Florida National University Foundation of Clinical Psychology Essay

1. Please read Chapter 3 (Current Issues in Clinical Psychology) and Chapter 4 (Research Methods in Clinical Psychology from your textbook.
2. Please complete a 2-page summary.

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CLINICAL
PSYCHOLOGY
EIGHTH EDITION
TIMOTHY J. TRULL
University of Missouri–Columbia
MITCHELL J. PRINSTEIN
University of North Carolina at Chapel Hill
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Clinical Psychology, Eighth Edition
Timothy J. Trull and Mitchell J. Prinstein
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1 2 3 4 5 6 7 16 15 14 13 12
About the Authors
Dr. Timothy Trull is the Curator’s Professor of
Psychological Sciences and Byler Distinguished
Professor at the University of Missouri–Columbia.
He enjoys both teaching a variety of courses in clinical psychology, particularly abnormal psychology
and clinical psychology, and supervising clinical
psychology graduate students in their research,
assessment, and clinical work. Tim earned his M.A.
and Ph.D. in clinical psychology at the University of
Kentucky. He is a co-author of the Structured Interview for the Five-Factor Model of Personality (SIFFM),
which assesses both adaptive and maladaptive personality features. Tim publishes much of his research
in the Journal of Abnormal Psychology, Psychological
Assessment, and the Journal of Personality Disorders. Sponsored through grants
from the National Institute of Health, the National Institute on Alcohol
Abuse and Alcoholism, and the Borderline Personality Disorder Research
Foundation, his research projects include evaluating etiological models of
borderline personality disorder, exploring the relations between personality
disorders and substance use disorders, assessing genetic and environmental influences on personality and psychopathology, and using of ambulatory assessment
in clinical psychology. In addition to his work at the university, Tim is a member of the scientific faculty at the Midwest Alcoholism Research Center
(MARC) and is a practicing clinical psychologist. He has won a number of
awards that include Outstanding Alumnus, University of Kentucky; the
Graduate Faulty Mentoring Award, University of Missouri; the Robert S.
Daniels Junior Faculty Teaching Award; and the Psi Chi Professor of
the Year. Tim is a Fellow of the American Psychological Association and the
Association for Psychological Science.
iii
iv
ABOUT THE AUTHORS
Dr. Mitchell J. Prinstein is a Bowman and Gordon
Gray Distinguished Term Professor and the Director
of Clinical Psychology at the University of North
Carolina at Chapel Hill. He received his Ph.D. in
clinical psychology from the University of Miami
and completed his internship and postdoctoral fellowship at the Brown University Clinical Psychology
Training Consortium. Mitch’s research examines
interpersonal models of internalizing symptoms and
health risk behaviors among adolescents, with a specific focus on the unique role of peer relationships in
the developmental psychopathology of depression
and self-injury. He is the PI on several past and active
grants from the National Institute of Mental Health,
the National Institute of Child and Human Development, and several private
foundations. He serves as the Editor for the Journal of Clinical Child and Adolescent
Psychology, and an editorial board member for several developmental psychopathology journals. Mitch has received several national and university-based awards
recognizing his contributions to research (American Psychological Association
Society of Clinical Psychology Theodore Blau Early Career Award, Columbia
University/Brickell Award for research on suicidality, APA Fellow of the
Society of Clinical Child and Adolescent Psychology and the Society of Clinical
Psychology), teaching (UNC Chapel Hill Tanner Award for Undergraduate
Teaching; Psi Chi Professor of the Year), professional development of graduate
students (American Psychological Association of Graduate Students Raymond
D. Fowler Award), and undergraduate students (Psychology Club Department
Research Mentor Award).
This edition is dedicated to the memory of my father-in-law Armin Klein,
an inspiring clinical psychologist whose life, compassion, wit, and
intellect touched many of us. (TJT)
Dedicated to my amazing wife, to my happy baby daughter, and to
future students of clinical psychology who are looking for inspiration. (MJP)
Brief Contents
PART I
Foundations of Clinical Psychology
1
2
3
4
5
P A R T II
1
Clinical Psychology: An Introduction 3
Historical Overview of Clinical Psychology 32
Current Issues in Clinical Psychology 59
Research Methods in Clinical Psychology 93
Diagnosis and Classification of Psychological Problems
Clinical Assessment
128
159
6 The Assessment Interview 161
7 The Assessment of Intelligence 191
8 Personality Assessment 218
9 Behavioral Assessment
255
10 Clinical Judgment 283
P A R T III
Clinical Interventions
11
12
13
14
15
P A R T IV
309
Psychological Interventions 311
Psychotherapy: The Psychodynamic Perspective 343
Psychotherapy: Phenomenological and Humanistic-Existential
Perspectives 370
Psychotherapy: Behavioral and Cognitive-Behavioral
Perspectives 397
Group Therapy, Family Therapy, and Couples Therapy 431
Specialties in Clinical Psychology
16
17
18
19
457
Community Psychology 459
Health Psychology and Behavioral Medicine
Neuropsychology 513
Forensic Psychology 539
vi
485
Contents
PREFACE
PART I
xxiii
Foundations of Clinical Psychology
1
1
Clinical Psychology: An Introduction 3
What Is Clinical Psychology? 4
Closely Related Mental Health Professions 5
Psychiatrists 5
BOX 1.1
Professional Issues: But Is It the Right Prescription for
Clinical Psychology?
6
Counseling Psychologists 7
Other Mental Health Professionals 8
Professions and Titles Not Regulated by the Government
The Clinical Psychologist 12
Activities of Clinical Psychologists 12
Employment Sites 17
A Week in the Life of Dr. Karen C 17
Some Demographic Notes 20
Research and the Scientific Tradition 21
Training: Toward a Clinical Identity 21
An Overview 22
Clinical Psychology Training Programs 22
A Profession in Movement 25
Women in Clinical Psychology 25
BOX 1.2
A Graduate Student Perspective: Julia Martinez
vii
26
12
viii
CONTENTS
Training Models 27
Clinical Practice 28
A Tolerance for Ambiguity and a Thirst for New Knowledge
CHAPTER SUMMARY
29
KEY TERMS
29
WEB SITES OF INTEREST
31
2
Historical Overview of Clinical Psychology 32
Historical Roots 33
Diagnosis and Assessment 34
The Beginnings (1850–1899) 34
The Advent of the Modern Era (1900–1919) 35
Between the Wars (1920–1939) 35
World War II and Beyond (1940–Present) 36
Interventions 39
The Beginnings (1850–1899) 39
The Advent of the Modern Era (1900–1919) 40
Between the Wars (1920–1939) 41
World War II and Beyond (1940–Present) 42
Research 45
The Beginnings (1850–1899) 45
The Advent of the Modern Era (1900–1919) 46
Between the Wars (1920–1939) 46
World War II and Beyond (1940–Present) 46
The Profession 49
The Beginnings (1850–1899) 49
The Advent of the Modern Era (1900–1919) 50
Between the Wars (1920–1939) 51
World War II and Beyond (1940–1969) 52
The Growth of a Profession (1970–Present) 53
The 1988 Schism 54
CHAPTER SUMMARY
56
KEY TERMS
56
WEB SITES OF INTEREST
58
3
Current Issues in Clinical Psychology 59
Models of Training in Clinical Psychology 60
The Scientist-Practitioner Model 60
The Doctor of Psychology (Psy.D.) Degree
Professional Schools 62
Clinical Scientist Model 63
61
28
CONTENTS
BOX 3.1
Clinical Psychologist Perspective:
Richard M. McFall, Ph.D.
64
Combined Professional-Scientific Training Programs
Graduate Programs: Past and Future 66
Professional Regulation 67
BOX 3.2
Graduate Student Perspective: Christine Maldonado
66
68
Private Practice 71
The Costs of Health Care 72
Prescription Privileges 75
BOX 3.3
Clinical Psychologist Perspective:
Patrick H. DeLeon, Ph.D., J.D.
BOX 3.4
76
Clinical Psychologist Perspective:
Elaine M. Heiby, Ph.D.
79
Technological Innovations 81
Telehealth 81
Ambulatory Assessment 81
Computer-Assisted Therapy 82
Culturally Sensitive Mental Health Services
Ethical Standards 86
Competence 86
83
BOX 3.5
Focus on Professional Issues Clinicians Who Participate in
Radio Call-In Shows, TV Talk Shows, or Internet Groups: Are They
Ethical?
87
Privacy and Confidentiality
Human Relations 88
CHAPTER SUMMARY
89
KEY TERMS
90
WEB SITES OF INTEREST
91
4
87
Research Methods in Clinical Psychology
Introduction to Research 94
Methods 95
Observation 95
BOX 4.1
Clinical Applications: What Case Studies Can Tell Us About
Phobias and Early Trauma
BOX 4.2
Therapy
93
98
Clinical Applications: Generating Hypotheses from
99
Epidemiological Methods 100
Correlational Methods 101
Cross-Sectional Versus Longitudinal Approaches
The Experimental Method 106
105
ix
x
CONTENTS
BOX 4.3
Clinical Psychologist Perspective: Scott O.
Lilienfeld, Ph.D.
108
Single-Case Designs
BOX 4.4
113
Clinical Applications: The Treatment of Mixed Anxiety
and Depression
116
Mixed Designs 117
Strengths and Weaknesses of Research Methods
Statistical Versus Practical Significance 118
BOX 4.5
Graduate Student Perspective: Elizabeth A. Martin
Research and Ethics
Who Should Be Studied?
BOX 4.7
Sample Consent Form
KEY TERMS
121
122
123
124
WEB SITES OF INTEREST
126
Diagnosis and Classification of Psychological
Problems 128
What Is Abnormal Behavior? 130
Statistical Infrequency or Violation of Social Norms
The Case of Dmitri A.
130
The Case of Juanita L.
131
BOX 5.1
132
The Case of Cynthia S.
135
Subjective Distress
135
The Case of Kwame G.
135
Focus on Professional Issues: Culture and Diagnosis
Disability, Dysfunction, or Impairment
The Case of Richard Z.
138
The Case of Phyllis H.
138
Where Does This Leave Us?
Mental Illness 139
BOX 5.3
130
Clinical Psychologist Perspective:
Kenneth J. Sher, Ph.D.
BOX 5.2
119
120
BOX 4.6
CHAPTER SUMMARY
5
118
137
139
Clinical Psychologist Perspective: Elaine
Walker, Ph.D.
140
The Importance of Diagnosis 142
Early Classification Systems 143
DSM-IV-TR 144
The Case of Michelle M.
146
General Issues in Classification
146
136
CONTENTS
Causes of Abnormal Behavior and Mental Illness
Major Models of Psychopathology 153
Diathesis-Stress Model 153
The Value of Classification 155
CHAPTER SUMMARY
155
KEY TERMS
156
WEB SITES OF INTEREST
157
P A R T II
Clinical Assessment
6
153
159
The Assessment Interview 161
Assessment in Clinical Psychology 162
Definition and Purpose 162
The Referral 162
The Case of Billy G.
