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From Wikipedia, the free encyclopedia
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Clinical psychology is an integration of science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective and behavioural well-being and personal development.[1][2] Central to its practice are psychological assessment and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration.[3] In many countries, clinical psychology is regulated as a health care profession.

The field is often considered to have begun in 1896 with the opening of the first psychological clinic at the University of Pennsylvania by Lightner Witmer. In the first half of the 20th century, clinical psychology was focused on psychological assessment, with little attention given to treatment. This changed after the 1940s when World War II resulted in the need for a large increase in the number of trained clinicians. Since that time, two main educational models have developed—the Ph.D. scientist–practitioner model (requiring a doctoral dissertation and therefore research as well as clinical expertise) and, in the U.S. the Psy.D. practitioner–scholar model.

Clinical psychologists provide psychotherapy, psychological testing, and diagnosis of mental illness. They generally train within four primary theoretical orientations—psychodynamic, humanistic, behavior therapy/cognitive-behavioral, and systems or family therapy. Many continue clinical training in post-doctoral programs in which they might specialize in disciplines such as psychoanalytic approaches or child and adolescent treatment modalities.

History[edit]

Many 18th-century treatments for psychological distress were based on pseudo-scientific ideas, such as phrenology.

Although research in psychology is often dated to the opening of the first psychological laboratory by Wilhelm Wundt in 1879, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical, and/or medical perspectives.[4] Early examples of such physicians included Patañjali, Padmasambhava,[5] Rhazes, Avicenna,[6] and Rumi.[7]

In the early 19th century, one could have his or her head examined, literally, using phrenology, the study of personality by the shape of the skull. Other popular treatments included physiognomy—the study of the shape of the face—and mesmerism, Mesmer's treatment by the use of magnets. Spiritualism and Phineas Quimby's "mental healing" were also popular.[8]

While the scientific community eventually rejected these methods, academic psychologists also were not concerned with serious forms of mental illness. That area was already being addressed by the then-developing fields of psychiatry and neurology within the asylum movement.[4] It was not until the end of the 19th century, around the time when Sigmund Freud was first developing the recent idea of a "talking cure" in Vienna, that the first clinical applications of psychology began.[citation needed]

Early clinical psychology[edit]

Lightner Witmer, the father of modern clinical psychology

By the second half of the 1800s, the scientific study of psychology was becoming well established in university laboratories. Although there were a few scattered voices calling for an applied psychology, the general field looked down upon this idea and insisted on "pure" science as the only respectable practice.[4] This changed when Lightner Witmer (1867–1956), a past student of Wundt and head of the psychology department at the University of Pennsylvania, agreed to treat a young boy who had trouble with spelling. His successful treatment was soon to lead to Witmer's opening of the first psychological clinic at Penn in 1896, dedicated to helping children with learning disabilities.[9] Ten years later in 1907, Witmer was to found the first journal of this new field, The Psychological Clinic, where he coined the term "clinical psychology," which he defined as "the study of individuals, by observation or experimentation, with the intention of promoting change."[10] The field was slow to follow Witmer's example, but by 1914, there were 26 similar clinics in the US.[11]

Even as clinical psychology was growing, working with issues of serious mental distress remained the domain of psychiatrists and neurologists.[12] However, clinical psychologists continued to make inroads into this area due to their increasing skill at psychological assessment. Psychologists' reputation as assessment experts grew during World War I with the development of two intelligence tests, Army Alpha and Army Beta (testing verbal and nonverbal skills, respectively), which could be used to screen large groups of military recruits.[8][9] Due in large part to the success of these tests, assessment became the core function of clinical psychology for the next quarter century, when another war would propel the field into treatment.[citation needed]

Early professional organizations[edit]

The field began to organize under the name "clinical psychology" in 1917, when J. E. Wallace Wallin led the founding of the American Association of Clinical Psychology. This only lasted until 1919, after which the American Psychological Association (founded by G. Stanley Hall in 1892) developed a section on Clinical Psychology, which offered certification until 1927.[11] Growth in the field was slow for the next few years when various unconnected psychological organizations came together as the American Association of Applied Psychology in 1930, which would act as the primary forum for psychologists until after World War II when the APA reorganized.[13] In 1945, the APA created what is now called The Society of Clinical Psychology (Division 12), which remains a leading organization in the field. Psychological societies and associations in other English-speaking countries developed similar divisions, including in Britain, Canada, Australia and New Zealand.[citation needed]

World War II and the integration of treatment[edit]

The US army conducts a psychological test developed by clinical psychologists for selection purposes. The image is card IV of the Rorschach inkblot test.

