception Test  - Christiana Morgan and Henry Murray published - Testtakers’ patterns of responses were compared it in 1935. with those of groups in the standardization - It was similar to the Rorschach in that the test sample who represented many diagnostic taker responded to cards featuring ambiguous categories. stimuli. - It had a built-in system to detect random - TAT cards depicted people in scenes or situations responding or intentionally misleading responses. that could be interpreted in a wide variety of - It became very popular, and by 1959, there were ways. more than 200 separate scales consisting of Draw-a-Person Test combinations of MMPI items. - In which psychologists infer personality Minnesota Multiphasic Personality Inventory-2 characteristics from clients’ drawings of human - It was released in 1989. figures. - Its norms were more appropriate than those of the Incomplete Sentence Blank original MMPI, especially in terms of including - Julian Rotter minorities and individuals from various regions - Psychologists assess personality by examining of the country in the standardization sample. the ways clients finish sentence stems. - It also eliminated some of the outdated or Objective Personality Tests confusing language from the original test. - Typically, these tests were pencil-and-paper Minnesota Multiphasic Personality Inventory-Adolescent instruments for which clients answered multiple- - Followed in 1992 choice or true/false questions about themselves, All versions of the MMPI have featured hallmarks of their experiences, or their preferences. high-quality objective personality tests: easy - Some objective tests focused on specific aspects administration and scoring, demonstrable reliability and of personality, whereas others aimed to provide a validity, and clinical utility. more comprehensive overview of an individual’s Other objective tests have come and gone but none with personality. the lasting impact or research base of the MMPI. Minnesota Multiphasic Personality Inventory - NEO Personality Inventory (NEO-PI) - Written by Starke Hathaway and J. C. McKinley, - NEO-PI-R is perhaps the best example of a comprehensive - NEO-PI-3 personality measure. Instruments measuring more specific states or traits have - When it was originally published in 1943, it also appeared, including: consisted of 550 true/false statements. - The Beck Depression Inventory (now in its second edition)  - The Beck Anxiety Inventory behavioral approaches that many therapists and In recent decades, personality assessment tools have been clients found attractive. used for an increasingly wider range of purposes. ○ Family therapy revolution took root in the - Job screenings 1950s, and as the 1960s and 1970s arrived, - Forensic purposes understanding mentally ill individuals as symptomatic of a flawed system and the preferred therapeutic perspective. Psychotherapy Without the psychological consequences of World War This is the primary activity of clinical psychologists today, but that II in the U.S. Soldiers, psychotherapy might have hasn’t always been the case. remained an uncommon activity of clinical psychologists even longer. Timeline Mid-20th century: The psychodynamic approach to 1990s: In the first half of 1990s, psychological testing therapy dominated. With time, challengers to the was familiar territory for clinical psychologists. approach emerged. 1930: After Witmer founded the field, almost every Most recently: Cognitive therapy, with its emphasis on clinical psychologist worked in academia (rather than as logical thinking as the foundation of psychological a practitioner). wellness, has become the most popular singular 1940s or 1950s: Psychotherapy played a significant role orientation among clinical psychologists (excluding in the history of clinical psychology. eclectic or integrative approaches). 1950s and 1960s: Behaviorism surfaced as a ○ The most striking feature of the current therapy fundamentally different approach to human beings and marketplace is the utter range of therapy their behavioral or emotional problems. approaches. Modern graduate textbooks typically ○ Behavioral approach – emphasizes an empirical include at least a dozen chapters on distinct method, with problems and progress measured in approaches, with each chapter representing a full observable, quantifiable terms. This emphasis spectrum of more specific variations. was in part a reaction to the lack of empiricism Recent decades have witnessed a movement toward combining evident in psychodynamic psychotherapy. therapy approaches, in either eclectic or integrative ways, as well ○ Humanistic (or “client-centered”) therapy as the influence of cultural competence on any and all such (1960s) – Carl Rogers’s relationship- and growth- approaches. The plethora of therapy options currently available to oriented approach to therapy offered an clinical psychologists did not always exist. These methods have alternative to both psychodynamic and evolved over the history of the discipline. THE INFLUENCE OF WAR ON CLINICAL Accreditation of Clinical Psychology Doctoral PSYCHOLOGY Training Programs - As a response to the aftermath of WWII, the Therapy, assessment, and training have all been shaped by U.S. Government (Veterans Administration- attempts of various governments and individuals to select soldiers now the Department of Veterans Administration and treat them after they have served their countries. Numerous Affairs) requested the American Psychological critical incidents in the history of clinical psychology can directly Association to formalize the training of clinical be tied to military factors. psychologists and provide significant funding to ensure the availability of such training Robert Yerkes opportunities. - Chaired the committee on the Psychological - This strengthened the relationship between Examination of Recruits. Veteran Affairs and Clinical Psychology - Created the Alpha and Beta intelligence tests in Training which produced a large number of World War I to measure the intelligence of internships at various levels. recruits and soldiers that are considered - As the Scientist-Practitioner (Boulder) model precursors to today's most widely used measures continues to dominate the field by 2014, there of intelligence. were 4,700 psychologists (clinical and Wechsler-Bellevue counseling) working within the Department of - An intelligence test created by David Wechsler Veterans Affairs. that is his first intelligence test stemming from Spread of Theories and Clinical Approaches to his clinical experiences in World war I, England and United States measuring the intellectual capacities of military - The Nazi presence in Eastern Europe in the personnel. 