163
What Influences How the Clinician Addresses the Referral
Question? 164
The Interview 165
General Characteristics of Interviews 165
BOX 6.1
Computer Interviewing: Are Clinicians Necessary?
166
Interviewing Essentials and Techniques 166
Rapport 168
Communication 169
The Patient’s Frame of Reference 172
The Clinician’s Frame of Reference 172
Varieties of Interviews 173
The Intake-Admission Interview 173
The Case-History Interview 174
The Mental Status Examination Interview 174
BOX 6.2
Sample Intake Report
175
The Crisis Interview 176
The Diagnostic Interview 178
BOX 6.3
Clinical Psychologist Perspective: Thomas A.
Widiger, Ph.D. 178
Reliability and Validity of Interviews 184
Reliability 185
Validity 186
Suggestions for Improving Reliability and Validity
The Art and Science of Interviewing 188
CHAPTER SUMMARY
189
KEY TERMS
189
188
xi
xii
CONTENTS
7
The Assessment of Intelligence 191
Intelligence Testing: Yesterday and Today 192
The Concept of Intelligence 194
Brief Review of Reliability and Validity 194
BOX 7.1
The Bell Curve
195
Definitions of Intelligence 197
Theories of Intelligence 197
The IQ: Its Meaning and Its Correlates 200
The Intelligence Quotient (IQ) 200
Correlates of the IQ 200
Heredity and Stability of IQ Scores 201
BOX 7.2
Behavioral Genetics
202
BOX 7.3
The Concept of Heritability
204
The Clinical Assessment of Intelligence
The Stanford-Binet Scales 206
The Wechsler Scales 207
The WAIS-IV 207
The WISC-IV 209
205
A Brief Case Report: Intellectual Evaluation
211
The WPPSI-III 212
The Clinical Use of Intelligence Tests
213
The Case of Harold
213
Some Final Observations and Conclusions
CHAPTER SUMMARY
215
KEY TERMS
215
WEB SITES OF INTEREST
217
8
214
Personality Assessment 218
Objective Tests 219
Advantages 219
Disadvantages 221
Methods of Construction for Objective Tests
The MMPI and the MMPI-2 223
221
BOX 8.1
Clinical Psychologist Perspective: Yossef S.
Ben-Porath, Ph.D. 226
A Summary Evaluation of the MMPI and MMPI-2
The Revised NEO-Personality Inventory 232
NEO-PI-R Case Illustration
234
Projective Tests 236
The Nature of Projective Tests
236
229
CONTENTS
Measurement and Standardization
The Rorschach 237
Rorschach Case Illustration 1
239
Rorschach Case Illustration 2
239
The Thematic Apperception Test
TAT Case Illustration
244
Graduate Student Perspective: Danielle L. Burchett
CHAPTER SUMMARY
KEY TERMS
251
252
WEB SITES OF INTEREST
9
242
243
Sentence Completion Techniques
Illusory Correlation 246
Incremental Validity and Utility 246
The Use and Abuse of Testing 247
BOX 8.2
237
253
Behavioral Assessment 255
The Behavioral Tradition 256
Sample Versus Sign 256
Functional Analysis 257
Behavioral Assessment as an Ongoing Process
Behavioral Interviews 259
BOX 9.1
257
Clinical Psychologist Perspective: Stephen N.
Haynes, Ph.D.
260
Observation Methods 262
Naturalistic Observation 262
Examples of Naturalistic Observation 263
Controlled Observation 264
Controlled Performance Techniques 265
Self-Monitoring 267
Variables Affecting Reliability of Observations 268
Variables Affecting Validity of Observations 270
Suggestions for Improving Reliability and Validity of
Observations 272
Contemporary Trends in Data Acquisition 272
Role-Playing Methods 274
Inventories and Checklists 274
Cognitive-Behavioral Assessment 275
BOX 9.2
Clinical Psychologist Perspective: Karen D.
Rudolph, Ph.D.
276
Strengths and Weaknesses of Behavioral Assessment
278
248
xiii
xiv
CONTENTS
279
CHAPTER SUMMARY
KEY TERMS
280
WEB SITES OF INTEREST
281
10 Clinical Judgment 283
Process and Accuracy 284
Interpretation 284
Theory and Interpretation 284
Quantitative Versus Subjective Approaches
The Case for a Statistical Approach 287
285
BOX 10.1
Focus on Clinical Applications An Example of a “Barnum
Effect”: Purported Characteristics of Adult Children of Alcoholics
(ACOAs)
288
The Case for a Clinical Approach 289
Comparing Clinical and Actuarial Approaches
BOX 10.2
Clinical Psychologist Perspective:
Howard N. Garb, Ph.D.
Conclusions
BOX 10.3
290
295
296
Focus on Professional Issues: How Do Psychiatrists Make
Clinical Decisions?
297
Improving Judgment and Interpretation 298
Information Processing 298
The Reading-in Syndrome 298
Validation and Records 298
Vague Reports, Concepts, and Criteria 298
The Effects of Predictions 298
Prediction to Unknown Situations 299
Fallacious Prediction Principles 299
The Influence of Stereotyped Beliefs 299
“Why I Do Not Attend Case Conferences” 300
Communication: The Clinical Report 300
The Referral Source 301
Aids to Communication 301
A Case Illustration of a Clinical Report
CHAPTER SUMMARY
KEY TERMS
P A R T III
306
307
Clinical Interventions
309
11 Psychological Interventions 311
Intervention Defined 312
Does Psychotherapy Help? 313
303
CONTENTS
BOX 11.1
Clinical Psychologist Perspective:
Martin E. P. Seligman, Ph.D.
314
Evidence-Based Treatment and Evidence-Based Practice
Features Common to Many Therapies 317
BOX 11.2
Clinical Psychologist Perspective:
Dianne L. Chambless, Ph.D.
318
Nature of Specific Therapeutic Variables
The Patient or Client 321
BOX 11.3
321
Focus on Professional Issues: Cultural Competence
The Therapist 325
Course of Clinical Intervention 329
Initial Contact 329
Assessment 330
The Goals of Treatment 330
Implementing Treatment 331
Termination, Evaluation, and Follow-up
BOX 11.4
324
331
Focus on Clinical Applications: Information Patients Have
a Right to Know
332
Stages of Change 333
Psychotherapy Research
BOX 11.5
314
333
Focus on Professional Issues: Eysenck’s Bombshell
Issues in Psychotherapy Research
Comparative Studies 336
Process Research 337
Recent Trends 338
Some General Conclusions 340
CHAPTER SUMMARY
340
KEY TERMS
341
WEB SITES OF INTEREST
342
334
334
12 Psychotherapy: The Psychodynamic Perspective
Psychoanalysis: The Beginnings 344
Anna O. 344
BOX 12.1
Focus on Professional Issues: A Brief Biography of
Sigmund Freud 345
The Freudian View: A Brief Review 346
From Theory to Practice 349
The Role of Insight 349
Techniques of Psychodynamic Psychotherapy 350
Free Association 350
Analysis of Dreams 351
343
xv
xvi
CONTENTS
Psychopathology of Everyday Life
BOX 12.2
351
Focus on Professional Issues: Freud’s Self-Analysis
Resistance
352
352
A Case Illustration of Resistance
353
Transference 354
Interpretation 354
A Case Illustration of Interpretation
355
Psychoanalytic Alternatives 356
Ego Analysis 356
Other Developments 357
Contemporary Psychodynamic Psychotherapy 357
Interpersonal Psychotherapy: An Empirically Supported
Treatment 357
BOX 12.3
Focus on Clinical Applications: Features of Interpersonal
Psychotherapy (IPT)
358
Summary Evaluation of Psychodynamic Psychotherapy
Does Psychodynamic Psychotherapy Work? 358
BOX 12.4
Clinical Psychologist Perspective:
Kenneth N. Levy, Ph.D
359
Interpretation and Insight 362
Curative Factors 363
The Lack of Emphasis on Behavior
BOX 12.5
364
365
Graduate Student Perspective: Joseph E. Beeney
CHAPTER SUMMARY
KEY TERMS
363
Clinical Psychologist Perspective: Ali Khadivi, Ph.D.
The Economics of Psychotherapy
BOX 12.6
358
366
366
367
WEB SITES OF INTEREST
369
13 Psychotherapy: Phenomenological and HumanisticExistential Perspectives 370
Client-Centered Therapy 371
Origins 371
The Phenomenological World 371
BOX 13.1
Focus on Professional Issues: A Brief Biography of Carl
Rogers
372
Theoretical Propositions 373
Core Features 374
The Therapeutic Process 375
Diagnosis 376
CONTENTS
A Case Illustration of Client-Centered Therapy
Other Applications 378
Some Concluding Remarks 378
The Humanistic-Existential Movement
Humanism 381
BOX 13.2
377
381
Clinical Psychologist Perspective:
Leslie S. Greenberg, Ph.D.
382
Existential Therapy 382
Logotherapy 384
Gestalt Therapy 385
Emotion-Focused Therapy 388
Summary Evaluation of Phenomenological and HumanisticExistential Therapies 388
BOX 13.3
Focus on Clinical Applications: Features of Emotion-
Focused Therapy
389
Strengths 389
Limitations 390
BOX 13.4
Graduate Student Perspective: Catalina Woldarsky
Meneses, M. A. 392
CHAPTER SUMMARY
KEY TERMS
394
395
WEB SITES OF INTEREST
396
14 Psychotherapy: Behavioral and Cognitive-Behavioral
Perspectives 397
Origins of the Behavioral Approach 398
Definition 398
A Brief History 398
Traditional Techniques of Behavior Therapy 400
The Relationship 400
Broad Spectrum of Treatment 400
Systematic Desensitization 401
BOX 14.1
Psychologist Perspective: Judith S. Beck, Ph.D.
Exposure Therapy
402
406
BOX 14.2
Focus on Clinical Applications: Rationale for Exposure
Therapy Presented to a Client with Panic Disorder 407
BOX 14.3
Focus on Clinical Applications Behavior Therapy for
Obsessive-Compulsive Disorder: Exposure Plus Response
Prevention 408
Behavior Rehearsal 408
Contingency Management
Aversion Therapy 411
410
xvii
xviii
CONTENTS
Cognitive-Behavioral Therapy
Background 412
BOX 14.4
412
Graduate Student Perspective: John Guerry, M.A.
414
Modeling 416
Rational Restructuring 416
Stress Inoculation Training 417
BOX 14.5
Ideas
Focus on Clinical Applications: Common “Irrational”
418
Beck’s Cognitive Therapy
BOX 14.6
418
Focus on Clinical Applications: Features of Cognitive
Therapy for Depression
419
Dialectical Behavior Therapy 420
An Evaluation of Behavior Therapy 420
Strengths 420
BOX 14.7
Focus on Clinical Applications: Excerpts from Sessions of
Dialectical Behavior Therapy (DBT) 422
BOX 14.8
Psychologist Perspective: Rhonda Oswalt
Reitz, Ph.D.