When World War II broke out, the military once again called upon clinical psychologists. As soldiers began to return from combat, psychologists started to notice symptoms of psychological trauma labeled "shell shock" (eventually to be termed posttraumatic stress disorder) that were best treated as soon as possible.[9] Because physicians (including psychiatrists) were over-extended in treating bodily injuries, psychologists were called to help treat this condition.[14] At the same time, female psychologists (who were excluded from the war effort) formed the National Council of Women Psychologists with the purpose of helping communities deal with the stresses of war and giving young mothers advice on child rearing.[10] After the war, the Veterans Administration in the US made an enormous investment to set up programs to train doctoral-level clinical psychologists to help treat the thousands of veterans needing care. As a consequence, the US went from having no formal university programs in clinical psychology in 1946 to over half of all Ph.D.s in psychology in 1950 being awarded in clinical psychology.[10]

WWII helped bring dramatic changes to clinical psychology, not just in America but internationally as well. Graduate education in psychology began adding psychotherapy to the science and research focus based on the 1947 scientist–practitioner model, known today as the Boulder Model, for Ph.D. programs in clinical psychology.[15] Clinical psychology in Britain developed much like in the U.S. after WWII, specifically within the context of the National Health Service[16] with qualifications, standards, and salaries managed by the British Psychological Society.[17]

Development of the Doctor of Psychology degree[edit]

Despite some resistance from psychiatrists, psychotherapy became a part of clinical psychologists' practice in the US.[18] However, for many the Ph.D. educational model did not offer the necessary training for those interested in practice rather than research. There was a growing argument that said the field of psychology in the US had developed to a degree warranting explicit training in clinical practice. The concept of a practice-oriented degree was debated in 1965 and narrowly gained approval for a pilot program at the University of Illinois starting in 1968.[19] Several other similar programs were instituted soon after, and in 1973, at the Vail Conference on Professional Training in Psychology, the Practitioner–Scholar Model of Clinical Psychology—or Vail Model—resulting in the Doctor of Psychology (Psy.D.) degree was recognized.[20] Although training would continue to include research skills and a scientific understanding of psychology, the intent would be to produce highly trained professionals, similar to programs in medicine, dentistry, and law. The longest-running PsyD programs are Widener University[21] (1970),[a] Baylor University[22] (1971); and Rutgers University[23] (1973).[19] Today, about half of all American graduate students in clinical psychology are enrolled in Psy.D. programs.[20]

A changing profession[edit]

Since the 1970s, clinical psychology has continued growing into a robust profession and academic field of study. Although the exact number of practicing clinical psychologists is unknown, it is estimated that between 1974 and 1990, the number in the US grew from 20,000 to 63,000.[24] Clinical psychologists continue to be experts in assessment and psychotherapy while expanding their focus to address issues of gerontology, sports, and the criminal justice system to name a few. One important field is health psychology, the fastest-growing employment setting for clinical psychologists in the past decade.[8] Other major changes include the impact of managed care on mental health care; an increasing realization of the importance of knowledge relating to multicultural and diverse populations; and emerging privileges to prescribe psychotropic medication. Approximately 20% of clinical health psychologists identify themselves as counseling psychologists as well.[25]

In the UK psychology is now one of the most popular degree subjects, and over 15,000 people graduate in psychology each year, many with the hope of developing this into a career, although only around 600 places for doctoral training in clinical psychology means there is intense competition for these places.[26][27] There is also fierce competition to get into US Ph.D. programs in clinical psychology, with an average acceptance rate of 8%.[28]

Professional practice[edit]

Clinical psychologists can offer a range of professional services, including:[10]

  • Administer and interpret psychological assessment and testing
  • Conduct psychological research
  • Consultation (especially for multi-disciplinary teams in mental health settings, such as psychiatric wards and increasingly other healthcare settings, schools and businesses)
  • Development of prevention and treatment programs
  • Program administration
  • Provide expert testimony (forensic psychology)
  • Provide psychological/ mental treatment (psychotherapy, or/and psychopharmacology "prescribing psychologists")
  • Teach

In practice, clinical psychologists may work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies. Most clinical psychologists who engage in research and teaching do so within a college or university setting. Clinical psychologists may also choose to specialize in a particular field—common areas of specialization, some of which can earn board certification,[29] include:

The latest proceedings from psychology professors, aggregated from across several institutions have been published and is available here. This represents both European and US perspectives from the academic world.

