Clinical Psychology - History, Directions, Schools, Methods, Salaries

Clinical psychology represents an integration of the humanities, behavioral science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically based distress or dysfunction, and of promoting subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.

Clinical psychology is a branch of psychological knowledge that closely connects psychology with a whole range of natural, humanitarian, and even technical sciences. In choosing this specialization, a psychologist masters a competency model of a specialist whose subject-matter activity lies in the fields of medicine, education, emergency response units, law enforcement agencies, and social support. The leading goal of a clinical psychologist's activity is the prevention and overcoming of personal maladjustment.

The object of clinical psychology is a person with difficulties in adaptation and self-realization connected to their physical, social, and psychological condition.

The subject of a clinical psychologist's professional activity is the mechanisms, factors, and conditions that determine the success of adaptation and self-realization, the specifics of the course of adaptation, habilitation, and rehabilitation of a person experiencing difficulties in functioning and development connected to their physical, social, and/or psychological condition.

The term "clinical psychology" comes from the Greek "kline" – "bed," "hospital bed." Based on this understanding, clinical psychology is often used to refer to any psychological knowledge obtained in a clinical setting (or connected to medicine or a medical institution), or the methods that are applied in the clinic (in medicine). In modern psychology, the terms "clinical" and "medical" are very often used as synonyms. It's worth noting that there is a tradition among physicians of referring to this field of knowledge as medical psychology, while psychologists call it clinical psychology

History

The earliest recorded approaches to the assessment and treatment of mental disorders were a combination of religious, magical, and/or medical viewpoints.

Although the scientific community eventually rejected all these treatments for mental illness, academic psychologists were also not interested in serious forms of mental illness. The study of mental illness was already being carried out in the developing fields of psychiatry and neurology within the asylum movement.

Many 18th-century treatments for psychological disorders were based on pseudoscientific ideas such as phrenology.

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

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

Early clinical psychology

By the second half of the 1800s, scientific psychological research was firmly established in university laboratories. Although a few scattered voices called for applied psychology, this idea was generally looked down upon, with an insistence on "pure" science as the only respectable practice.

Even as clinical psychology developed, working with serious mental disorders remained the prerogative of psychiatrists and neurologists.

Early professional organizations

The field began to take shape under the name "clinical psychology" in 1917 with the founding of the American Association of Clinical Psychology. This lasted only until 1919, after which the American Psychological Association (founded by G. Stanley Hall in 1892) developed a clinical psychology section, which offered certification until 1927.

World War II and the integration of treatment

When World War II broke out, the military again turned to clinical psychologists. When soldiers began returning from combat, psychologists started noticing symptoms of psychological trauma known as "shell shock" (later renamed post-traumatic stress disorder), which were best treated as soon as possible.

World War II contributed to fundamental changes in clinical psychology not only in America but around the world. Graduate education in psychology began adding psychotherapy to scientific and research training, based on the 1947 scientist-practitioner model, known today as the Boulder Model, for doctoral programs in clinical psychology.

Development of the Doctor of Psychology degree

By the 1960s, psychotherapy had become an integral part of clinical psychology, but for many, the PhD educational model did not offer the training needed by those interested in practice rather than research. There was a growing opinion that the field of psychology in the US had developed to the point where it required thorough training in clinical practice. The concept of a practice-oriented degree was discussed in 1965 and received approval for a pilot program at the University of Illinois starting in 1968.

A changing profession

Since the 1970s, clinical psychology has continued to develop into a solid profession and academic field of research. Although the exact number of practicing clinical psychologists is unknown, it is estimated that between 1974 and 1990 their number in the US grew from 20,000 to 63,000.

Professional practice

Clinical psychologists engage in a wide range of activities. Some focus exclusively on research into the assessment, treatment, or causes of mental illness and related conditions. Some teach, whether at a medical school or hospital, or in an academic department (e.g., a psychology department) at a higher education institution. Most clinical psychologists engage in some form of clinical practice, providing professional services including psychological assessment, psychotherapy, the development and administration of clinical programs, and forensic examination (e.g., providing expert testimony in court proceedings).

In clinical practice, clinical psychologists may work with individuals, couples, families, or groups in a variety of settings, including private practice, hospitals, mental health organizations, schools, businesses, and non-profit agencies. Clinical psychologists providing clinical services may also choose to specialize. Some specializations are codified and certified by the regulatory bodies of the country of practice.

Training and certification for practice

Clinical psychologists study a general psychology program plus graduate training and/or clinical placement and supervision. The length of training varies around the world: from four years plus supervised practice after obtaining a bachelor's degree.