424
Limitations 425
The Future 427
CHAPTER SUMMARY
KEY TERMS
427
428
WEB SITES OF INTEREST
430
15 Group Therapy, Family Therapy, and Couples
Therapy 431
Group Therapy 432
A Historical Perspective 432
Approaches to Group Therapy 433
A Case Illustration of Psychoanalytic Group Therapy
The Arrangements
BOX 15.1
434
437
Focus on Clinical Applications: Time-Effective Group
Psychotherapy for Patients with Personality Disorders
The Curative Factors 439
Does Group Therapy Work? 439
The Future of Group Therapy 440
Family Therapy 440
The Development of Family Therapy 440
The Concept of Communication 441
Forms and Methods 441
438
CONTENTS
BOX 15.2
ABPP
Clinical Psychologist Perspective: Greta Francis, Ph.D.,
442
Conjoint Family Therapy
445
A Case Illustration of Conjoint Family Therapy
Other Varieties of Family Therapy
BOX 15.3
445
447
Graduate Student Perspective: David Wagner, M.A.
When to Conduct Family Therapy?
Couples Therapy 450
448
450
BOX 15.4
Focus on Clinical Applications: The Nine Steps of
Emotionally Focused Couples Therapy (EFT) 451
Do Family Therapy and Couples Therapy Work?
454
KEY TERMS
454
WEB SITES OF INTEREST
456
452
CHAPTER SUMMARY
P A R T IV
Specialties in Clinical Psychology
457
16 Community Psychology 459
Perspectives and History 460
The Community Psychology Perspective 460
Chronology and Catalyzing Events 461
Key Concepts 464
Ecological Levels of Analysis 464
The Concept of Community Mental Health 465
The Concept of Prevention 466
BOX 16.1
Clinical Psychologist Perspective: Kristin Hawley, Ph.D.
BOX 16.2
Focus on Clinical Applications: The High/Scope Perry
Preschool Program
BOX 16.3
468
470
Focus on Clinical Applications: The JOBS Program
470
BOX 16.4
Focus on Clinical Applications: Primary Prevention Mental
Health Programs for Children and Adolescents 471
Empowerment 471
Diversity 473
BOX 16.5
Graduate Student Perspective:
Shawn C.T. Jones, M.H.S
474
Social Intervention Concepts 474
Methods of Intervention and Change 476
Consultation 476
Community Alternatives to Hospitalization
Intervention in Early Childhood 478
Self-Help 478
477
xix
xx
CONTENTS
Paraprofessionals 479
Concluding Comments 480
Questions of Effectiveness 480
Values, Power, and Civil Rights 480
The Training of Community Psychologists
The Future of Prevention 481
CHAPTER SUMMARY
482
KEY TERMS
483
WEB SITES OF INTEREST
484
481
17 Health Psychology and Behavioral Medicine 485
History and Perspectives 486
Definitions 486
History 487
Linking Stress, Lifestyle and Behavior, Personality, Social
Support, and Health 488
BOX 17.1
Focus on Clinical Applications Stress and Everyday Life:
What Are the Most Common Stressors for Undergraduate
Students?
491
Range of Applications 494
Methods of Intervention 494
Respondent Methods 494
BOX 17.2
Focus on Professional Issues The Role of Health
Psychology: HIV and Acquired Immune Deficiency Syndrome
(AIDS)
495
Operant Methods 496
Cognitive-Behavioral Methods 496
Biofeedback 497
Prevention of Health Problems 499
Cigarette Smoking 499
BOX 17.3
Focus on Professional Issues: Ethnicity and Cancer
Outcomes 500
Alcohol Abuse and Dependence 500
Obesity 501
Other Applications 502
Coping with Medical Procedures 502
Compliance with Regimens 503
Future Directions 506
Health Care Trends 506
Training Issues 506
Other Challenges 507
CONTENTS
BOX 17.4
Clinical Psychologist Perspective:
Beth E. Meyerowitz, Ph.D.
KEY TERMS
508
510
CHAPTER SUMMARY
510
WEB SITES OF INTEREST
512
18 Neuropsychology 513
Perspectives and History 514
Definitions 514
Roles of Neuropsychologists
History of Neuropsychology
514
515
BOX 18.1
Clinical Psychologist Perspective:
Brick Johnstone, Ph.D. 516
The Brain: Structure, Function, and Impairment 518
Structure and Function 518
Antecedents or Causes of Brain Damage 519
Consequences and Symptoms of Neurological Damage
Brain–Behavior Relationships 521
BOX 18.2
Focus on Clinical Applications Personality Changes
Following Brain Injury: A Case Example
522
Methods of Neuropsychological Assessment 523
Major Approaches 523
Interpretation of Neuropsychological Test Results
Neurodiagnostic Procedures 524
Testing Areas of Cognitive Functioning 524
Test Batteries 527
BOX 18.3
520
523
Focus on Clinical Applications: A Brief Neuropsychological
Report Based on Halstead-Reitan and Other Information
528
Variables That Affect Performance on Neuropsychological
Tests 529
Intervention and Rehabilitation 529
BOX 18.4
Graduate Student Perspective: Andrew Wegrzyn
BOX 18.5
Focus on Professional Issues: Cross-cultural
Neuropsychology
532
Concluding Remarks 532
Training 532
The Future 533
BOX 18.6
Clinical Psychologist Perspective:
Paula Zuffante, Ph.D.
CHAPTER SUMMARY
KEY TERMS
534
536
536
WEB SITES OF INTEREST
538
530
xxi
xxii
CONTENTS
19 Forensic Psychology 539
Perspectives and History 540
Definitions 540
History 540
BOX 19.1
Focus on Professional Issues: Munsterberg on Trial
Professional Issues 542
Some Major Activities of Forensic Psychologists
The Expert Witness 543
Criminal Cases 545
541
543
BOX 19.2
Clinical Psychologist Perspective:
David DeMatteo, J.D., Ph.D. 546
Civil Cases 548
Rights of Patients 550
Predicting Dangerousness
BOX 19.3
550
Focus on Clinical Applications Legal Controversies: Forcible
Medication
551
Psychological Treatment
Consultation 552
552
BOX 19.4
Clinical Psychologist Perspective:
Marina Tolou-Shams, Ph.D. 554
Research and Forensic Psychology
BOX 19.5
Graduate Student Perspective: Lizzy Foster
CHAPTER SUMMARY
559
560
KEY TERMS
WEB SITES OF INTEREST
APPENDIX
REFERENCES
556
562
590
PHOTO CREDITS
629
NAME INDEX
631
SUBJECT INDEX
645
561
558
Preface
W
elcome to the eighth edition of Clinical Psychology! Clinical Psychology
strives to present an in-depth look at the field of clinical psychology, document the many activities of clinical psychologists, and highlight the trends in
the field that are likely to shape the field in the coming years. This book emphasizes evidence-based assessment and treatment approaches, as well as the influence of culture, gender, and diversity in these approaches. The first major
change you will notice is that Mitch Prinstein, Ph.D. has joined the author
team. Mitch brings some great expertise and perspectives to this edition. In addition to being an expert in child and adolescent psychopathology, Mitch is
known for his accomplishments in the teaching of clinical psychology, in mentoring undergraduate students who seek careers in psychology, and in training
the next generation of clinical psychologists. You will see his “fingerprints”
throughout this edition.
As before, this edition of the text has been updated to reflect changes in the
field of clinical psychology and new empirical evidence evaluating major
approaches to prevention, assessment, and treatment. Briefly, we would like to
highlight some of this edition’s major features.
Clinical Psychology: Defining the Field
What features define clinical psychology, and what aspects of clinical psychology
make it a unique specialty? Chapters 1–3 present definitions of clinical psychology
and its historical roots, contrast clinical psychology with other related fields, and discuss
trends and issues (e.g., managed care, prescription privileges, technological innovations) that are influencing the field. In addition, information regarding various training
models for clinical psychologists is presented in order to provide a better understanding of the diversity of training within the field. Furthermore, important issues
related to multiculturalism and diversity are presented in Chapter 3 (and throughout
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PREFACE
the book). Finally, we discuss how a clinical psychologist might provide culturally
sensitive mental health services throughout the book but particularly in Chapters 3,
11, and 16.
Scientific Foundations of Clinical Psychology
What is the scientific basis of clinical psychology, and what scientific procedures
are used in the field? The field of clinical psychology has increasingly focused on
establishing and demonstrating the scientific basis for assessment and treatment.
Chapter 4 presents the primary research methodology that is used in clinical psychology, while the remaining chapters present the empirical evidence supporting
(or in some cases, not supporting) approaches to assessment and intervention.
The American Psychological Association’s (APA) 2002 Ethical Guidelines that
are relevant to research are discussed in this chapter as well. As stated above,
each chapter presents and interprets the empirical evidence that is available to
address the topic at hand, whether it is the utility of a psychological test, the
support for a treatment approach, or the adequacy of a theory.
Clinical Assessment
What clinical assessment procedures are used in the field, and what procedures
have the strongest evidence base? Chapters 5–10 provide an in-depth look into
major assessment approaches and procedures used by clinical psychologists,
including diagnostic assessment, interviewing, intelligence testing, personality
assessment, behavioral assessment, and clinical judgment. There are new assessment approaches covered in this edition (e.g., WAIS-IV), new technological
advances (Internet-based assessments), as well as a focus on the issue of incremental validity of psychological tests and procedures.
Interventions
What are the leading evidence-based treatments that are used by clinical psychologists? Chapters 11–15 present the major intervention models and techniques.
These chapters also take a critical look at the efficacy and utility of these
approaches. These issues are further addressed in Chapters 16–19 (which discuss
specialties).
Lifespan Approach
The eighth edition of Clinical Psychology has been revised to reflect a lifespan
approach to the field of clinical psychology. This edition reflects the broad
focus both on youth populations (in clinical child and adolescent psychology)
PREFACE
and on adult populations (clinical adult psychology) that are the subject of
research, assessment, and treatment in the field. All chapters have been revised
to reflect this perspective.
Specialties in Clinical Psychology
As in previous editions, several specialty areas are discussed in this textbook:
community psychology, health psychology and behavioral medicine, neuropsychology, and forensic psychology. We focus on these specialties because of their
growth potential and interest for students and clinical psychologists in training.
Ethical Guidelines
The American Psychological Association published a new version of Ethical
Guidelines in 2002. These guidelines are discussed throughout the text, but especially in Chapters 3 and 4. We also discuss the issue of psychological testing and
the American Disabilities Act in Chapter 8.
New Features
This edition contains several new features that provide greater focus on important
issues. Specifically, we include boxes called (1) Focus on Professional Issues, (2)
Focus on Clinical Applications, (3) Clinical Psychologist Perspective, and (4) Graduate Student Perspective. The first two box types highlight issues that are relevant
to the profession of clinical psychology (both past and present) and issues concerning the application of clinical psychology (e.g., testing, treatment, etc.), respectively. The latter two box types present personal perspectives written by clinical
psychologists about both the general field of clinical psychology as well as specialties in clinical psychology, and personal perspectives on applying to graduate
school and being a graduate student in clinical psychology, respectively.