Salary and employment of clinical psychologists[edit]

In 2009, the APA estimated that the median full-time salary for licensed doctoral-level clinical psychologists in the United States was $87,015.[30] According to the US Bureau of Labor Statistics the median salary of US clinical psychologists was $67,650 in 2012.[31] As of 2008 approximately 34% of psychologists were self-employed, mostly in private practices.[32]

Employment for the field of clinical psychology is anticipated to grow 11% from 2012 to 2022 which is similar to growth for all other professions.[31] Doctoral degree holders from a leading university in an applied specialty will face the best prospects. M.A. degree holders will face keen competition for jobs while there will be very limited positions for those with B.A. degrees in the field of psychology.[33] Average doctoral starting and post-doctoral salaries range from $25,000–90,000.[citation needed]

Training and certification to practice[edit]

The University of Pennsylvania was the first to offer formal education in clinical psychology.

Clinical psychologists study a generalist program in psychology plus postgraduate training and/or clinical placement and supervision. The length of training differs across the world, ranging from four years plus post-Bachelors supervised practice[34] to a doctorate of three to six years which combines clinical placement.[35]

In the US, clinical psychology doctoral programs typically range from five to seven years post-college and require a one year full-time clinical internship and dissertation. There is currently an "internship crisis" in the field (see below). Graduates must also accrue 1–2 years of supervised training post-Ph.D. before licensure in most states (3,000 hours) and need to pass the EPPP (plus, other state exams). About half of all clinical psychology graduate students are being trained in Ph.D. programs—a model that emphasizes research—with the other half in Psy.D. programs, which has more focus on practice (similar to professional degrees for medicine and law).[20] Both models are accredited by the American Psychological Association[36] and many other English-speaking psychological societies. A smaller number of schools offer accredited programs in clinical psychology resulting in a Masters degree, which usually take two to three years post-Bachelors. In a 2009 survey, median debt related to doctoral education in clinical psychology was $68,000 for clinical Ph.D. recipients and $120,000 for clinical Psy.D. recipients.[37]

In the UK, clinical psychologists undertake a Doctor of Clinical Psychology (D.Clin.Psych.), which is a practitioner doctorate with both clinical and research components. This is a three-year full-time salaried program sponsored by the National Health Service (NHS) and based in universities and the NHS. Entry into these programs is highly competitive, and requires at least a three-year undergraduate degree in psychology plus some form of experience, usually in either the NHS as an Assistant Psychologist or in academia as a Research Assistant. It is not unusual for applicants to apply several times before being accepted onto a training course as only about one-fifth of applicants are accepted each year.[38] These clinical psychology doctoral degrees are accredited by the British Psychological Society and the Health Professions Council (HPC). The HPC is the statutory regulator for practitioner psychologists in the UK. Those who successfully complete clinical psychology doctoral degrees are eligible to apply for registration with the HPC as a clinical psychologist.[citation needed]

The practice of clinical psychology requires a license in the United States, Canada, the United Kingdom, and many other countries. Although each of the US states is somewhat different in terms of requirements and licenses, there are three common elements:[39]

  1. Graduation from an accredited school with the appropriate degree
  2. Completion of supervised clinical experience or internship
  3. Passing a written examination and, in some states, an oral examination

All US state and Canadian province licensing boards are members of the Association of State and Provincial Psychology Boards (ASPPB) which created and maintains the Examination for Professional Practice in Psychology (EPPP). Many states require other examinations in addition to the EPPP, such as a jurisprudence (i.e. mental health law) examination and/or an oral examination.[39] Most states also require a certain number of continuing education credits per year in order to renew a license, which can be obtained though various means, such as taking audited classes and attending approved workshops. Clinical psychologists require the psychologist license to practice, although licenses can be obtained with a masters-level degree, such as Marriage and Family Therapist (MFT), Licensed Professional Counselor (LPC), and Licensed Psychological Associate (LPA).[40]

In the UK, registration as a clinical psychologist with the Health Professions Council (HPC) is necessary. The HPC is the statutory regulator for practitioner psychologists in the UK. In the UK the following titles are restricted by law: "registered psychologist" and "practitioner psychologist"; in addition, the specialist title "clinical psychologist" is also restricted by law.[citation needed]

Internship crisis in US clinical psychology programs[edit]

In the US, clinical psychology Ph.D. and Psy.D. programs typically require students to complete a one-year full-time (or two-year part-time) clinical internship in order to graduate. However, there is currently an "internship crisis" as defined by the American Psychological Association, in that approximately 25% of clinical psychology doctoral students are unable to find an internship each year, and only 50% are able to attend an APA-accredited internship.[41] This crisis has led to many students (approximately 1,000 each year) re-applying for internship the following year (thus delaying graduation) or completing an unaccredited internship, both of which can have emotional and financial consequences.[42] This internship crisis stems from an increase in the production of psychology students. A recent study found that ~30% of unmatched students stem from 15 degree programs, representing only 4% of all programs participating in the internship match. These programs enrolled larger cohorts of students than average and 14 of the 15 were PsyD programs. All but one was APA accredited.[43] The authors argue that it would be futile to simply increase internship slots. Internship slots already have increased over the years and as internship slots have increased, these schools increase production. Students who do not complete an APA-accredited internship are barred from certain employment settings, such as with the VA Hospitals, and may not be able to get licensed in some states.[44] Additionally, the majority of post-doctoral fellowships and other employment settings require or prefer the completion of an APA-accredited internship.[44] The median rate of applicants accepted by APA-accredited internship sites is 5.5%[45] and the median internship stipend was $24,218 in 2011.[46]

