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Practitioners of clinical psychology can work with individuals, couples, children, older adults, families or small groups. They may work in psychiatric hospitals, general practice, psychological clinics, or academic centers. They may work individually or in multi-disciplinary teams involving other professionals, commonly with licensed psychologists, social workers, psychiatric nurses and psychiatrists and they themselves may be a licensed psychologist, a social worker, a therapist, a counselor, a psychiatric nurse, or a psychiatrist.
HistoryImage:Witmer.jpg Lightner Witmer, the "father" of clinical psychology.
Selfhood, or the idea of an autonomous self, was developed in and is unique to western psychology. The developing field of psychiatry dominated mental healthcare using physical treatments based in asylums. In the 19th century, the Mental hygiene and moral treatment movements gave impetus to public health and psychosocial approaches to "madness". At the turn of the 20th Century, experimental psychology and psychoanalysis were developing. A recognized practice of clinical psychology developed as these psychological methods and theories were applied in clinics. The American Lightner Witmer, who had studied under Wilhelm Wundt in Germany, coined the term "clinical psychology" in 1907 to describe the practice of a clinic for children established in 1896 at the University of Pennsylvania.[3] Witmer specifically defined it as the study of individuals, by observation or experimentation, with the intention of promoting change.[4] He also founded the first journal of clinical psychology, Psychological Clinic. Witmer's call for clinical involvement by psychologists was slow to gain acceptance, but there were twenty-six more psycho-education clinics in the U.S. by 1914.[5] While Witmer focused on children with intellectual delays and deficits, other clinics developed which focused on those in mental distress, and clinical psychology was developing in mental hospitals as psychologists gained staff positions, often working alongside psychiatrists.[6] The applied psychologists of this time did not generally engage in psychotherapy — a practice that was mainly limited to psychiatrists (i.e. those with a medical degree). Rather, they focused mostly on psychological assessment, and this aspect of early clinical psychology came fully into its own as a result of an increasing focus during World War I when the U.S. military required clinical psychologists to assess thousands of new soldiers.[3] Clinical psychologists began to organize under that name in 1917 with the founding of the American Association of Clinical Psychology. This only lasted until 1919, after which the American Psychological Association developed a Section on Clinical Psychology[5] which certified clinical psychologists until 1927. Growth in the field was slow for the next few years as various unconnected psychological organizations came together as the American Association of Applied Psychology in 1930. Formal training for a distinct profession of clinical psychology began in the 1930s with the introduction in the US of approved internships and tentative plans for training curricula. In 1945 APA created what is now called Division 12, its division of clinical psychology. Psychological societies and associations in other English-speaking countries developed similar divisions, including in Britain, Canada, Australia and New Zealand. Different countries adapted clinical psychological practice and training to suit different cultural perceptions and needs. Clinical psychology in Japan developed in various and changing ways, moving towards a more integrative socially-orientated counseling methodology. Practice in India developed from both traditional metaphysical and ayurvedic systems and Western methodologies.[7] The assessment-only focus of clinical psychology changed during and after World War II in the US and UK, partly because the military gave greater recognition to the condition they termed "shell shock" (now called Post Traumatic Stress Disorder or PTSD),[3] and military personnel needed psychological care.[8] There was also increasing interest in the impact of stress on the efficiency of the industrial workforce. Some clinical psychologists practiced psychodyanamic therapy, which included various techniques based on Freud's psychoanalysis, particularly in the US and southern Europe. Others practiced behavior therapy, using techniques based on theories of operant conditioning, classical conditioning and social learning theory. Other approaches developed over the second half of the century, reflecting changing paradigms in psychology and therapy, notably cognitivism and humanistic therapy.[8] Clinical psychology faced territorial boundary issues with psychiatry and later other professionals practising psychotherapy or counseling. After WWII, the Veterans Administration in the US made an enormous investment to set up programs to train doctoral-level clinical psychologists. As a consequence, the U.S. went from having no formal university programs in clinical psychology in 1946 to over half of all PhDs in psychology in 1950 being awarded in clinical psychology.[4] As a result of this shift, a report was drafted in 1947 that led to the scientist/practitioner model of clinical psychology, known today as the Boulder Model. This model of graduate training in the US maintained the science and research-oriented focus of the field while adding training in psychotherapy.[5] The process of professionalization in the UK was somewhat different, relating to the development of the National Health Service and with less emphasis on psychoanalysis.