Another new feature in this edition appears in the Appendix, A Primer for
Applying to Graduate Programs in Clinical Psychology. We hope this is helpful to
those considering a career in clinical psychology by highlighting the differences
among mental health professionals, the differences between degrees in clinical
psychology, the differences in graduate training programs for clinical psychologists, and the nuts and bolts of the application process.
Clinical Psychologist
and Graduate Student Perspectives
As we mentioned, new to this edition are a number of Clinical Psychologist and
Graduate Student Perspective profiles. In addition to clinical psychologists, we
chose to feature graduate students as well. It is our belief that prospective
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PREFACE
students in clinical psychology are likely to benefit greatly from the sage advice
and experience of those who have been through the application process recently
and who have experienced the rigors and rewards of graduate school in clinical
psychology.
A total of 36 perspectives appear in the eighth edition of Clinical Psychology,
including 11 from graduate students in clinical psychology. Here is the complete
list of those profiled in this edition:
Clinical Psychologists
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Judith Beck, Ph.D., Beck Institute of Cognitive Therapy and Research
Yossef Ben-Porath, Ph.D., Kent State University
Diane Chambless, Ph.D., University of Pennsylvania
Patrick DeLeon, Ph.D., J.D., Staff, United States Senate
David DeMateo, J.D., Ph.D., Drexel University
Greta Francis, Ph.D., Brown University
Howard Garb, Ph.D., Wilford Hall Medical Center
Leslie Greenberg, Ph.D., York University
Kristin Hawley, Ph.D., University of Missouri
Stephen Haynes, Ph.D., University of Hawaii
Elaine Heiby, Ph.D., University of Hawaii
Brick Johnstone, Ph.D., University of Missouri
Ali Khadivi, Ph.D., Bronx-Lebanon Hospital Center
Kenneth Levy, Ph.D., Penn State
Scott Lilienfeld, Ph.D., Emory University
Richard McFall, Ph.D., Indiana University
Beth Meyerowitz, Ph.D., University of Southern California
Ronda Reitz, Ph.D., Missouri Department of Mental Health
Karen Rudolph, Ph.D., University of Illinois, Urbana-Champaign
Martin Seligman, Ph.D., University of Pennsylvania
Kenneth Sher, Ph.D., University of Missouri
Marina Tolou-Shams, Ph.D., Brown University
Elaine Walker, Ph.D., Emory University
Thomas Widiger, Ph.D., University of Kentucky
Paula Zuffante, Ph.D., Children’s Neuropsychological Services, Albany NY
Clinical Graduate Students
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Joseph Beeney, Penn State
Danielle Burchett, Kent State
Lizzy Foster, Drexel University
PREFACE
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John Guerry, University of North Carolina, Chapel Hill
Shawn Jones, University of North Carolina, Chapel Hill
Christine Maldanado, University of Missouri
Elizabeth Martin, University of Missouri
Julia Martinez, University of Missouri
David Wagner, University of Missouri
Andrew Wegrzyn, University of Missouri
Catalina Woldarsky Meneses, York University
Resources for Student Success
A textbook needs to be engaging, clearly written, and organized well so that
students can readily comprehend and retain the information provided. Toward
this end, a number of features and additional resources are included in this edition. At the beginning of each chapter, focus questions and a chapter outline
appear; and each chapter closes with a summary, definitions of key terms, and a
list of Web sites of interest.
An Instructor’s Manual with a Test Bank is also available. Topic summaries and
suggestions to improve class presentations are included in the manual. Furthermore, the manual provides a list of film and video resources, as well as student
exercises and activities relevant to the Web sites that are referred to in the book.
The Future of Clinical Psychology
We believe that the future of clinical psychology is bright, provided that clinical
psychologists continue to receive rigorous training in research methods and in
evidence-based approaches to assessment and intervention. Further, we must anticipate trends in the marketplace. One important trend is that doctoral-level clinical
psychologists are less frequently called upon to provide direct services (e.g., psychotherapy). Managed care (and the associated lower-reimbursement rate for
doctoral-level clinicians) has made direct service a less attractive option for clinical
psychologists. Further, the mental health field is becoming saturated with service
providers from other disciplines. In most cases, these other mental health professionals charge less for their services. However, the rigorous research training and
the training in evidence-based assessment and treatment that defines clinical psychology will be an advantage in such a scenario. Increasingly, clinical psychologists
will be asked to oversee the training of direct service providers and to evaluate the
effectiveness of the interventions that are implemented.
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PREFACE
Thanks and Kudos
I am thankful to have such a supportive and loving partner, Meg, and two amazing daughters, Molly and Janey. I am thankful for the support and friendship of
many clinical psychology colleagues, especially Kenny Sher and Tom Widiger.
Finally, Ray Ronci has been a great source of friendship and inspiration. Thanks
Ray! (TJT)
I am grateful to my always supportive wife, and my very cute baby daughter,
for their inspiration and love. I am indebted to my mentors, Drs. Annette La
Greca, and Tony Spirito, for their outstanding commitment to the field and
the lessons they have taught me about “giving back” to clinical psychology.
(MJP)
We are extremely fortunate to have the benefit of the expertise of the
Cengage Learning staff. We especially want to thank Jessica Alderman and
Jaime Perkins for supporting our efforts and guiding us through the revision
process.
We also want to thank those who agreed to be “profiled” for this book.
Their comments really help clinical psychology “come alive.”
The feedback and comments from the reviewers of the chapters of this book
were extremely helpful: Leonard Burns, Washington State University; Glenn
Callaghan, San Jose State University; Chris Correia, Auburn University; Jenny
M. Cundiff, University of Utah; Regan Gurung, University of Wisconsin, Green
Bay; Barb J. Heine, University of California, Irvine; Jean Hill, New Mexico Highlands
University; Cindy Lou Matyi, Ohio University, Chillicothe; Jennifer Muehlenkamp,
University of Wisconsin, Eau Claire; Keith Renshaw, University of Utah; Denise
Sloan, Boston University; Jasper Smits, Southern Methodist University; Mary Spiers,
Drexel University; David Topor, Cleveland State University; Dustin Wygant, Eastern
Kentucky University; Eric Youngstrom, University of North Carolina, Chapel Hill.
PART
I
Foundations of
Clinical Psychology
1
2
Historical Overview of Clinical Psychology
3
4
5
Clinical Psychology: An Introduction
Current Issues in Clinical Psychology
Research Methods in Clinical Psychology
Diagnosis and Classification of Psychological Problems
1
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1
Clinical Psychology:
An Introduction
FOCUS QUESTIONS
4. What are the major components of a doctoral
program in clinical psychology?
5. What are the general qualifications for graduate study in clinical psychology?
1. What distinguishes a clinical psychologist from
other mental health professionals?
2. How does a clinical psychologist integrate
research and practice (clinical work)?
3. What current trends will likely affect the future
roles of clinical psychologists?
CHAPTER OUTLINE
Training: Toward a Clinical Identity
An Overview
Clinical Psychology Training Programs
BOX 1-2: Graduate Student Perspective: Julia
Martinez
What Is Clinical Psychology?
Closely Related Mental Health Professions
Psychiatrists
BOX 1-1: Professional Issues: But is it the Right
Prescription for Clinical Psychology?
Counseling Psychologists
Other Mental Health Professionals
A Profession in Movement
Women in Clinical Psychology
Training Models
Clinical Practice
Professions and Titles Not Regulated by the
Government
A Tolerance for Ambiguity and a Thirst for New
Knowledge
The Clinical Psychologist
Activities of Clinical Psychologists
Employment Sites
A Week in the Life of Dr. Karen C
Some Demographic Notes
Research and the Scientific Tradition
CHAPTER SUMMARY
KEY TERMS
WEB SITES OF INTEREST
3
4
CHAPTER 1
WHAT IS CLINICAL PSYCHOLOGY?
What is a clinical psychologist? Although it seems as
though we are inundated with real and fictional
portrayals of clinical psychologists in the media,
the general public remains rather confused about
what psychologists do as well as their educational
backgrounds. Perhaps this should not be too surprising given that clinical psychologists are a heterogeneous group with respect to age, gender,
theoretical allegiance, and roles (Norcross, Karpiak,
& Santoro, 2005). Equally confusing, there are
many titles that people use to indicate that they
practice therapy (e.g., psychotherapist, psychoanalyst) or conduct research related to psychology (e.g.,
professor, clinical scientist). However, not all of
these titles indicate that someone is a clinical psychologist. Indeed, the American Psychological
Association and the licensing boards of each
North American state and province reserve the
title “clinical psychologist” for a very select group
of professionals with specific training and qualifications (described in more detail below).
Still, the field of clinical psychology is confusing and often misunderstood. After all these years,
people still confuse clinical psychologists with medical doctors/psychiatrists. Some continue to believe
that clinical psychology is synonymous with psychoanalysis. Others see a bit of the witch doctor
in clinical psychologists, and still others view them
as somewhat peculiar. Fortunately, there are many
who accurately regard clinical psychologists as
researchers, members of prestigious professional
societies, and providers of important human
services.
In an attempt to define and describe clinical
psychology, J. H. Resnick (1991) proposed the following definition and description of clinical
psychology:
The field of clinical psychology involves
research, teaching, and services relevant to
the applications of principles, methods, and
procedures for understanding, predicting,
and alleviating intellectual, emotional,
biological, psychological, social and
behavioral maladjustment, disability and
discomfort, applied to a wide range of
client populations. (p. 7)
According to Resnick, the skill areas central to
the field of clinical psychology include assessment
and diagnosis, intervention or treatment, consultation, research, and the application of ethical and
professional principles. Clinical psychologists are
distinguished by their expertise in the areas of psychopathology, personality, and their integration of
science, theory, and practice.
A more recent definition of clinical psychology appears on the Web page of the American
Psychological Association’s Division 12 (Society
of Clinical Psychology; www.div12.org/aboutclinical-psychology):
The field of Clinical Psychology integrates
science, theory, and practice to understand,
predict, and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and
personal development. Clinical Psychology focuses on the intellectual, emotional,
biological, psychological, social, and
behavioral aspects of human functioning
across the life span, in varying cultures, and
at all socioeconomic levels.
Clinical psychologists work with a range of
individuals, from infants to the elderly. Their
work can involve individuals themselves, families/
partners, school personnel, other health care workers, and communities. Clinical psychologists often
work in a large range of settings, including universities, hospitals, private practice offices, or group
medical practices. Of all of the possible mental
health degrees and fields available, some have
described the doctoral (Ph.D.) degree in clinical
psychology to be the most versatile, since it can
lead to a very wide range of possible job
opportunities.