Assessment[edit]

An important area of expertise for many clinical psychologists is assessment, and there are indications that as many as 91% of psychologists utilize this core clinical practice.[47] Such evaluations are usually conducted in order to gain insight into, and form hypotheses about, psychological or behavioral problems. As such, the results of these assessments are often used to clarify a person's diagnosis and assist in planning treatments or arranging for services. Methods used to gather information include formal tests, clinical interviews, reviews of past records, and behavioral observations.[2]

There exist literally hundreds of various assessment tools, although only a few have been shown to have both high statistical validity (i.e., test actually measures what it claims to measure) and reliability (i.e., consistency). These measures generally fall within one of several categories, including the following:

  • Intelligence & achievement tests – These tests are designed to measure certain aspects of cognitive functioning (often referred to as IQ) in comparison to a group of people with similar characteristics (such as age or education). These tests, including the WISC-IV and WAIS-IV, attempt to measure traits such as general knowledge, verbal comprehension, working memory, attention/concentration, logical reasoning, and visual/spatial perception.[47] Several of these tests have been shown to accurately predict scholastic achievement and occupational performance, and help to identify a person's cognitive strengths and weaknesses.[47]
  • Personality tests – These tests aim to describe patterns of behavior, thoughts, and feelings, and generally fall within two categories: objective and projective. Objective measures, such as the MMPI-2 or the MCMI-III, are based on forced-choice responses—such as yes/no, true/false, or a rating scale—and generate scores that can be compared to a normative group. Projective tests, such as the Rorschach inkblot test, use open-ended responses, often based on ambiguous stimuli, to reveal non-conscious psychological dynamics such as motivations and perceptions of the self and the world.[47]
  • Neuropsychological tests - Tests in this category are often used to evaluate a person's cognitive functioning and its relationship to a person's behavior or psychological functioning.[48] They are used in a variety of settings, for purposes such as clarifying a diagnosis (especially in distinguishing between psychiatric and neurological symptoms), better understanding the impact of a person's neurological condition on their behavior, treatment planning (especially in rehabilitation settings), and for legal questions, such as determining if a person is faking their symptoms (also referred to as malingering) or if they are capable to stand trial.[48]
  • Clinical interviews – Clinical psychologists are also trained to gather data by observing behavior and collecting detailed histories. The clinical interview is a vital part of assessment, even when using other formalized measures, as it provides a context in which to understand test results. Psychologists can employ a structured format (such as the SCID or the MMSE), a semi-structured format (such as a sequence of questions) or an unstructured format to gather information about a person's symptoms and past and present functioning.[47] Such assessments often include evaluations of general appearance and behavior, mood and affect, perception, comprehension, orientation, memory, thought process, and/or communication.[47]

Diagnostic impressions[edit]

See also: Mental disorder

After assessment, clinical psychologists often provide a diagnostic impression. Many countries use the International Statistical Classification of Diseases and Related Health Problems (ICD-10) while the US most often uses the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Both utilize medical concepts and terms, and state that there are categorical disorders that can be diagnosed by set lists of descriptive criteria.[49] Several new models are being discussed, including a "dimensional model" based on empirically validated models of human differences (such as the five factor model of personality[49][50] and a "psychosocial model," which would place greater emphasis on changing, intersubjective states.[51] In fact, the DSM-5, which is still being edited, will be using a dimensional approach.[52] The proponents of these models claim that they would offer greater diagnostic flexibility and clinical utility without depending on the medical concept of illness. However, they also admit that these models are not yet robust enough to gain widespread use, and should continue to be developed.[citation needed] Some clinical psychologists prefer not to use diagnoses and instead use clinical formulations—an individualized map of the strengths and difficulties that the patient or client faces, with an emphasis on predisposing, precipitating and perpetuating (maintaining) factors.[53]

Clinical theories and interventions[edit]

Clinical psychologists work with individuals, children, families, couples, or small groups.
Main article: Psychotherapy

Psychotherapy involves a formal relationship between professional and client—usually an individual, couple, family, or small group—that employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving.[2][54]