[7] Similar organizational and theoretical developments took place in other countries in the 1950s, and the number of clinical psychologists proliferated. In 1973 in the US, the Practitioner-Scholar Model of Clinical Psychology—or Vail Model—resulting in the Doctor of Psychology (PsyD) degree was recognized by the Vail Conference on models of training in clinical psychology.[9] At this conference, it was argued that the field of psychology in the US had grown to a degree warranting training persons explicitly in the clinical practice of psychology. Although training would continue to include research skills and a scientific understanding of psychology, the intent would be to produce highly trained professionals, similar to programs in medicine, dentistry, and law. The first pilot PsyD program was instituted at the University of Illinois in 1968[10] Cognitive and behavioral approaches were increasingly combined during the 1970s, and Cognitive behavioral therapy[8] came in to widespread usage by clinical psychologists. Numerous other individual and group-based therapies, systems therapies and psychosocial approaches also developed. The range of associated theories and practices also proliferated, with some consensus towards a biopsychosocial model.[7] TrainingMain article being created at Clinical Psychology - Training & Licensing Image:Penn campus 2.jpg The University of Pennsylvania was the first to offer formal education in clinical psychology. Doctoral level trainingClinical psychologists in the US undergo many hours of graduate training—usually 4 to 6 years post-Bachelors—in order to gain demonstrable competence and experience. Today, in America, about half of all clinical psychology graduate students are being trained in PhD programs—a model that emphasizes research and is usually housed in universities—with the other half in PsyD programs, which has more focus on practice (similar to professional degrees for medicine and law).[9] Both models envision practicing Clinical Psychology in a research-based, scientifically valid manner, and are accredited by the American Psychological Association[11] and many other English-speaking psychological societies. Doctorate (PhD and PsyD) programs usually involve some variation on the following 4 to 6 year, 90-unit curriculum:
Masters level training
Where subject is required by both the state and the school, it is shown under the school's required column. Similar courses have been lumped together, for example "Group Treatment Techniques" and "Couples Counseling" were combined, their units added together and called "Group and Couples Treatment"—just to keep the table of manageable size. There are a number of U.S. schools offering accredited programs in clinical psychology resulting in a Masters degree. Such programs can range from 48 to 84 units, most often taking 2 to 3 years to complete post-Bachelors. Training usually emphasizes theory and treatment over research, quite often with a focus on school or couples and family counseling. Similar to doctoral programs, Masters-level students usually must fulfill time in a clinical practicum under supervision and undergo a minimum amount of personal psychotherapy.[12] While many graduates from Masters-level training go on to doctoral programs, a large number also go directly into practice—often as a Licensed Professional Counselor (LPC), Marriage and Family Therapist (MFT) or other similar license.[13] Other related licenses open to Masters-level graduates in the US include: Marriage and Family Therapist (MFT), Licensed Professional Counselor (LPC), and Licensed Psychological Associate. (LPA). Training in BritainIn the U.K., clinical psychologists undertake a DClinPsy (or similar), which is a doctorate with both clinical and research components. This is a three-year full-time salaried program sponsored by the National Health Service (NHS). Entry into these programs is highly competitive, and requires at least a three-year undergraduate degree in psychology approved by the British Psychological Society or an approved conversion course, plus some form of experience, usually in either the NHS as an Assistant Psychologist or in academia as a Research Assistant.[14] Professional practiceClinical psychologists can offer a range of professional services, including:[4]
In practice, clinical psychologists may work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies. Most clinical psychologists who engage in research and teaching do so within a college or university setting. Clinical psychologists may also choose to specialize in a particular field—common areas of specialization, some of which can earn board certification,[15] include: LicensureMain article being created at Clinical Psychology - Training & Licensing The practice of clinical psychology requires a license in the United States, Canada, the United Kingdom, and many other countries. Although each of the U.S. states is somewhat different in terms of requirements and licenses (see [2] and [3] for examples), there are three common elements:[16]
Sources:[17][18][19][20][21][22] All U.S. state and Canada province licensing boards are members of the Association of State and Provincial Psychology Boards (ASPPB) which created and maintains the Examination for Professional Practice in Psychology (EPPP). Many states require other examinations in addition to the EPPP, such as a jurisprudence (i.e. mental health law) examination and/or an oral examination.[16] Most states also require a certain number of continuing education credits per year in order to renew a license, which can be obtained though various means, such as taking audited classes and attending approved workshops. There are several licenses that allow one to practice clinical psychology, usually awarded in relation to one's educational degree.