In the United Kingdom, clinical psychologists earn a Doctorate in Clinical Psychology (DClinPsych), which is a practicing doctoral degree that includes both clinical and research components. It is a three-year, full-time paid program sponsored by the National Health Service (NHS) and based at universities and the NHS. Admission to these programs is highly competitive and requires at least a three-year bachelor's degree in psychology plus some work experience, usually either in the National Health Service as an assistant psychologist or in academia as a research assistant. Candidates often apply several times before being admitted to a course, since only about one-fifth of applicants are accepted each year.

The practice of clinical psychology requires a license in the US, Canada, the UK, and many other countries. Although each US state differs somewhat in terms of requirements and licenses, there are three common elements:

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

All state and provincial licensing boards in the US are members of the Association of State and Provincial Psychology Boards (ASPPB), which created and maintains the Examination for Professional Practice in Psychology (EPPP). In many states, in addition to the EPPP, other exams are required, such as a jurisprudence exam (i.e., mental health law) and/or an oral exam.

In the UK, registration of a clinical psychologist with the Health Professions Council (HPC) is required. The HPC is the official regulatory body for practicing 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.

Assessment

Areas of measurement

Psychological measures usually fall into one of several categories, including the following:

• Personality tests. The purpose of personality tests is to describe patterns of behavior, thoughts, and feelings. They are usually divided into two categories: objective and projective. Objective measures, such as the MMPI, are based on limited responses such as yes/no, true/false, or a rating scale, which allow scores to be calculated that can be compared to a normative group. Projective tests, such as the Rorschach inkblot test, allow open-ended responses, often based on ambiguous stimuli. Other commonly used personality assessment measures include the PAI and NEO.
• Neuropsychological tests. Neuropsychological tests consist of specially designed tasks used to measure psychological functions known to be associated with a particular brain structure or pathway. They are commonly used to assess impairments following injury or illness known to affect neurocognitive function, or when used in research to compare neuropsychological abilities across experimental groups.
• Diagnostic measurement instruments. Clinical psychologists can diagnose psychological disorders and related conditions listed in the DSM-5 and ICD-10. Many assessment tests have been developed to complement clinicians' clinical observation and other assessment activities. Some of these include the SCID-IV, the MINI, and some specific to particular psychological disorders, such as the CAPS-5 for trauma, and the ASEBA and K-SADS for affective disorders and schizophrenia in children.

Diagnostic impressions

Clinical versus mechanical prediction

What came to be called the debate over "clinical versus statistical prediction" was first described in detail in 1954 by Paul Meehl, who examined the claim that mechanical (formal, algorithmic) methods of combining data could outperform clinical (e.g., subjective, informal, "in the clinician's head") methods when such combinations are used to predict behavior. Meehl concluded that mechanical ways of combining data work as well as or even better than clinical ways. A subsequent meta-analysis of studies that directly compared mechanical and clinical predictions confirmed Meehl's 1954 findings. A 2009 survey of practicing clinical psychologists found that clinicians almost exclusively use their clinical judgment to predict their patients' behavior, including diagnosis and prognosis.

Intervention

Psychotherapy involves a formal relationship between a professional and a client (usually an individual, couple, family, or small group), in which a set of procedures is used designed to build a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving.

Clinicians may use a wide range of individual interventions, often guided by their training — for example, a cognitive behavioral therapy (CBT) clinician might use worksheets to record anxious thoughts, a psychoanalyst might encourage free association, and a psychologist trained in Gestalt methods might focus on the immediate interaction between the client and therapist. Clinical psychologists generally strive to base their work on scientific evidence and research findings, as well as trained clinical judgment. Although there are literally dozens of recognized therapeutic orientations, their differences can often be divided along two dimensions: insight versus action, and in-session versus out-of-session.

• Insight — emphasis is placed on gaining a deeper understanding of the motives underlying thoughts and feelings (e.g., psychodynamic therapy).
• Action — the main focus is on making changes to how a person thinks and acts (e.g., solution-focused therapy, cognitive behavioral therapy).
• In-session — interventions are focused on the client-therapist interaction here and now (e.g., humanistic therapy, Gestalt therapy).
• Out-of-session — most of the therapeutic work is meant to take place outside the session (e.g., bibliotherapy, rational emotive behavior therapy).

The methods used also vary depending on the population served, as well as the context and nature of the problem. Therapy will look different, say, for 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 decisive role in the psychotherapy process include the environment, culture, age, cognitive functioning, motivation, and duration (i.e., short-term or long-term therapy).

The four major schools

Many clinical psychologists are integrative or eclectic and use the evidence base of various therapy models in an integrative way, rather than adhering to one specific model.

In the UK, clinical psychologists must demonstrate competence in at least two models of therapy, including CBT, in order to obtain a doctoral degree. The Division of Clinical Psychology of the British Psychological Society openly states the need to follow the evidence base rather than adhere to any single model of therapy.