Clinicians have a wide range of individual interventions to draw from, often guided by their training—for example, a cognitive behavioral therapy (CBT) clinician might use worksheets to record distressing cognitions, a psychoanalyst might encourage free association, while a psychologist trained in Gestalt techniques might focus on immediate interactions between client and therapist. Clinical psychologists generally seek to base their work on research evidence and outcome studies as well as on trained clinical judgment. Although there are literally dozens of recognized therapeutic orientations, their differences can often be categorized on two dimensions: insight vs. action and in-session vs. out-session.[10]

  • Insight – emphasis is on gaining greater understanding of the motivations underlying one's thoughts and feelings (e.g. psychodynamic therapy)[citation needed]
  • Action – focus is on making changes in how one thinks and acts (e.g. solution-focused therapy, cognitive behavioral therapy)[citation needed]
  • In-session – interventions center on the here-and-now interaction between client and therapist (e.g. humanistic therapy, Gestalt therapy)[citation needed]
  • Out-session – a large portion of therapeutic work is intended to happen outside of session (e.g. bibliotherapy, rational emotive behavior therapy)[citation needed]

The methods used are also different in regards to the population being served as well as the context and nature of the problem. Therapy will look very different between, say, a traumatized child, a depressed but high-functioning adult, a group of people recovering from substance dependence, and a ward of the state suffering from terrifying delusions. Other elements that play a critical role in the process of psychotherapy include the environment, culture, age, cognitive functioning, motivation, and duration (i.e. brief or long-term therapy).[54][55]

Four main schools[edit]

The field is dominated in terms of training and practice by essentially four major schools of practice: psychodynamic, humanistic, behavioral/cognitive behavioral, and systems or family therapy.[2]

Psychodynamic[edit]

The psychodynamic perspective developed out of the psychoanalysis of Sigmund Freud. The core object of psychoanalysis is to make the unconscious conscious—to make the client aware of his or her own primal drives (namely those relating to sex and aggression) and the various defenses used to keep them in check.[54] The essential tools of the psychoanalytic process are the use of free association and an examination of the client's transference towards the therapist, defined as the tendency to take unconscious thoughts or emotions about a significant person (e.g. a parent) and "transfer" them onto another person. Major variations on Freudian psychoanalysis practiced today include self psychology, ego psychology, and object relations theory. These general orientations now fall under the umbrella term psychodynamic psychology, with common themes including examination of transference and defenses, an appreciation of the power of the unconscious, and a focus on how early developments in childhood have shaped the client's current psychological state.[54]

Humanistic[edit]

Main article: Humanistic psychology

Humanistic psychology was developed in the 1950s in reaction to both behaviorism and psychoanalysis, largely due to the person-centered therapy of Carl Rogers (often referred to as Rogerian Therapy) and existential psychology developed by Viktor Frankl and Rollo May.[2] Rogers believed that a client needed only three things from a clinician to experience therapeutic improvement: congruence, unconditional positive regard, and empathetic understanding.[56] By using phenomenology, intersubjectivity and first-person categories, the humanistic approach seeks to get a glimpse of the whole person and not just the fragmented parts of the personality.[57] This aspect of holism links up with another common aim of humanistic practice in psychotherapy, which is to seek an integration of the whole person, also called self-actualization. According to humanistic thinking,[58] each individual person already has inbuilt potentials and resources that might help them to build a stronger personality and self-concept. The mission of the humanistic psychologist is to help the individual employ these resources via the therapeutic relationship.[citation needed]

Behavioral and cognitive behavioral[edit]

Cognitive behavioral therapy (CBT) developed from the combination of cognitive therapy and rational emotive behavior therapy, both of which grew out of cognitive psychology and behaviorism. CBT is based on the theory that how we think (cognition), how we feel (emotion), and how we act (behavior) are related and interact together in complex ways. In this perspective, certain dysfunctional ways of interpreting and appraising the world (often through schemas or beliefs) can contribute to emotional distress or result in behavioral problems. The object of many cognitive behavioral therapies is to discover and identify the biased, dysfunctional ways of relating or reacting and through different methodologies help clients transcend these in ways that will lead to increased well-being.[59] There are many techniques used, such as systematic desensitization, socratic questioning, and keeping a cognition observation log. Modified approaches that fall into the category of CBT have also developed, including dialectical behavior therapy and mindfulness-based cognitive therapy.[60]