Although these definitions describe what clinical psychologists aim to do and, by implication, the
skills they possess, we must also take note of how
others see the profession and try to correct any false
CLINICAL PSYCHOLOGY: AN INTRODUCTION
impressions. The main purpose of this first chapter
is to clarify the nature of clinical psychology by
describing what clinical psychologists do and
where they do it, how they became clinicians,
and how they differ from other professionals who
also tend to people’s mental health needs. In the
process, we should gain a better understanding of
the field of clinical psychology.
CLOSELY RELATED MENTAL
HEALTH PROFESSIONS
Before we examine the nature of clinical psychology, let us briefly review some of the other major
professions in the mental health field. Because most
confusion lies in contrasting clinical psychology
with psychiatry and with counseling psychology,
we focus most of our discussion on these fields.
Following this review, we can better present the
characteristics that give clinical psychology its
unique identity.
Psychiatrists
A psychiatrist is a physician. Psychiatry is rooted in
the medical tradition and exists within the framework of organized medicine. Thus, psychiatrists are
often accorded the power and status of the medical
profession, even though their intellectual heritage
comes from the non-medical contributions of
Freud, Jung, Adler, and others. Although the latter
were physicians, they stepped out of the medical
tradition to develop a psychoanalytic system of
thought that had very little to do with medicine.
The psychiatric profession has vocally and effectively pushed for a superior role in the mental
health professional hierarchy, and much of the profession’s argument has been based on its medical
background. Consistent with its roots in the medical tradition, psychiatry regards psychopathology as
a mental “illness” with discrete (often biologically
based) causes that can best be remedied with a medical treatment, such as psychotropic medication.
5
Psychiatrists, like all medical doctors, complete
a general medical school curriculum early in their
training. Because of their medical training, psychiatrists have the skills to function as physicians. They
may prescribe medication, treat physical ailments,
and give physical examinations. In addition to
some training in psychotherapy and psychiatric
diagnosis, psychiatrists make extensive use of a variety of medications in treating their patients’ psychological difficulties. Furthermore, their medical
training makes them potentially better able to recognize medical problems that may be contributing
to the patient’s psychological distress. However, as
Box 1-1 suggests, even these traditional lines that
have served to distinguish psychiatrists from clinical
psychologists may become more blurred in the
future.
Following completion of the medical degree
and the general medical internship required of all
physicians, the typical psychiatrist-to-be receives
psychiatric training during a four-year residency.
This apprenticeship period involves supervised
work with patients in an outpatient or hospital setting, accompanied by seminars, reading, discussion,
and related activities. The amount of formal psychiatric coursework varies, but the core training experience
is the treatment of patients under the supervision of a
more experienced psychiatrist.
The following description of a psychiatrist
appears on the Web page HealthyMinds.org (www.
healthyminds.org/Main-Topic/What-is-a-Psychiatrist.aspx), which is maintained by the American Psychiatric Association:
A psychiatrist is a medical physician who
specializes in the diagnosis, treatment, and
prevention of mental illnesses, including
substance use disorders. Psychiatrists are
qualified to assess both the mental and
physical aspects of psychological disturbance. A psychiatrist has completed medical school (is an M.D. or D.O.) and an
additional four or more years of residency
training in psychiatry…. Because they are
physicians, psychiatrists can order or perform a full range of medical laboratory and
6
CHAPTER 1
BOX 1-1
Professional Issues: But Is It the Right Prescription for Clinical Psychology?
For decades, a number of clinical psychologists
expressed the hope that they may eventually be
accorded the same privilege of writing prescriptions
that psychiatrists have long enjoyed (McGrath, 2009).
In particular, they want to prescribe psychotropic
medications that affect mental activity, mood, or
behavior. But others have urged caution here. They
suggest that the reason clinical psychology has flourished is that it is different from psychiatry. Clinical
psychologists have developed unique skills in psychological assessment. They have built a profession on a
solid scientific basis. To imitate psychiatry by an illadvised attempt to write prescriptions might destroy
clinical psychology’s very uniqueness, they say.
Clinical psychologists frequently stress to troubled
clients their autonomy and the necessity that they, as
clients, collaborate with the therapist in the change
process. In contrast, psychiatrists often come from a
more authoritarian tradition. The doctor is an expert
who tells patients what is wrong with them and then
may prescribe medication to ease their suffering and to
make life better. Traditionally, clinical psychologists
have been committed to psychological, not biological,
treatments. Clinicians have not subscribed to the credo
of “better living through chemistry” when applied to
psychological problems. Although few clinical psychologists would argue that medication is never necessary,
psychological tests which, combined with
interviews/discussions with patients, help
provide a picture of a patient’s physical and
mental state. Their education and years of
clinical training and experience equip them
to understand the complex relationship
between emotional and other medical illnesses, to evaluate medical and psychological data, to make a diagnosis, and to work
with a patient to develop a treatment plan.
In contrast to psychiatrists, clinical psychologists
typically receive little training in medicine. However, clinical psychologists do receive more extensive training in the psychological principles
governing human behavior, in formal assessment
of psychological functioning, and in scientific
research methods. As compared to psychiatrists,
many would argue that, ultimately, most clients must
learn to come to grips psychologically with their emotional and behavioral problems. The bottom line seems
to be that, at present, the field is conflicted about the
value of prescription privileges.
Despite the field’s ambivalence, the American Psychological Association did officially endorse this pursuit
in 1995 (Martin, 1995). Currently, two states (New Mexico and Louisiana) allow “appropriately” trained psychologists to prescribe medications for treatment of
certain mental health conditions (McGrath, 2010). This
development has important implications for research,
training, and practice. For example, major changes in
graduate training would be required to prepare clinical
psychologists for this new role.
It is clear that programs will have to be lengthened by at least 1 year to provide even rudimentary
training to prepare graduate in this new arena of
practice. In some cases, programs would have to be
completely revamped. Currently, it appears that the
specialization required to earn the right to prescribe
will occur at the postdoctoral level (after the Ph.D. or
Psy.D. is granted). Most agree that this decision by the
APA to pursue prescription privileges will have a lasting impact on the direction of the field. Whether it is a
positive or negative effect remains to be seen. We’ll
have a lot more to say about this issue in Chapter 3.
clinical psychologists also receive more extensive
training in psychotherapy (i.e., “talk” therapy as
opposed to medications) and are more likely to
view psychopathology as a consequence of interactions between individuals’ biological/psychological/
social predispositions and their experiences within
the environment.
Psychiatry no longer enjoys the prestige and
popularity it once did. The proportion of medical
school graduates who choose psychiatric residencies
has generally declined since 1970, but over the last
5 years has stabilized at about 4.1 to 4.6% (Moran,
2011). In 2011, 640 U.S. medical school graduates
matched with a psychiatry residency program.
Unlike psychiatry, the medical specialties of family
medicine, pediatrics, and internal medicine are
enjoying significant growth (Moran, 2011). Further,
a large percentage of those entering psychiatry
7
killerb10/iStockphoto
CLINICAL PSYCHOLOGY: AN INTRODUCTION
Psychiatrists are medical doctors that specialize in mental health.
residency programs in the United States, approximately 40% over the last 5 years, consists of international medical school students (Moran, 2007, 2011).
Reasons offered for the decline in interest, especially
among medical students from the United States,
include psychiatry’s increased emphasis on biological
approaches (thus making the field more conventional
and similar to other medical specialties), the economic impact of managed care on psychiatric practice, and the increased competition from other
mental health specialties, such as clinical psychology.
Consequently, many psychiatrists do not conduct
extensive psychotherapy with their patients, but
rather often schedule brief (i.e., quarter-hour) “medication management” appointments with each
patient (e.g., see Harris, 2011). Opportunities to
work in depth with individuals experiencing psychological symptoms or to help teach behavioral skills
that may reduce and prevent symptoms are more limited in psychiatry than in clinical psychology.
As mentioned in Box 1-1, a major battleground for the profession of psychiatry is that
of prescription privileges for non-medical health
care professionals, including clinical psychologists
(Katschnig, 2010; Rabinowitz, 2008). Some have
even pointed to the granting of prescription privileges to psychologists in a handful of states to date
(e.g., New Mexico, Louisiana), as well as the fact
that many physicians do not rely on psychiatrists for
advice or guidance concerning the prescription of
psychiatric medications, as a signal of the “demise of
psychiatry” as a medical specialty (Koocher, 2007).
Whether this takes place remains to be seen. However, there is no doubt that the field of psychiatry is
suffering currently from a bit of an identity crisis
(Katschnig, 2010; Tasar, 2008).
Counseling Psychologists
The activities of counseling psychologists overlap with
those of clinical psychologists. Traditionally,
counseling psychologists work with normal or
moderately maladjusted individuals. Their work
may involve group counseling or counseling with
individuals. Their principal method of assessment is
usually the interview, but counseling psychologists
also do testing (e.g., assessment of abilities,
8
CHAPTER 1
personality, interests, and vocational aptitude). Historically, these professionals have focused on conducting educational and occupational counseling,
often from a person-centered or humanistic orientation. Currently, however, it is much more common to encounter counseling psychologists
representing a wide range of theoretical orientations
(e.g., cognitive-behavioral, psychodynamic) and
treating clients across the life span.
Traditionally, the most frequent employment
settings for counseling psychologists have been educational settings, especially colleges and universities.
However, counseling psychologists (like clinical psychologists) also work in hospitals, rehabilitation centers, mental health clinics, and industry. A good
example of the kind of work conducted by counseling psychologists within educational settings is suggested in the heading that appeared above an article in
a campus newspaper several years ago: “Counseling
Center Responds to Married Students’ Needs.” The
article went on to describe group counseling sessions
designed to help students who are parents deal with
the special problems that marriage and children create
for them in pursuing their academic goals.
In general, counseling psychologists see themselves providing the following services: (a) preventive treatment, (b) consultation, (c) development of
outreach programs, (d) vocational counseling, and
(e) short-term counseling/therapy of from one to
fifteen sessions. However, more and more counselors are engaged in activities, such as individual psychotherapy and even psychological testing, that are
traditionally in the clinical province. Today, they
are frequently less interested in vocational or career
counseling and more interested in private practice.
Although there are a number of similarities
between counseling and clinical psychology, there
are several distinguishing features as well (Norcross,
Sayette, & Mayne, 2008). The field of clinical psychology is much larger in terms of the number of
doctoral-level professionals as well as the number of
accredited doctoral training programs. There are
approximately 3 times as many accredited doctoral
programs, producing 4 times as many graduates,
in clinical psychology as in counseling psychology.
In contrast to the majority of clinical psychology
programs, counseling programs are less frequently
housed in psychology departments. Rather, many
counseling psychology programs may be based in a
department or school of education. Finally, as noted
above, counseling psychologists are more likely to
provide services for mildly disturbed or maladjusted
clients and are more likely to specialize in career or
vocational assessment. Norcross, Sayette, Mayne,
Karg, and Turkson (1998) indicate several further
distinctions between doctoral programs in clinical
and counseling psychology:
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About twice as many people apply to clinical
programs, although acceptance rates are similar.