In the U.K., many mental health titles, including "psychologist", are not protected—although statutory registration of all the mental health professions is planned in the near future to help the public know who is qualified to practice. Currently, protected titles include "clinical psychologist", "counselling psychologist", and "educational psychologist". One can also become "Chartered" by the British Psychological Society. The title of "Assistant Psychologist" is used by a psychology graduate under the supervision of a qualified clinical psychologist, and the title "Trainee Clinical Psychologist" is used during the three-year doctoral program. AssessmentAn important area of expertise for many clinical psychologists is psychological assessment, and there are indications that as many as 91% of psychologists engage in this core clinical practice.[26] Such evaluation is usually done in service to gaining insight into and forming hypotheses about psychological or behavioral problems. As such, the results of such assessments are usually used to create generalized impressions rather than diagnoses. There exists literally hundreds of various assessment tools, although only a few have been shown to have both high validity (i.e., test actually measures what it claims to measure) and reliability (i.e., test is consistent—internally, over time, and regardless of administrator). These measures generally fall within one of several categories, including the following:
Diagnostic impressionsMain article - Mental disorder. After assessment, clinical psychologists often provide a diagnostic impression. Many countries use the International Statistical Classification of Diseases and Related Health Problems. In the U.S., many psychologists use the Diagnostic and Statistical Manual of Mental Disorders (the DSM version IV-TR). In both case these are necessary when working with an HMO or insurance company or involving a legal matter. Both assume medical concepts and terms, and state that there are categorical disorders that can be diagnosed by set lists of descriptive criteria, which serve psychologists by providing a familiar frame of reference for discussing and understanding the clinical experience and for guiding treatment.[27] The DSM IV uses a categorical medical model and views psychological problems in terms of discrete illnesses that can be defined by a minimum set of criteria (such as presenting problems, intensity, behaviors, duration, onset, etc.). While convenient for prescribing medications, there is a growing awareness that this model is not the only way to understand psychological functioning and the various causes of mental distress. Moreover, there is little justification for the cutoff criteria, which, except for schizotypal and borderline diagnoses, are essentially arbitrary.[28] As such, there are many debates in the field regarding alternative methods of diagnosing psychological problems. One such debate is the position of adopting a dimensional model which could be based on empirically validated models of human differences, such as the five factor model of personality. A dimensional model would arguably have several major advantages, including—addressing quantitative variation and shifts (between various disorders as well as between what is considered normal and pathological); dealing with co-occurrence of multiple problems; and a more constructive way of looking at otherwise 'sub-threshold' conditions.[28][27] Another variation is called the psychosocial model, which could be more relevant for the practice of psychotherapy (as opposed to medicine).[29] While the medical model of the DSM is based on assumptions of biology, stability of diagnosis, and objective traits, the psychosocial model is more psychological, intersubjective, and diagnostically flexible over the course of therapy. British clinical psychologists do not tend to diagnose, but rather use formulation—an individualized map of the difficulties that the patient or client faces, encompassing predisposing, precipitating and perpetuating (maintaining) factors.[30] Theories and interventionsImage:Grouptherapy.jpg Clinical psychologists work with individuals, children, families, couples, or small groups. There are different theories and models of psychological processes used in clinical psychology. Clinical psychologists generally seek to base their work on research evidence and outcome studies as well as on clinical judgement and empathy. They help to research and develop evidence-based theories and models of the psychological causes and mediators of mental health problems, which can be applied to individual clients. Clinical psychologists often provide psychotherapy (also known as "talking therapy"), using various techniques to change thoughts, feelings or behaviors in order to enhance well-being, mental health, and life functioning. Clinical psychologists often also provide social skills training or other skills-based or psycho-educational interventions, either to clients themselves and/or to family members or others in sigificant relations with the client. Generally speaking, psychotherapy involves a formal relationship between professional and client—usually an individual, couple, family, or small group—that employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking or behaving. Although there are literally dozens of recognized therapeutic orientations, their differences could be categorized on two dimensions: insight vs. action and in-session vs. out-session.[4]