Behavior therapy is a rich tradition. It is well-researched with a strong evidence base. Its roots are in behaviorism. In behavior therapy, environmental events predict the way we think and feel. Our behavior sets up conditions for the environment to feed back on it. Sometimes the feedback leads the behavior to increase (reinforcement), and sometimes the behavior decreases (punishment). Often behavior therapists are called applied behavior analysts. They have studied many areas from developmental disabilities to depression and anxiety disorders. In the area of mental health and addictions a recent article looked at APA's list for well-established and promising practices and found a considerable number of them based on the principles of operant and respondent conditioning.[61] Multiple assessment techniques have come from this approach including functional analysis (psychology), which has found a strong focus in the school system. In addition, multiple intervention programs have come from this tradition including community reinforcement approach and family training for treating addictions, acceptance and commitment therapy, functional analytic psychotherapy, integrative behavioral couples therapy including dialectical behavior therapy and behavioral activation. In addition, specific techniques such as contingency management and exposure therapy have come from this tradition.[citation needed]

Systems or family therapy[edit]

Main article: Family therapy

Systems or family therapy works with couples and families, and emphasizes family relationships as an important factor in psychological health. The central focus tends to be on interpersonal dynamics, especially in terms of how change in one person will affect the entire system.[62] Therapy is therefore conducted with as many significant members of the "system" as possible. Goals can include improving communication, establishing healthy roles, creating alternative narratives, and addressing problematic behaviors. Contributors include John Gottman, Jay Haley, Sue Johnson, and Virginia Satir.[citation needed]

Other major therapeutic orientations[edit]

There exist dozens of recognized schools or orientations of psychotherapy—the list below represents a few influential orientations not given above. Although they all have some typical set of techniques practitioners employ, they are generally better known for providing a framework of theory and philosophy that guides a therapist in his or her working with a client.

  • ExistentialExistential psychotherapy postulates that people are largely free to choose who we are and how we interpret and interact with the world. It intends to help the client find deeper meaning in life and to accept responsibility for living. As such, it addresses fundamental issues of life, such as death, aloneness, and freedom. The therapist emphasizes the client's ability to be self-aware, freely make choices in the present, establish personal identity and social relationships, create meaning, and cope with the natural anxiety of living.[63] Important writers in existential therapy include Rollo May, Viktor Frankl, James Bugental, and Irvin Yalom.[citation needed]

One influential therapy that came out of existential therapy is Gestalt therapy, primarily founded by Fritz Perls in the 1950s. It is well known for techniques designed to increase various kinds of self-awareness—the best-known perhaps being the "empty chair technique"—which are generally intended to explore resistance to "authentic contact," resolve internal conflicts, and help the client complete "unfinished business."[64]

  • Postmodern – Postmodern psychology says that the experience of reality is a subjective construction built upon language, social context, and history, with no essential truths.[65] Since "mental illness" and "mental health" are not recognized as objective, definable realities, the postmodern psychologist instead sees the goal of therapy strictly as something constructed by the client and therapist.[66] Forms of postmodern psychotherapy include narrative therapy, solution-focused therapy, and coherence therapy.[citation needed]

Other perspectives[edit]

  • Multiculturalism – Although the theoretical foundations of psychology are rooted in European culture, there is a growing recognition that there exist profound differences between various ethnic and social groups and that systems of psychotherapy need to take those differences into greater consideration.[55] Further, the generations following immigrant migration will have some combination of two or more cultures—with aspects coming from the parents and from the surrounding society—and this process of acculturation can play a strong role in therapy (and might itself be the presenting problem). Culture influences ideas about change, help-seeking, locus of control, authority, and the importance of the individual versus the group, all of which can potentially clash with certain givens in mainstream psychotherapeutic theory and practice.[68] As such, there is a growing movement to integrate knowledge of various cultural groups in order to inform therapeutic practice in a more culturally sensitive and effective way.[69]
  • FeminismFeminist therapy is an orientation arising from the disparity between the origin of most psychological theories (which have male authors) and the majority of people seeking counseling being female. It focuses on societal, cultural, and political causes and solutions to issues faced in the counseling process. It openly encourages the client to participate in the world in a more social and political way.[70]
  • Positive psychologyPositive psychology is the scientific study of human happiness and well-being, which started to gain momentum in 1998 due to the call of Martin Seligman,[71] then president of the APA. The history of psychology shows that the field has been primarily dedicated to addressing mental illness rather than mental wellness. Applied positive psychology's main focus, therefore, is to increase one's positive experience of life and ability to flourish by promoting such things as optimism about the future, a sense of flow in the present, and personal traits like courage, perseverance, and altruism.[72][73] There is now preliminary empirical evidence to show that by promoting Seligman's three components of happiness—positive emotion (the pleasant life), engagement (the engaged life), and meaning (the meaningful life) —positive therapy can decrease clinical depression.[74]

Integration[edit]