Average GRE scores of accepted students are
slightly higher in clinical than in counseling
programs.
Counseling programs accept a higher percentage of ethnic minority students and students
with a master’s degree.
Research focusing on minority/cross-cultural
issues and vocational testing is more common
among counseling faculty at doctoral programs.
Research focusing on psychological disorders,
clinical health psychology, and clinical child
and adolescent psychology is more common
among clinical faculty at doctoral programs.
There are about 70 doctoral training programs
in counseling psychology accredited by the American Psychological Association (APA), and about
360 doctoral degrees in counseling psychology
were granted by these programs in 2009–2010
(Kohut & Wicherski, 2010).
Other Mental Health Professionals
Clinical Social Workers. The professional activities of clinically trained social workers often seem
similar to those of psychiatrists and clinical psychologists. Many social workers conduct psychotherapy
on an individual or group basis and contribute to
the diagnostic process as well. Interestingly, there
are more clinically trained social workers than psychiatrists, psychologists, and psychiatric nurses combined! The Web site of the National Association of
CLINICAL PSYCHOLOGY: AN INTRODUCTION
Social Workers (www.naswdc.org/pressroom/features/general/profession.asp) defines the profession
of social work in the following manner:
Professional social workers assist individuals, groups, or communities to restore or
enhance their capacity for social functioning, while creating societal conditions
favorable to their goals. The practice of
social work requires knowledge of human
development and behavior, of social, economic and cultural institutions, and of the
interaction of all these factors.
Perhaps it was the close association with psychiatrists and psychologists that led many social
workers to focus less on social or environmental factors and to become more interested in addressing
psychological factors that may play a role in individuals’ and family’s difficulties. Regardless, clinically
trained social workers often perform many of the
same psychotherapeutic activities as their psychological and psychiatric counterparts. Typically, however, social workers still place a greater focus on the
familial and social determinants of psychopathology.
The social work profession has been a leader in
the use of supervised fieldwork as a learning device
for students. Fieldwork placement is part of the
program for the master’s degree (usually the terminal degree for social workers), which typically
requires 2 years. Compared to the training of
clinical psychologists and psychiatrists, social work
training is rather brief. As a result, the responsibilities of the social worker are generally not as great as
those of the psychiatrist or clinical psychologist.
Characteristic of social workers is their intense
© National Geographic Image Collection/Alamy
In years past, social workers tended to deal with
the social forces and external agents that were contributing to the patient’s difficulties. The social
worker would take the case history, interview
employers and relatives, make arrangements for vocational placement, or counsel parents; the psychiatrist
conducted psychotherapy with patients; and the clinical psychologist tested them. However, these professional roles have blurred over the years.
9
Social workers typically focus more on the familial and social determinants of mental
health problems.
10
CHAPTER 1
involvement with the everyday lives and stresses of
their patients. They are more likely to visit the
home, the workplace, or the street—the places
where their patients spend the bulk of their lives.
Their role tends to be active, and they are less concerned with the abstract, theoretical generalizations
that can be drawn from a particular case than they
are with the practical matters of living.
Many clinical social workers are employed by
public agencies of one sort or another. Some find
their way into private practice, where their work in
individual or family therapy is often indistinguishable from that of psychiatrists or clinical psychologists. Other clinical social workers function as part
of the mental health team (including psychiatrists
and clinical psychologists) in hospitals, social service
agencies, or mental health clinics.
The field of social work appears to be growing
tremendously. It is estimated that social workers provide more than half of all the nation’s mental health
services, and social workers are likely to gain an even
greater foothold in the mental health market in the
future because they are a low-cost alternative to psychiatrists and psychologists. Enrollment in social
work programs continues to increase, and the number of clinical social workers is predicted to continue
rising, perhaps by as much as 30% from 2004 to 2014
(Bureau of Labor Statistics, www.bls.org).
School Psychologists. School psychologists work
with students, educators, parents, and school
administrators to promote the intellectual, social,
and emotional growth of school-age children and
adolescents. Toward this end, school psychologists
may conduct psychological and educational assessments, develop learning programs and evaluate
their effectiveness, and consult with teachers, parents, and school officials. To take one example, a
school psychologist may develop a program to assist
the development of children with special intellectual, emotional, or social needs. This might begin
with an evaluation of the children in question, followed by recommendations concerning special
programs, treatment, or placement if necessary. In
addition, the school psychologist might consult
with teachers and school officials on the
implementation of the programs as well as issues
of school policy or classroom management.
School psychologists are in high demand, as
U.S. laws require that children who may require
special educational resources must receive a thorough educational assessment. School psychologists
conduct the majority of these assessments, and
thus, there is a great need for school psychologists
to evaluate the intellectual ability and academic
achievement of youth, many of whom remain on
waiting lists for months or years until someone is
available to conduct an evaluation. The majority of
school psychologists work in schools, but some also
work in nurseries, day-care centers, hospitals,
clinics, and even penal institutions. A few are in
private practice. There are about 60 APAaccredited programs in school psychology, and
approximately 200 doctoral degrees in school
psychology were awarded by these programs in
2009–2010 (Kohut & Wicherski, 2010).
Health and Rehabilitation Psychologists. Although many health and rehabilitation psychologists
have doctoral degrees in clinical psychology, there is
no requirement for this. Indeed, counseling, social,
and experimental psychologists, for example, may
specialize in either health or rehabilitation psychology. Such specialization typically occurs at the graduate and postdoctoral level. Because Chapter 17 of
this book discusses both health and rehabilitation
psychology in more detail, only a brief introduction
will be provided here.
The field of health psychology has emerged in
the last few decades and continues to grow rapidly.
Health psychologists are those who, through their
research or practice, contribute to the promotion
and maintenance of good health. They are also
involved in the prevention and treatment of illness.
They may design, execute, and study programs to
help people stop smoking, manage stress, lose
weight, or stay fit. Because this is an emerging
field, those in it come from a variety of backgrounds, including clinical psychology, counseling
psychology, social psychology, and others. Many
health psychologists are employed in medical
centers, but increasingly they are serving as
CLINICAL PSYCHOLOGY: AN INTRODUCTION
consultants to business and industry—in any organization that recognizes the importance of keeping
its employees or members well. As we will discuss
in Chapter 3, this specialty is likely to profit most
from the sweeping changes in health care.
In both research and practice, the focus of
rehabilitation psychologists is on people who are
physically or cognitively disabled. The disability
may result from a birth defect or later illness or
injury. Rehabilitation psychologists help individuals adjust to their disabilities and the physical,
psychological, social, and environmental barriers
that often accompany them. Thus, they advocate
for the improvement of life conditions for those
with disabilities and help develop and promote
legislation to promote this cause (e.g., the
Americans with Disabilities Act). Rehabilitation
psychologists often work at acute care facilities,
medical centers, rehabilitation institutes and hospitals, community agencies, VA hospitals, and universities. In addition to clinical care, rehabilitation
psychologists may provide expert testimony in
insurance cases, conduct testing, and serve on
interdisciplinary teams.
Psychiatric Nurses. We have long been aware of
the role of psychiatric nurses. Because they spend
many hours in close contact with patients, they are
not only in a position to provide information about
patients’ hospital adjustment but also can play a
crucial and sensitive role in fostering an appropriate
therapeutic environment. Working in close collaboration with the psychiatrist or the clinical psychologist,
they (along with those they supervise—attendants,
nurse’s aides, volunteers, etc.) implement therapeutic
recommendations. Certified nurse practitioners now
have prescription privileges in all but a few states in the
United States. Therefore, nurses may be used increasingly in the front line of mental health services.
AJPfilm/Custom Medical Stock
Psychiatric nurses often work on a team of mental health
providers.
11
Others. Most well-staffed hospitals employ a
variety of other therapeutic personnel, including
occupational therapists, recreational therapists, art
therapists, and so on. By virtue of their training
and experience, these people can play a vital adjunctive role in enhancing the adjustment patterns of
patients. They can teach skills that will help patients
in a variety of non-hospital settings. They can help
make hospitalization a more tolerable experience,
and they can provide outlets that increase the therapeutic value of institutions. Whether their role is to
help put patients in touch with their feelings via art,
music, gardening, or dancing or to enhance patients’
personal and social skills, the contributions of such
therapeutic personnel are significant.
People who are trained to assist professional
mental health workers are called paraprofessionals,
and their role has expanded greatly in recent
years. Volunteers are often provided short training
sessions and then become the most visible personnel
in crisis centers (both walk-in and telephone). Certain paraprofessional activities have become
accepted practice. Research indicates strongly that
the efforts of paraprofessionals can effectively supplement the work of professionals (e.g., see Christensen & Jacobson, 1994). We will discuss this issue
extensively in Chapter 16.
12
CHAPTER 1
T A B L E 1-1 Clinicians’ Activities
Percentage involved in
Activity
1995
2003
Mean percentage of time
1973
1981
1986
1995
2003
Psychotherapy
84
80
31
35
35
37
34
Diagnosis/Assessment
74
64
10
13
16
15
15
Teaching
50
49
14
12
14
09
10
Clinical Supervision
62
50
08
08
11
07
06
Research/Writing
47
51
07
08
15
10
14
Consultation
54
47
05a
07
11
07
07
Administration
52
53
13
13
16
11
13
a
Garfield and Kurtz percentage is for “community consultation.”
SOURCE: Adapted from Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psychologists across the years: The Division of Clinical Psychology from
1960 to 2003. Journal of Clinical Psychology, 61, 1467–1483.
PROFESSIONS AND TITLES NOT
REGULATED BY THE GOVERNMENT
Most of the professionals and paraprofessionals listed
above have fulfilled specific educational requirements
and licensing requirements regulated by state and provincial governments. In other words, these mental
health workers must (1) document that they have
obtained appropriate professional training; (2) pass a
licensing exam indicating familiarity with current
practice parameters, ethical regulations, and state
laws; (3) and maintain their current knowledge of
the field through ongoing educational requirements
(i.e., continuing professional education). However,
some titles are not regulated by the government
(e.g., “therapist,” “psychotherapist”), and virtually
anyone can offer services using this title. Unfortunately, some members of the public are not aware
of this distinction and may confuse the services offered
by a professional with other unregulated services.
Now that we have briefly examined some of
the other helping professions, let us turn to the
work of the clinical psychologist.
THE CLINICAL PSYCHOLOGIST
It is extraordinarily difficult to list comprehensively
all of the issues and symptoms that are relevant to
the field of clinical psychology. The number and
kinds of problems are so extensive as to boggle
the mind: depression, anxiety, psychosis, personality
disorders, mental retardation, addictions, learning
disabilities, conduct disorder, attention deficit
hyperactivity disorder, pervasive developmental disorders, suicide, vocational problems, and sexual difficulties—to name but a few. Further, this list does
not cover those individuals who seek out psychotherapy not because of current dysfunctional symptoms, but as a way to better understand themselves.