The methods used are also different in regards to the population being served as well as the context and nature of the problem. Therapy will look very different between, say, a traumatized child, a depressed but high-functioning adult, a group of people recovering from substance dependence, and a ward of the state suffering from terrifying delusions. Other elements that play a critical role in the process of psychotherapy include the environment, culture, age, cognitive functioning, motivation, and duration (i.e. brief or long-term therapy). Three main perspectivesThe field can be seen as recognizing essentially three major perspectives[citation needed]: Psychodynamic, Cognitive Behavioral, and Humanistic. Cognitive BehavioralCognitive Behavioral Therapy (CBT) developed from the combination of Cognitive psychology and Behaviorism, and from more specific earlier therapies known as cognitive therapy and rational emotive behavior therapy. CBT is based on the theory that how we think (cognition), how we feel (emotion), and how we act (behavior) all interact together. In this perspective, certain thoughts or ways of interpreting the world (often called schemas) can cause emotional distress or result in behavioral problems. Certain behaviors, such as avoidance of feared situations, can also maintain distress. The object of CBT is to discover the biased or irrational thinking that leads to emotional problems and to help the client take control over his or her thinking processes and behaviors in such a way that will lead to increased well-being.[31] There are several techniques used, including Systematic Desensitization. Modified approaches that fall into the category of CBT have also developed, including Dialectic Behavior Therapy and Mindfulness-based Cognitive Therapy[32] HumanisticHumanistic psychology was developed in the 1950s in reaction to both behaviorism and psychoanalysis, largely due to the Person-Centered Therapy of Carl Rogers (often referred to as Rogerian Therapy). Rogers believed that a client needed only three things from a clinician to experience therapeutic improvement—congruence, unconditional positive regard, and empathetic understanding.[33] The aim of much humanistic therapy is to give a holistic description of the person. By using Phenomenology, Intersubjectivity and first-person categories, the humanistic approach seeks to get a glimpse of the whole person and not just the fragmented parts of the personality.[34] This aspect of holism links up with another common aim of humanistic practice in clinical psychology, which is to seek an integration of the whole person, also called self-actualization. According to humanistic thinking, each individual person already has inbuilt potentials and resources that might help them to build a stronger personality and self-concept. The mission of the humanistic psychologist is to help the individual employ these resources via the therapeutic relationship. PsychodynamicThe Psychodynamic perspective developed out of the Psychoanalysis of Sigmund Freud. The core object of Psychoanalysis is to make the unconscious conscious—to make the client aware of his or her own primal drives (namely those relating to sex and aggression) and the various defenses used to keep them in check. The essential tools of the psychoanalytic process are the use of free association and an examination of the client's transference towards the therapist, defined as the tendency to take unconscious thoughts or emotions about a significant person (e.g. a parent) and "transfer" them onto another person.[35] Major variations on Freudian psychoanalysis practiced today include Self Psychology, Ego Psychology, and Object Relations Theory. These general orientations now fall under the umbrella term psychodynamic psychology, with common themes including examination of transference and defenses, an appreciation of the power of the unconscious, and a focus on how early developments in childhood have shaped the client's current psychological state.[35]. Other major therapeutic orientations
There exist literally dozens of recognized schools or orientations of psychotherapy—the list below represents those that have been pivotal in the development of clinical psychology[citation needed]. Although they all have some typical set of techniques practitioners employ, they are generally better known for providing a framework of theory and philosophy that guides a therapist in his or her working with a client.