In the last couple of decades, there has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of cultural, gender, spiritual, and sexual-orientation issues. Clinical psychologists are beginning to look at the various strengths and weaknesses of each orientation while also working with related fields, such as neuroscience, genetics, evolutionary biology, and psychopharmacology. The result is a growing practice of eclecticism, with psychologists learning various systems and the most efficacious methods of therapy with the intent to provide the best solution for any given problem.[75]

Telehealth[edit]

See also: Telehealth

Using communication technology in therapy situations, (telehealth) specifically Web based technology, is becoming more prominent within the clinical psychology field.[76] There have been noted benefits for interventions using web based technology, specifically those using web cameras; among the benefits are: circumventing stigmas of attending mental health facilities, avoiding time and travel concerns, and allowing those in areas isolated from mental health professionals to receive therapy.[76] Additionally, those individuals with severe anxiety disorders which generate avoidance behaviors may prefer an online setting to a physical setting.[76] For all the benefits of online therapy there are certain logistical issues such as reimbursement, licensing and jurisdiction.[76] Additionally, there is the concern that an online interaction versus a face to face interaction might devalue the bond between therapist and client.[76] However, a recent study measuring the opinions of licensed psychologists and doctoral students suggests that attitudes towards telehealth are moving in a more favorable direction.[76] Specifically, the current and future psychologists were interested in web camera based therapeutic interventions for those dealing with depressive or anxiety disorders.[76]

Professional ethics[edit]

The field of clinical psychology in most countries is strongly regulated by a code of ethics. In the US, professional ethics are largely defined by the APA Code of Conduct, which is often used by states to define licensing requirements. The APA Code generally sets a higher standard than that which is required by law as it is designed to guide responsible behavior, the protection of clients, and the improvement of individuals, organizations, and society.[77] The Code is applicable to all psychologists in both research and applied fields. The APA Code is based on five principles: Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and Respect for People's Rights and Dignity.[77] Detailed elements address how to resolve ethical issues, competence, human relations, privacy and confidentiality, advertising, record keeping, fees, training, research, publication, assessment, and therapy.[citation needed]

The BPS Code of Ethics and Conduct similarly sets a high standard for psychologist. It is based on four principles: respect, competence, responsibility and integrity.[78]

Comparison with other mental health professions[edit]

Psychiatry[edit]

Fluoxetine hydrochloride, branded by Lilly as Prozac, is a common antidepressant drug prescribed by psychiatrists. There is a small but growing movement to give prescription privileges to qualified psychologists.[citation needed]

Although clinical psychologists and psychiatrists can be said to share a same fundamental aim—the treatment of mental disorders—their training, outlook, and methodologies are often quite different. Perhaps the most significant difference is that psychiatrists are licensed physicians. As such, psychiatrists often use the medical model to assess psychological problems (i.e., those they treat are seen as patients with an illness) and rely on psychotropic medications as the chief method of addressing the illness[79]—although many employ psychotherapy as well. Psychiatrists and medical psychologists (who are clinical psychologists that are also licensed to prescribe) are able to conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT; MRI; and PET scanning.[citation needed]

Clinical psychologists generally do not prescribe medication, although there is a movement for psychologists to have prescribing privileges.[80] These medical privileges require additional training and education. To date, medical psychologists may prescribe psychotropic medications in Guam, New Mexico, and Louisiana, as well as United States military psychologists.[81] Psychologists usually receive more thorough training in research methods, psychological assessment, and psychotherapeutic treatment, compared with psychiatrists.[citation needed]

Counseling psychology[edit]

Counseling psychologists study and use many of the same interventions and tools as clinical psychologists, including psychotherapy and assessment. Traditionally, counseling psychologists help people with what might be considered normal or moderate psychological problems—such as the feelings of anxiety or sadness resulting from major life changes or events.[3][10] Many counseling psychologists also receive specialized training in career assessment, group therapy, and relationship counseling, although some counseling psychologists also work with the more serious problems that clinical psychologists are trained for, such as dementia or psychosis.[citation needed]

There are fewer counseling psychology graduate programs than those for clinical psychology and they are more often housed in departments of education rather than psychology. The two professions can be found working in all the same settings but counseling psychologists are more frequently employed in university counseling centers compared to hospitals and private practice for clinical psychologists.[82]

School psychology[edit]

Comparison of mental health professionals in USA
Occupation Degree Common Licenses Prescription Privilege Ave. 2004
Income (USD)
Clinical Psychologist PhD/PsyD Psychologist Mostly no $75,000
Counseling Psychologist (Doctorate) PhD MFT/LPC No $65,000
Counseling Psychologist (Master's) MA/MS/MC MFT/LPC/LPA No $49,000
School Psychologist PhD, EdD Psychologist No $78,000
Psychiatrist MD/DO Psychiatrist Yes $145,600
Clinical Social Worker PhD/MSW LCSW No $36,170
Psychiatric Nurse PhD/MSN/BSN APRN/PMHN No $53,450
Psychiatric and mental health Nurse Practitioner DNP/MSN MHNP Yes (Varies by state) $75,711
Expressive/Art Therapist MA ATR No $45,000