Instead of defining clinical psychology in terms
of problems or issues clinical psychologists are asked
to address, we will try to give a picture of the field by
reviewing the activities engaged in by clinical
psychologists.
Activities of Clinical Psychologists
Much of our information about clinical activities
comes from a series of studies conducted between
1973 and 2003. Each study involved a random sample of members of Division 12 (Division of Clinical
Psychology) of the American Psychological Association (APA). Garfield and Kurtz (1976) examined
more than 800 questionnaires collected in 1973;
Norcross and Prochaska (1982) analyzed nearly
500 surveys gathered in 1981; Norcross, Prochaska,
and Gallagher (1989b) were able to analyze 579
questionnaires from 1986; Norcross, Karg, and
Prochaska (1997a, 1997b) surveyed 546 clinical
CLINICAL PSYCHOLOGY: AN INTRODUCTION
Therapy/Intervention. It is clear from Table 1-1
that therapy is the activity that most frequently
engages the typical clinical psychologist’s efforts and
to which the most time is devoted. Many people
have an image of the therapy situation as one in
which the client lies on a couch while the therapist,
bearded and mysterious, sits behind with notepad
and furrowed brow. Actually, therapy comes in
many different sizes and shapes. A few (but very
few!) therapists still use a couch, but more often,
the client sits face-to-face across from the therapist.
In most cases, therapy involves a one-to-one relationship, but today, couple’s therapy, family therapy,
parent training, and group therapy are also very common. For example, a group of six or eight clients, all
having trouble with alcohol use, may meet together
with a therapist to work on their problems. Or a
psychologist may meet with a child’s parents to discuss ways that reinforcements in the home may
reduce the child’s disruptive behavior. Finally, sizable
proportions of therapists are women, not men. This
gender disparity among therapists is likely to continue for some time, given that over 70% of clinical
psychology graduate students each year are women.
Michael Newman/PhotoEdit
psychologists in 1994–1995; and finally, Norcross et
al. (2005) surveyed 694 clinical psychologists in
2003. The results of these five surveys are presented
in Table 1-1 and Table 1-2.
From Table 1-1, it is apparent that psychotherapy of one sort or another is the most frequently
engaged in activity and occupies the most time, as
it has in all the cited surveys from 1973 to 2003.
Diagnosis and assessment also continue as major
activities. Research activity has grown over the
years (to around 14% of the 2003 respondents’
time), which is a bit surprising in light of the
fact that 39% of the 2003 sample was employed
full-time in private practice. Still, it is important to
note that some clinical psychologists never publish a
research paper and that only 10–15% of all clinicians
produce 40–50% of all the work published by clinical psychologists (Norcross et al., 1989b, 1997b).
Teaching is another relatively common activity
among clinical psychologists. Unfortunately, the
time devoted to administration remains significant,
perhaps reflecting the bureaucracy that is so prevalent
in modern society. Let us now take a closer look at
the six activities represented in Table 1-1.
13
Psychotherapy remains one of the major activities of clinical psychologists.
14
CHAPTER 1
Historically, therapy involved mainly a search
for insight into the origins of one’s problems or the
purposes served by one’s undesirable behavior. In
other cases, therapy consisted primarily of a relationship between client and therapist designed to produce an atmosphere of trust that would help dissolve
the client’s debilitating defenses. Today, therapy
may involve some “insight-oriented” work, but
research suggests that therapies involving specific
skills may be more useful for reducing client’s problems. For instance, cognitive-behavioral therapies
involve a structured format to help the client learn
new and more satisfying ways of thinking and
behaving. Sometimes the goals of therapy are
sweeping and involve major changes in behavior.
Other times patients desire help only with a single
type of symptom (e.g., a troublesome fear) that prevents them from achieving certain goals. Therapy
varies, then, along many different dimensions.
■
Diagnosis/Assessment. All practicing clinicians
engage in assessment of one form or another.
Take, for example, the following cases:
Common to all these examples is the effort to
better understand the individual so that a more
informed decision can be made or the most
■
■
© Blend Images/Alamy
■
A child who is failing the fourth grade is
administered an intelligence test and an
achievement test. Does she have a learning
disability?
Personality tests are given to a client who is
depressed and has lost all zest for life. Can the
test results shed light on personality factors
contributing to the depression?
An adolescent has been talking excessively,
moving quickly, switching from one idea to
another, and has been engaging in more risktaking behaviors. A diagnostic assessment is
conducted to determine whether he may have
Bipolar Disorder, ADHD, or some other possible psychological disturbance.
A father has been charged with child abuse. He
is interviewed and tested to determine whether
he suffers from a mental disorder that influences his judgment and impulse control.
Some clinical psychologists specialize in psychological testing and assessment.
CLINICAL PSYCHOLOGY: AN INTRODUCTION
desirable course of action selected. Assessment,
whether through observation, testing, or interviewing, is a way of gathering information so that an
important question can be answered or so that a
problem can be solved. These questions or problems are virtually infinite in variety, as the foregoing examples suggest. Assessment has long been a
critical part of the clinical psychologist’s role.
Indeed, for many years, assessment, especially testing, was the chief element in the clinician’s professional identity.
Teaching. Clinical psychologists who have fullor part-time academic appointments obviously
devote a considerable amount of time to teaching.
Those whose responsibilities are primarily in the
area of graduate education teach courses in
advanced psychopathology, psychological testing,
interviewing, intervention, personality theory,
developmental psychopathology, and so on. Some
of them may also teach undergraduate courses such
as introductory psychology, personality, abnormal
psychology, introduction to clinical psychology,
psychological testing, and others. Even clinicians
whose primary appointments are in clinics or hospitals or who operate a private practice sometimes
teach evening courses at a nearby college or university or may even have part-time appointments in
graduate programs to help teach or supervise students working towards their doctoral degree.
Much of this teaching is of the familiar
classroom-lecture type. But a considerable amount
of teaching is also done on a one-to-one, supervisory basis. Clinical psychologists in clinical settings
may also teach informal classes or do orientation
work with other mental health personnel, such as
nurses, aides, social workers, occupational therapists, and so on. In some cases, the clinician may
go out into the community and lead workshops on
various topics for police officers, volunteers, ministers, probation officers, and others.
Clinical Supervision. Clinical supervision is
really another form of teaching. However, it typically involves more one-to-one teaching, small
group approaches, and other less formal, non-
15
classroom varieties of instruction. Whether in university, internship, or general clinical settings, clinical psychologists often spend significant portions of
their time supervising students, interns, and others.
Becoming skilled in the intricacies of therapy and
assessment techniques requires more than just reading textbooks. It also involves seeing clients and
then discussing their cases with a more experienced
supervisor. In short, one learns by doing, but under
the controlled and secure conditions of a trainee–
supervisor relationship. This kind of “practicum”
teaching and supervision can occur both in university and internship settings and in postdoctoral programs as well.
Research. Clinical psychology has grown out of
an academic research tradition. As a result, when
clinical training programs were first established
after World War II, the scientist-practitioner
model was adopted. This meant that, in contrast
to other mental health workers such as psychiatrists
or social workers, all clinicians were to be trained
as scientists and as practitioners. This model was
not adopted because it was expected that all
clinical psychologists would engage in both clinical and research work with equal emphasis, but
rather because it was believed that to be an effective clinical psychologist, one must have expertise
in “thinking like a scientist.” The scientistpractitioner model suggests that clinical work is
enhanced by a knowledge of scientific methods,
and research is improved by exposure to clinical
practice. Although the research emphasis may not
be so prominent in some “scientist-practitioner”
training programs as it once was, the fact remains
that clinical psychologists are in a unique position
both to evaluate research conducted by others and
to conduct their own research. By virtue of their
training in research, their extensive experience
with people in distress, and their knowledge of
both therapy and assessment, clinical psychologists
have the ability to consume and to produce new
knowledge.
The range of research projects carried out by
clinicians is enormous. Studies include searching for
the causes of mental disorders, development and
16
CHAPTER 1
October 2010
Volume 78, Number 5
Journal of Consulting and Clinical Psychology ®
www.apa.org/pubs/journals/ccp
Copyright © 2010 by the American Psychological Association, Inc.
Featured Articles
599
Posttraumatic Stress Symptoms Among National Guard Soldiers Deployed to Iraq: Associations With Parenting Behaviors and Couple Adjustment
Abigail H. Gewirtz, Melissa A. Polusny, David S. DeGarmo, Anna Khaylis, and Christopher R. Erbes
611
Longitudinal Analyses of Family Functioning in Veterans and Their Partners Across Treatment
Lynette Evans, Sean Cowlishaw, David Forbes, Ruth Parslow, and Virginia Lewis
Couples/Families
623
Coping and Parenting: Mediators of 12-Month Outcomes of a Family Group Cognitive—Behavioral Preventive Intervention With Families of Depressed Parents
Bruce E. Compas, Jennifer E. Champion, Rex Forehand, David A. Cole, Kristen L. Reeslund, Jessica Fear, Emily J. Hardcastle, Gary Keller, Aaron Rakow, Emily Garai, Mary
Jane Merchant, and Lorinda Roberts
635
The Alliance in Couple Therapy: Partner Influence, Early Change, and Alliance Patterns in a Naturalistic Sample
Morten G. Anker, Jesse Owen, Barry L. Duncan, and Jacqueline A. Sparks
646
Hostility, Relationship Quality, and Health Among African American Couples
Max Guyll, Carolyn Cutrona, Rebecca Burzette, and Daniel Russell
655
Acculturative Family Distancing (AFD) and Depression in Chinese American Families
Wei-Chin Hwang, Jeffrey J. Wood, and Ken Fujimoto
Regular Articles
668
Does Pretreatment Severity Moderate the Efficacy of Psychological Treatment of Adult Outpatient Depression? A Meta-Analysis
Ellen Driessen, Pim Cuijpers, Steven D. Hollon, and Jack J. M. Dekker
681
Heterogeneity Moderates Treatment Response Among Patients With Binge Eating Disorder
Robyn Sysko, Tom Hildebrandt, G. Terence Wilson, Denise E. Wilfley, and W. Stewart Agras
691
Respiratory and Cognitive Mediators of Treatment Change in Panic Disorder: Evidence for Intervention Specificity
Alicia E. Meuret, David Rosenfield, Anke Seidel, Lavanya Bhaskara, and Stefan G. Hofmann
705
A Randomized Clinical Trial of Acceptance and Commitment Therapy Versus Progressive Relaxation Training for Obsessive-Compulsive Disorder
Michael P. Twohig, Steven C. Hayes, Jennifer C. Plumb, Larry D. Pruitt, Angela B. Collins, Holly Hazlett-Stevens, and Michelle R. Woidneck
717
Effects of Psychotherapy Training and Intervention Use on Session Outcome
James F. Boswell, Louis G. Castonguay, and Rachel H. Wasserman
724
Effectiveness of Stepped Care for Chronic Fatigue Syndrome: A Randomized Noninferiority Trial
Marcia Tummers, Hans Knoop, and Gijs Bleijenberg
(Contents continue)
F I G U R E 1-1
Sample table of contents from the Journal of Consulting and Clinical Psychology.