In the US, training and practice in intervention and research is dominated by four major schools of practice: psychodynamic, humanistic, behavioral/cognitive-behavioral, and systemic or family therapy.

Psychodynamic Psychodynamic psychotherapy

The psychodynamic perspective developed out of Sigmund Freud's psychoanalysis. The main goal of psychoanalysis is to make the unconscious conscious — to help the client become aware of their own primary drives (namely those related to sex and aggression) and the various defenses used to control them. The main tools of the psychoanalytic process are the use of free association and the exploration of the client's transference onto 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. The main variations of Freudian psychoanalysis practiced today include self psychology, ego psychology, and object relations theory. These general directions now fall under the umbrella term psychodynamic psychology, with common themes including exploring transference and defenses, understanding the power of the unconscious, and emphasizing how early childhood development shaped the client's current psychological state.

Humanistic/Experiential - Humanistic psychology

Humanistic psychology was developed in the 1950s as a reaction against behaviorism and psychoanalysis, largely thanks to Carl Rogers's person-centered therapy (often called Rogerian therapy) and the existential psychology developed by Viktor Frankl and Rollo May. Rogers believed that a client needs only three things from a clinician to experience therapeutic improvement: congruence, unconditional positive regard, and empathic understanding. Using phenomenology, intersubjectivity, and first-person categories, the humanistic approach seeks to gain an understanding of the whole person, rather than only fragmented parts of the personality. This aspect of holism is connected to another common goal of humanistic practice in clinical psychology, which is the pursuit of integration of the whole personality, also called self-actualization. Since 1980, Hans-Werner Gessmann has integrated ideas from humanistic psychology into group psychotherapy as humanistic psychodrama. According to humanistic thinking, every individual already has built-in potentials and resources that can help them build a stronger personality and self-esteem. The mission of the humanistic psychologist is to help the person use these resources through the therapeutic relationship.

Emotion-focused therapy/Emotionally focused therapy (EFT), not to be confused with the Emotional Freedom Technique, was originally based on humanistic-phenomenological and Gestalt theories of therapy. "Emotion-focused therapy can be defined as a therapeutic practice based on understanding the role of emotion in psychotherapeutic change. EFT is based on a careful and thorough analysis of the meanings and contributions of emotion to human experience and change in psychotherapy. This focus leads the therapist and client to strategies that promote the awareness, acceptance, expression, use, regulation, and transformation of emotions, as well as corrective emotional experiences with the therapist. The goals of EFT are to strengthen the self, regulate affect, and create new meaning." Like some approaches in psychodynamic therapy, EFT draws heavily on attachment theory. The pioneers of EFT are Les Greenberg and Sue Johnson. EFT is often used in individual therapy and can be especially helpful for couples therapy. Founded in 1998, Sue Johnson and others lead the International Centre for Excellence in Emotionally Focused Therapy (ICEEFT), where clinicians can receive EFT training internationally. EFT is also a frequently chosen treatment for clinically diagnosed trauma.

Behavioral and cognitive-behavioral

Cognitive behavioral therapy (CBT) emerged from a combination of cognitive therapy and rational emotive behavior therapy, 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 interconnected and interact in complex ways. From this perspective, certain dysfunctional ways of interpreting and evaluating the world (often through schemas or beliefs) can contribute to emotional distress or lead to behavioral problems. The goal of many cognitive behavioral therapies is to detect and identify biased, dysfunctional ways of interacting or responding and, through various methodologies, help clients overcome them in a way that leads to increased well-being. Many techniques are used, such as systematic desensitization, Socratic questioning, and keeping a journal to track cognitive processes. Modified approaches falling under the CBT category have also been developed, including dialectical behavior therapy and mindfulness-based cognitive therapy.

Behavioral therapy is a rich tradition. It is well researched and has a strong evidence base. Its roots lie in behaviorism. In behavioral therapy, environmental events predict how we think and feel. Our behavior creates conditions for the environment to provide feedback on it. Sometimes this feedback leads to an increase in behavior (reinforcement), and sometimes to a decrease in behavior (punishment). Behavioral therapists are often called applied behavior analysts or behavioral health consultants. They have studied many areas, from developmental disorders to depression and anxiety disorders. A recent article on mental health and addiction reviewed a list of well-established and promising APA practices and found that a significant number of them are based on the principles of operant and respondent conditioning. This approach has given rise to numerous assessment methods, including functional analysis (psychology), which has found wide application in the school system. In addition, numerous intervention programs have emerged from this tradition, including the community reinforcement approach for treating addiction, acceptance and commitment therapy, functional analytic psychotherapy, including dialectical behavior therapy and behavioral activation. In addition, specific methods such as contingency management and exposure therapy have emerged from this tradition.