School psychologists are primarily concerned with the academic, social, and emotional well-being of children and adolescents within a scholastic environment. In the UK, they are known as "educational psychologists." They typically hold a master's degree.[citation needed] Like clinical psychologists, school psychologists with doctoral degrees are eligible for licensure as health service psychologists, and many work in private practice. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning. Common degrees include the Educational Specialist Degree (Ed.S.), Doctor of Philosophy (Ph.D.), and Doctor of Education (Ed.D.).[citation needed]

Traditional job roles for school psychologists employed in school settings have focused mainly on assessment of students to determine their eligibility for special education services in schools, and on consultation with teachers and other school professionals to design and carry out interventions on behalf of students. Other major roles also include offering individual and group therapy with children and their families, designing prevention programs (e.g. for reducing dropout), evaluating school programs, and working with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically.[89][90]

Clinical social work[edit]

Social workers provide a variety of services, generally concerned with social problems, their causes, and their solutions. With specific training, clinical social workers may also provide psychological counseling (in the US and Canada), in addition to more traditional social work. The Masters in Social Work in the US is a two-year, sixty credit program that includes a practicum each year, totaling at least 900 hours.[91] The requirements to become a Licensed Clinical Social Worker, which offers similar privileges to that of a psychologist, vary by state. The requirements in NY, for example, include a Master's Degree in Social Work from an accredited graduate school that includes course hours in clinical coursework, 2000 post-graduate, practice hours directly with clients at an approved site providing "diagnosis, psychotherapy and assessment-based treatment planning" under the supervision of a qualified psychiatrit, clinical psychologist, or LCSW; the experience hours must be accumulated over a minimum of 3 years & cannot exceed 6 years, and there is an additional minimum of 60 minutes each week for supervision meeting. After meeting the educational, experience, and supervision requirements, the candidate must pass a written exam demonstrating clinical knowledge and ethical responsibility.[92]

Occupational therapy[edit]

Occupational therapy—often abbreviated OT—is the "use of productive or creative activity in the treatment or rehabilitation of physically, cognitively, or emotionally disabled people."[93] Most commonly, occupational therapists work with people with disabilities to enable them to maximize their skills and abilities. Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the physical, emotional, psychological, sociocultural, cognitive and environmental components of illness and injury. They commonly work alongside clinical psychologists in settings such as inpatient and outpatient mental health, pain management clinics, eating disorder clinics, and child development services. OT's use support groups, individual counseling sessions, and activity-based approaches to address psychiatric symptoms and maximize functioning in life activities. In chronic pain management, occupational therapists use the common cognitive behavioral therapy approach, often incorporating cognitive behavioral therapy techniques and helping clients generalize or integrate their pain management strategies into their lives. In this way, occupational therapists both support and extend the work that clinical psychologists carry out in a clinical setting.[94]

Criticisms and controversies[edit]

Clinical psychology is a diverse field and there have been recurring tensions over the degree to which clinical practice should be limited to treatments supported by empirical research.[95] Despite some evidence showing that all the major therapeutic orientations are about of equal effectiveness,[96][97] there remains much debate about the efficacy of various forms treatment in use in clinical psychology.[98]

It has been reported that clinical psychology has rarely allied itself with client groups and tends to individualize problems to the neglect of wider economic, political and social inequality issues that may not be the responsibility of the client.[95] It has been argued that therapeutic practices are inevitably bound up with power inequalities, which can be used for good and bad.[99] A critical psychology movement has argued that clinical psychology, and other professions making up a "psy complex," often fail to consider or address inequalities and power differences and can play a part in the social and moral control of disadvantage, deviance and unrest.[100][101]

An October 2009 editorial in the journal Nature suggests that a large number of clinical psychology practitioners in the United States consider scientific evidence to be "less important than their personal—that is, subjective—clinical experience."[102]

Clinical psychology journals[edit]

Cover of The Psychological Clinic, the first journal of clinical psychology, published in 1907 by Lightner Witmer

The following represents an (incomplete) listing of significant journals in or related to the field of clinical psychology.[citation needed]

See also a list of empirical journals published by the APA[105]

Major influences[edit]

[citation needed]

See also[edit]

Footnotes[edit]

  1. ^ Originally located at Hahnemann Medical College (now Drexel University College of Medicine) and moved to Widener University in 1989.

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