SOURCE: Copyright 2010 by the American Psychological Association. Adapted with permission.
validation of assessment devices, evaluation of therapy techniques, and so on. To provide something of
the flavor of these efforts, Figure 1-1 shows the table
of contents of a fairly recent issue of the Journal of
Consulting and Clinical Psychology, a major publication
outlet for research by clinical psychologists.
Consultation. In consultation and in teaching,
the goal is to increase the effectiveness of those to
whom one’s efforts are directed by imparting to
them some degree of expertise. Consultation takes
innumerable forms in many different settings. For
example, one might consult with a colleague who is
having difficulty with a therapy case. Such consultation
might be a one-shot affair with someone who simply
needs help with one specific case. In other instances,
however, a clinician might be retained on a relatively
permanent basis to provide the staff of an agency with
help. Perhaps, for example, our consulting clinician is
an expert on the problems of individuals addicted to
drugs. By working with the staff, the consultant can
increase the effectiveness of the entire agency. Consultation could come in the form of case-by-case advice,
or the consultant might be asked to discuss general
problems associated with drug addiction. Clinical psychologists also can serve as consultants to advertising
agencies or corporations interested in developing products that could improve the mental health of their
customers. Clinical psychologists offer valuable consultation services within the legal system as well, either by
assisting attorneys in the selection of jurors for a case or
consulting with police departments in hostage negotiations. Finally, a growing number of clinical psychologists serve as consultants to physicians who deliver
primary care services.
Consultation can run the gamut from clinical
cases to matters of business, personnel, and profit. It
can deal with individuals or entire organizations.
CLINICAL PSYCHOLOGY: AN INTRODUCTION
17
Sometimes it is remedial; other times it is oriented toward prevention. Consulting, regardless of
the setting in which it occurs or the particular purpose it has, is a significant activity of many clinical
psychologists today. We will discuss consultation in
more detail in Chapter 16.
university psychology department, chief psychologist in a state hospital, and director of a regional
crisis center.
Administration. It has been said half jokingly that
no one in clinical psychology enjoys administrative
work except masochists or those with obsessivecompulsive personalities. Nevertheless, nearly every
clinical psychologist spends time on administrative
tasks. For example, client records must be maintained, those infernal effort reports must be filled
out each month, and research projects must be
cleared by committees set up to safeguard the rights
of human subjects. Clinical psychologists who work
for agencies or institutions will likely serve on several
committees: personnel, research, patient rights, or
even the committee to select films for the patients’
Friday night movies.
Some really hardy souls become full-time
administrators. They do so for many reasons. Sometimes they are drafted by colleagues who regard
them as skillful in human relations. Others may
grow a bit weary of therapy or assessment and
want a change. Or maybe they have the fantasy
that administration is the route to power and
wealth. In any event, good administrators are the
ones who keep their organization running
smoothly and efficiently. Being sensitive to the
needs and problems of people in the organization
and having the patience to sometimes suffer in
silence are useful attributes of the good administrator. The ability to communicate well with those
under supervision is also important, as is a knack
for selecting the right people for the right jobs.
It would be difficult to list all the sorts of
administrative posts held by clinical psychologists.
However, here are a few examples: head of a university psychology department, director of a Veterans Administration clinic, vice president of a
consulting firm, director of the clinical training program, director of the psychological clinic in a
Where are clinical psychologists employed? Data
from the previously noted surveys will again help
answer this question. The results pertaining to work
settings from these surveys are shown in Table 1-2.
It is evident that private practice has grown steadily
over the years and is now clearly the most frequent
employment setting for clinical psychologists. University settings are the second most common
employment sites, with medical schools a distant
third. Although not shown in Table 1-2, the data
from Norcross et al. (1997b) indicate that of those
clinical psychologists whose primary job is that of a
full-time university professor, 59% are engaged in
some part-time form of private practice or supervision. From Tables 1-1 and 1-2, the diversity of both
activities and work settings is very obvious. This is
also evident in the increase over time in the numbers in the “Other” category in Table 1-2. This
diversity is illustrated in the background and activities of the hypothetical clinician described in the
next section.
Employment Sites
A Week in the Life of Dr. Karen C
Karen C. began her undergraduate career in journalism. However, following a course in general
psychology, she decided to switch to psychology.
After fulfilling the usual requirements for a psychology major (courses in psychobiology, statistics,
cognitive psychology, history and systems, personality, social psychology, etc.), she applied to
11 graduate schools. With a strong grade point
average and an equally strong set of scores on the
Graduate Record Examination, she was accepted
by 4 schools. She chose a large midwestern state
university and later did her internship at a local
state hospital.
CHAPTER 1
James Shaffer/PhotoEdit
18
Some clinical psychologists work at community mental health centers.
T A B L E 1-2 Employment Settings of Clinical Psychologists
1973
1981
1986
1995
2003
Employment Site
%
%
%
%
%
Psychiatric Hospital
08
08
09
05
04
General Hospital
06
08
05
04
03
Outpatient Clinic
05
05
04
04
04
Community Mental
Health Ctr
08
06
05
04
02
Medical School
08
07
07
09
08
Private Practice
23
31
35
40
39
University,
Psychology
22
17
17
15
18
University, Other
07
05
04
04
04
VA Medical Center
—
—
—
03
03
None
01
01
04
01
00
Othera
01
12
10
11
15
a
This category includes professional schools, correctional facilities, managed care organizations, nursing homes, child and family services, rehabilitation centers, school systems, psychoanalytic institutes, and health maintenance organizations, and so on.
SOURCE: Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psychologists across the years: The Division of Clinical Psychology from 1960 to 2003.
Journal of Clinical Psychology, 61, 1467–1483.
CLINICAL PSYCHOLOGY: AN INTRODUCTION
Five years after enrolling, she was awarded the
Ph.D. and began her career as a staff psychologist in
a tri-county outpatient clinic. Four years later, we
have a typical week in the life of Dr. Karen C.
Monday, Wednesday, Friday
8:00–9:00 A.M. Staff meeting. This meeting is
devoted to a variety of activities, including
discussion of cases, agency policy and
problems, insurance questions, and other
administrative business.
9:00–10:00 A.M. Psychotherapy. The current
case is that of a moderately depressed 48year-old woman who was recently
divorced. Mrs. G. is showing gradual
improvement, and the prospect of hospitalization seems to have passed. Dr. C. is
using what might be termed an eclectic
form of psychotherapy that is generally
cognitive-behavioral in flavor.
10:00–10:30 A.M. Psychotherapy. This
patient, Sam F., is 19 years old. He has
history of multiple arrests for shoplifting
and public intoxication. His intellectual
potential is limited, and his difficulties in
school led him to drop out of high school
at age 16. Dr. C. is using a behavior
therapy to focus in on enhancing Sam F.’s
repertoire of social skills and decreasing
the frequency of his maladaptive
behaviors.
10:30 A.M.–12:00 noon. This time period is
reserved for psychological testing, both for
Dr. C.’s patients and for the patients of
other therapists. Typically, intelligence
tests and self-report questionnaires are
administered by Dr. C. Occasionally, she
also conducts neuropsychological
assessment.
1:00–2:00 P.M. Clinical supervision. The local
university places several interns with
Dr. C.’s agency. This period is devoted to
supervising their psychotherapy and their
diagnostic efforts. The supervision of two
19
M.A.-level psychologists employed by the
agency is also included here.
2:00–3:00 P.M. Psychotherapy. Bob S. is a
university student. His major difficulty is
moderate depression and feelings of alienation. Dr. C. has tried a variety of therapeutic techniques, but nothing has seemed
to work. Although the patient has been
able to continue with his classes so far, the
prospects of hospitalization seem to be
increasing.
3:00–4:30 P.M. Group psychotherapy. This
period is devoted to the treatment of a
group of six men from diverse backgrounds who have alcohol dependence.
The group treatment approach is largely
supportive, and Dr. C. encourages and
reinforces abstinence from alcohol.
4:30–5:00 P.M. This time is typically devoted
to report writing, administrative duties,
and responding to the day’s e-mail.
Tuesday, Thursday
8:00–10:00 A.M. Dr. C. is engaged in a
research project to determine whether
certain psychological test responses (e.g.,
from the MMPI-2) can be used to predict
responsiveness to various forms of therapy.
Dr. C. is using cases from her own agency
along with cases from four other local
clinics and institutions.
10:00 A.M.–12:00 noon. Psychological testing.
1:00–3:00 P.M. Dr. C. is a consultant to the
local school system. She serves four schools
and meets with teachers to discuss their
handling of specific problem children. She
provides consultation for the school psychologist as well.
3:00–5:00 P.M. Dr. C. is advising a local
institution for patients with mental retardation on the establishment of a token
economy. The goal is to upgrade the selfcare habits of a group of adolescents and
young adults in the institution. It is hoped
20
CHAPTER 1
T A B L E 1-3 Wednesday at the University with Professor L
8:30–9:00 A.M.
Proofread test for class in Introduction to Clinical Psychology
9:00–10:00 A.M.
Research meeting with two graduate students
10:00–11:30 A.M.
Teaching: Clinical practicum supervision
11:30 A.M.–12:30 P.M.
Jog at the track, followed by brown-bag lunch in the office (read journal articles)
12:30–1:00 P.M.
Attend a Dissertation committee meeting to evaluate a doctoral student’s work
1:00–2:00 P.M.
Office hour for undergraduate students; write letters of recommendation for students
during unoccupied time
2:00–2:30 P.M.
Analyze data for submission to an upcoming professional conference
2:30–4:00 P.M.
Attend meeting of the campus committee on computer use
4:00–5:00 P.M.
Work on a revision of a manuscript submitted earlier to a journal
7:00–9:00 P.M.
Teaching: Seminar on empirically supported psychological treatments
that the project can serve as a prototype
demonstration for use throughout the
institution.
7:00–8:30 P.M. Two evenings a week, Dr. C.
teaches a course in abnormal psychology at
the local university. It is a fully accredited
course that enrolls both full- and part-time
undergraduate students.
Saturday
9:00 A.M.–1:00 P.M. Dr. C. sees a series of
patients in private practice. They are typically patients with a variety of concerns
(e.g., depression, anxiety). These patients
are usually referred by local physicians and
other professionals in the community who
are aware of Dr. C.’s excellent work and
reputation. Dr. C. also does some diagnostic testing on a referral basis during
this time.
In contrast to Dr. C., a clinical psychologist
who teaches at a major university might have a
quite different schedule. Table 1-3 offers a glimpse
of one such day for a new assistant professor. As you
can see, this clinical psychologist’s time is typically
devoted to teaching, training, and research.
Some Demographic Notes
Several demographic characteristics of clinical
psychologists are noteworthy (Norcross et al.,
2…