IntegrationIn the last couple of decades, there has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of cultural, gender, spiritual, and sexual-orientation issues. Clinical psychologists are beginning to look at the various strengths and weaknesses of each orientation while also working with related fields, such as neuroscience, genetics, evolutionary biology, and psychopharmacology. The result is a growing practice of eclecticism, with psychologists learning various systems and the most efficacious methods of therapy with the intent to provide the best solution for any given problem.[43] Other perspectives
Comparison with other mental health professions
PsychiatryImage:Prozac.jpg Fluoxetine hydrochloride, branded by Lilly as Prozac, is a common antidepressant drug prescribed by psychiatrists. There is a small but growing movement to give prescription privileges to qualified psychologists. Although clinical psychologists and psychiatrists can be said to share a same fundamental aim—the alleviation of mental distress—their training, outlook, and methodologies are often quite different. Perhaps the most significant difference is that psychiatrists are medical doctors with four years of medical school and another four years of residency in a medical setting where they may specialise in certain agegroups or specific conditions. Being medical doctors, they tend to use the medical model to assess psychological problems (i.e. those they treat are seen as patients with an illness) and often - at least in biopsychiatry rather than, say, social psychiatry, rely on psychotropic medications as the chief method of addressing them[51]—although many also employ psychotherapy as well. Their medical training enables them to conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. Clinical psychologists do not usually prescribe medication, although there is a growing movement for psychologists to have limited prescribing privileges.[52] Such privileges require additional, supervised training and education, and would mostly be limited to psychotropic medications. To date, qualified psychologists may prescribe psychotropic medications in Guam, New Mexico, and Louisiana.[53] In general, however, when medication is warranted many psychologists will work in cooperation with psychiatrists so that clients get all their therapeutic needs met.[1] Unless a psychiatrist voluntarily chooses to get extra training, such as in Cognitive behavioural therapy or at a psychoanalytic institute, they will have less training in the theory and practice of psychotherapy than will a licensed clinical psychologist.[54] Even though many psychiatrists do seek out such training, the majority of them increasingly focus on medication management, possibly because insurance tends to pay far more for this service than for psychotherapy.[55] Further, psychologists tend to have more training in psychological assessment. Counseling psychologyCounseling generally involves helping people with what might be considered "normal" or "moderate" psychological problems, such as the feelings of anxiety or sadness resulting from major life changes or events.[1][4] As such, counseling psychologists often help people adjust to or cope with their environment or major events, although many also work with more serious problems as well. Clinical psychologists, by comparison, are trained to help with these kinds of issues but also more debilitating or chronic problems, such as forms of dementia or psychosis. Other differences include: there are fewer counseling psychology graduate programs, they are usually housed in departments of education (as opposed to psychology departments for clin-psy programs), counseling psychologists tend to conduct more vocational assessment and less projective or objective assessment, and they are more likely to work in public service or university clinics (compared with clinical psychologists who are more likely to work in hospitals or private practice).[56] Despite these differences, there is considerable overlap between the two fields and distinctions between them continue to fade. Abnormal psychologyAbnormal psychology is the branch of academic psychology concerned with identifying, classifying and understanding psychopathology and unusual behaviors. Theories from abnormal psychology may form a part of the education and research of clinical psychologists, but abnormal psychology is not in itself a clinical profession. School psychologySchool psychologists, also known as educational psychologists, are primarily concerned with the academic, social, and emotional well-being of children within a scholastic environment. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning, often graduating with a post-Masters Educational Specialist Degree (EdS) or Doctor of Education (EdD) degree. Besides offering individual and group therapy with children and their families, school psychologists also evaluate school programs, provide cognitive assessment, help design prevention programs (e.g. reducing drops outs), and work with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically.[57] Social WorkersSocial Workers provide a variety of services, including psychology, in a clinical setting . This might be done on behalf of a mental health clinic, a private practice, in a school setting, a social welfare agency, a hospital or for a department of social services. For the most part, social workers are concerned with social problems, their causes, and their solutions, but many also work with clients as a psychotherapist or psychological counselor in addition to more traditional social work. The Master's in Social Work in the US is a two-year sixty credit program that usually includes at least a one year practicum. Unlike the Ph.D., which is an academic degree, the M.S.W. is considered a professional degree. Clinical psychology journalsThe following represents an (incomplete) listing of significant journals in or related to the field of clinical psychology.
Major influencesCriticisms and controversiesClinical psychology is a diverse field and there have been recurring tensions over the degree to which clinical psychology should be based in empirical research and evidence-based practice or in self-reflection and clinical judgement. Trainees may undertake courses with different emphases in this respect and qualified professionals may register with different kinds of representative organizations.[58] Clinical Psychology can be subject to similar criticisms leveled at psychiatry, for example by the anti-psychiatry movement, especially when more aligned with a biomedical model or using psychiatric diagnostic categories such as in the DSM. Others may view this positively. It has been reported that clinical psychology has rarely allied itself with client groups and tends to individualize problems to the neglect of wider economic, political and social inequality issues that may not be the responsibility of the client[58] It has been argued that therapeutic practices are inevitably bound up with power inequalities, which can be used for good and bad[59] A critical psychology movement has argued that clinical psychology, and other professions making up a "psy complex", often fail to consider or address inequalities and power differences and can play a part in the social and moral control of disadvantage, deviance and unrest[60] Clinical Psychologists are sometimes criticized by psychiatrists for not having sufficient training or scientific knowledge in general medicine, genetics or medication. There has been controversy over attempts by clinical psychologists to obtain prescribing privileges.[61] Despite a growing evidence-base, there remains much debate about the efficacy of various forms of assessment and treatment in use in clinical psychology[62] See alsoRelated listsReferences
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