1930s forced many influential figures in clinical - Led to creation of WAIS, WISC, and WPPSI, psychology- most notably Sigmund Freud and the revisions of which are currently the most other psychodynamic leaders to flee their home widely used measures of adult and child countries causing the spread. intelligence in the United States. Recent U.S. Military Events Posttraumatic Stress Disorder - Efforts in Iraq and Afghanistan have illustrated - The accepted diagnostic label for the the crucial role clinical psychologists continue to psychological effect of battle. This was called play for soldiers and veterans. "shell shock" during World War II, when many - Veterans Affairs is one of the country's largest U.S. veterans returned home with it. providers of mental Health services, with almost  1 million veterans receiving such services within significant discussion of clinical activities, reflecting a a recent 1-year period. new level of professional establishment for clinical psychology. DEVELOPMENT OF THE PROFESSION In the 1960s and 1970s, the profession of clinical Psychotherapy and assessment have evolved, as well as psychology continued to diversify, successfully recruiting more females and minorities into the field. the profession itself since its inception. In 1917, the American Association of Clinical Psychologists was Clinical approaches continued to diversify as well, as founded, and in 1919 it transitioned into the Clinical behaviorism, humanism, and dozens of other Section of the American Psychological Association. approaches garnered large followings. In 1921, the Psychological Corporation was founded, The first PsyD programs appeared, offering graduate foreshadowing the big business that was to become training options that emphasized applied clinical skills psychological tests and measures of intelligence and over research expertise. And signifying that personality. psychotherapy was becoming a recognized part of In the 1940s, education and training in clinical American health care, insurance companies began to psychology became more widespread and more authorize payment for clinical psychologists’ services just standardized. The number of training sites increased as they did for the services of many medical specialists. dramatically, and the American Psychological In the 1980s, clinical psychologists enjoyed increased Association began accrediting graduate programs that respect from the medical establishment as they gained offered appropriate training experiences in therapy, hospital admitting privileges and Medicare payment assessment, and research. privileges. Larger numbers of graduate training institutions continued to train larger numbers of new In 1949, the historic Boulder conference took place, at which training directors from around the country agreed clinical psychologists, and the number of American that both practice and research were essential facets of Psychological Association members who were clinicians approached 50%. PhD clinical psychology training. The 1950s produced more evidence that clinical Psychotherapy burgeoned, especially in private practice settings, but the use of intelligence and personality psychology was a burgeoning profession. Therapy approaches proliferated, with new behavioral and testing decreased. The growth of the profession humanistic/ existential approaches rivaling established continued through the 1990s and 2000s, as did the trend toward diversity in gender and ethnicity of those joining psychodynamic techniques. The American Psychological Association also published it. the first edition of its ethical code in 1953, with  In the late 1950s, only 14% of the U.S. population had mental disorder (“idiocy/insanity”) ever received any kind of psychological treatment; by 2010, that number had climbed to 50%. 1841 Dorothea Dix encounters mentally ill in Boston Today’s aspiring clinical psychologists have more prison, prompting extensive efforts for better choices than ever: the science/clinical balance of treatment traditional PhD programs, PsyD programs emphasizing clinical skills, and more selected PhD programs that 1880 U.S. Census Bureau lists seven categories of endorse the clinical scientist model of training and lean mental disorders heavily toward the empirical side of the science/clinical 1890 “Mental test” is used in print for the first time continuum. by Cattell Numerous specializations, including forensic psychology and health psychology (illustrated by the 1892 Lightner Witmer earns his doctoral degree inclusion of increasing numbers of clinical psychologists on primary health care teams), are flourishing. Empirical 1893 Emil Kraepelin proposes the early diagnostic support for clinical techniques, prescription privileges, category “dementia praecox” and new technologies (as described in Chapter 3) are 1896 Lightner Witmer opens the first psychological among the other major professional developments in clinic at the University of Pennsylvania recent years. 1905 Binet-Simon intelligence test is published in Timeline of Key Historical Events in Clinical Psychology France Year Event 1907 Lightner Witmer founds the first professional journal of clinical psychology, The 1796 William Tuke opens York Retreat in England Psychological Clinic 1801 Philippe Pinel publishes book on humane 1941 Psychology clinics proliferate; about 20 in treatment of mentally ill (MedicoPhilosophical operation Treatise on Mental Alienation or Mania) 1916 Stanford-Binet Intelligence Test (as translated 1824 Eli Todd opens The Retreat in Hartford, by Terman) is published in the United States Connecticut 1917 American Association of Clinical Psychologists 1840 U.S. Census Bureau lists one category of is founded 1921 Psychological Corporation is founded first ethical code 1921 Rorschach inkblot technique published 1955 Wechsler Adult Intelligence Scale (WAIS) published 1930s to Psychoanalysis dominates psychotherapy 1950s 1967 Wechsler Preschool and Primary Scale of Intelligence (WPPSI) published 1935 Thematic Apperception Test published 1968 DSM-II published 1935 Psychology clinics proliferate further; more than 150 in operation 1973 Vail conference held; yields PsyD and pra