Systemic or family therapy

Systemic or family therapy works with couples and families and emphasizes family relationships as an important factor in psychological health. The main focus tends to be on interpersonal dynamics, especially in terms of how a change in one person will affect the whole system. Therefore, therapy is conducted with as many significant members of the "system" as possible. Goals may include improving communication, establishing healthy roles, creating alternative narratives, and addressing problematic behavior.

Other therapeutic perspectives

There are dozens of recognized schools or orientations of psychotherapy — the list below presents several influential orientations not mentioned above. Although they all have some typical set of techniques that practitioners use, they tend to be better known for providing a framework of theory and philosophy that guides the therapist in their work with the client.

• Existential. Existential psychotherapy postulates that people are largely free to choose who we are, how to interpret the world, and how to interact with it. It is intended to help the client find deeper meaning in life and accept responsibility for their life. As such, it addresses fundamental issues of life such as death, loneliness, and freedom. The therapist emphasizes the client's ability to become self-aware, freely make choices in the present, establish personal identity and social relationships, create meaning, and cope with natural existential anxiety.
• Gestalt. Gestalt therapy was founded by Fritz Perls in the 1950s. This therapy is perhaps best known for its use of techniques designed to increase self-awareness, the most famous of which is perhaps the "empty chair technique." Such techniques are intended to reveal resistance to "authentic contact," resolve internal conflicts, and help the client complete "unfinished business."
• Postmodern. Postmodern psychology holds that the experience of reality is a subjective construction built on language, social context, and history, without any substantive truths. 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 created by the client and therapist. Forms of postmodern psychotherapy include narrative therapy, solution-focused therapy, and coherence therapy.
• Transpersonal. The transpersonal perspective places greater emphasis on the spiritual side of human experience. It is less a set of techniques than a desire to help the client explore spirituality and/or transcendent states of consciousness. Transpersonal psychology is concerned with helping clients achieve their highest potential.
• Multiculturalism. Although the theoretical foundations of psychology are rooted in European culture, there is growing recognition that there are profound differences between various ethnic and social groups, and that systems of psychotherapy should take these differences into account. In addition, generations following immigrant migration will have some combination of two or more cultures — with aspects coming from parents and from the surrounding society — and this process of acculturation can play an important role in therapy (and can itself present a challenge). 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 conflict with certain givens in mainstream psychotherapeutic theory and practice. Thus, there is a growing movement to integrate knowledge from various cultural groups in order to inform therapeutic practice in a more culturally sensitive and effective way.
• Feminism. Feminist therapy is an orientation arising from the discrepancy between the origins of most psychological theories (authored by men) and the fact that most people seeking counseling are women. The main focus is on the social, cultural, and political causes and solutions to the problems faced in the counseling process. It openly encourages the client to engage with the world in a more social and political way.
• Positive psychology. Positive psychology is the scientific study of human happiness and well-being, which began to gain momentum in 1998 at the call of Martin Seligman, then president of the APA. The history of psychology shows that the field has primarily been devoted to addressing mental illness rather than mental health. Thus, the main task of applied positive psychology is to increase positive life experience and the capacity to flourish, by promoting things such as optimism about the future, a sense of flow in the present, and personal qualities such as courage, perseverance, and altruism. There is currently preliminary empirical evidence showing 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 reduce clinical depression.

Community psychology approaches are often used for psychological harm prevention and clinical intervention.

Integration

Professional ethics

Comparison with other mental health professions

Psychiatry

Fluoxetine hydrochloride, marketed by Lilly under the trade name "Prozac," is an antidepressant prescribed by physicians, psychiatrists, and some nurses.

Counseling psychology

School psychology

School psychologists are primarily concerned with the academic, social, and emotional well-being of children and adolescents in the school environment. In the UK, they are called "educational psychologists." Like clinical (and counseling) psychologists, school psychologists with doctoral degrees are eligible to obtain a health service psychologist license, and many engage in private practice. Unlike clinical psychologists, they receive much more training in children's education, development, and behavior, as well as the psychology of learning. Common degrees include the Education Specialist degree (EdS), Doctor of Philosophy (PhD), and Doctor of Education (EdD).

Clinical social work

Social workers provide a variety of services, usually related to social problems, their causes, and solutions. After specialized training, clinical social workers may also provide psychological counseling (in the US and Canada) in addition to more traditional social work.

Occupational therapy

Occupational therapy — often abbreviated OT — is "the use of productive or creative activity in the treatment or rehabilitation of people with physical, cognitive, or emotional impairments."

Criticism and controversy

Clinical psychology is a diverse field, and disagreements periodically arise about the extent to which clinical practice should be limited to treatments validated by empirical research.

See also