INTRODUCTION TO CLINICAL PSYCHOLOGY YEAR 04

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CHAPTER 1 CLINICAL PSYCHOLOGY Balancing Practice and Science: The Scientist

DEFINITION AND TRAINING Practitioner (Boulder) Model (1949, Boulder
Colorado)
Definition
• To become a clinical psychologist, graduate
• Clinical psychology was first used in print by students would need to receive training and
Lightner Witmer (also first to operate a display competence in the application of
psychological clinic) in 1907 clinical methods and the research methods
necessary to study and evaluate the field
• Clinical psychology is essentially the branch of scientifically.
psychology that studies, assesses, and treats
people with psychological problems or disorders. Leaning Toward Practice: The Practitioner-
Scholar (Vail) Model (1973, Colorado)
• According to The Division of Clinical
• This model of training was born, along with a
Psychology (Division 12) of the American
new type of doctoral degree, the PsyD
Psychological Association (APA), the field of
• In the 1988 to 2001 time period alone, the
Clinical Psychology integrates science, theory,
number of PsyD degrees awarded increased by
and practice to understand, predict, and alleviate
more than 160%
maladjustment, disability, and discomfort as well
• Typically offer more coursework directly
as to promote human adaptation, adjustment,
related to practice and fewer related to
and personal development. Clinical Psychology
research and statistics.
also focuses on the intellectual, emotional,
biological, psychological, social, and behavioral Leaning Toward Science: The Clinical Scientist
aspects of human functioning across the life Model (1990)
span, in varying cultures, and at all
socioeconomic levels. • Stressed the scientific side of clinical
psychology more strongly than did the Boulder
• Definition from the textbook: Clinical psychology model.
involves rigorous study and applied practice • Here, they still award the PhD, however, a PhD
directed toward understanding and improving from a clinical scientist program implies a very
the psychological facets of the human strong emphasis on the scientific method
experience, including but not limited to issues or and evidence-based clinical methods.
problems of behavior, emotions, or intellect. Two initiating events:

• In 1991, Richard McFall, a professor of

Education and Training in Clinical Psychology
psychology at Indiana University, published an
• The aspiring clinical psychologist must obtain a article that served as a rallying call for the
doctoral degree in clinical psychology. clinical scientist movement.
• Few years later, a conference of prominent
• For those entering with a bachelor’s degree, leaders of select clinical psychology graduate
training typically consists of at least 4 years of programs took place at Indiana University and
intensive, full-time coursework, followed by a 1- the Academy of Psychological Clinical
year, full-time predoctoral internship. Science was founded.

• Three distinct models of training are the

scientist-practitioner (Boulder) model, the
practitioner-scholar (Vail) model, and the
clinical scientist model.
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What do Clinical Psychologists Do?

research methods, psychological testing, or
• Clinical psychologists are engaged in an physiological psychology.
enormous range of professional activities, but
psychotherapy is foremost. • School psychologists usually work in schools,
but some may work in day-care centers or
• Some are at least somewhat involved in each of correctional facilities. Their primary function is to
the following activities: diagnosis/assessment, enhance the intellectual, emotional, social,
teaching, supervision, research/writing, and developmental lives of students. They
consultation, and administration. conduct psychological testing and use or
develop programs designed to meet educational
Difference from Counseling Psychologists. and emotional needs.
Psychiatrists. Social Workers, School
Psychologists, and Professional Counselors • Professional counselors earn a master’s
• Compared with counseling psychologists, (rather than a doctoral) degree and often
clinical psychologists still tend to work with complete their training within 2 years.
Professional counselors’ work generally involves
more seriously disturbed populations and,
correspondingly, tend to work more often in counseling, with very little emphasis on
settings such as hospitals and inpatient psychological testing or conducting
psychiatric units. research.

• Both fields endorse the eclectic orientation more CHAPTER 2 EVOLUTION OF CLINICAL
than any other, but clinical psychologists tend PSYCHOLOGY
to endorse behaviorism more strongly.
William Tuke (1732–1822, England)
• Counseling psychologists tend to be more • He raised funds to open the York Retreat, a
interested in vocational testing and career residential treatment center where the mentally
counseling, whereas clinical psychologists tend ill would always be cared for with kindness,
to be more interested in applications of dignity, and decency.
psychology to medical settings. • Soon, similar institutions opened throughout
Europe and the United States.
• Clinical psychologists are certainly trained to
appreciate the biological aspects of their Philippe Pinel (1745-1826, France)
clients’ problems, but psychiatrists’ training
• Pinel worked successfully to move mentally ill
emphasizes biology to such an extent that
individuals out of dungeons in Paris.
disorders are viewed first and foremost as
• Pinel advocated for the staff to include in their
physiological abnormalities of the brain.
treatment of each patient a case history,
ongoing treatment notes, and an illness
• Social workers have focused their work on the
classification of some kind
interaction between an individual and the
components of society that may contribute to Eli Todd (1762–1832, USA)
or alleviate the individual’s problems. They
typically earn a master’s degree rather than a • He was a physician in Connecticut in 1800, a
doctorate, and although their training includes a time when only three states had hospitals for the
strong emphasis on supervised fieldwork, it mentally ill.
includes very little on
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• Todd was able to raise funds to open The Diagnosis

Retreat in Hartford, Connecticut, in 1824.
• In the 1800s in Europe, mental illnesses were
• He and his staff emphasized patients’ strengths
placed in one of the two categories: neurosis
rather than weaknesses, and they allowed
and psychosis
patients to have significant input in their own
• Neurotic individuals were thought to suffer
treatment decisions.
from some psychiatric symptoms but maintain an
Dorothea Dix (1802–1887, United States) intact grasp on reality.
• Psychotic individuals demonstrated a break
• In 1841, Dorothea Dix was working as a Sunday
from reality in the form of hallucinations,
school teacher in a jail in Boston, where she
delusions, or grossly disorganized thinking
saw that many of the inmates were there as a
result of mental illness or retardation rather than Emil Kraepelin (1855–1926; Father of descriptive
crime. psychiatry)
• She would travel to a city, collect data on its
• He offered a different two-category system of
treatment of the mentally ill, present her data to
mental illness, namely, exogenous (caused by
local community leaders, and persuade them to
external factors) and endogenous (caused by
treat the mentally ill more humanely and
internal factors).
adequately
• Ex. Dementia praecox – an endogenous
• Her efforts resulted in the establishment of more
disorder similar to what is now known as
than 30 state institutions for the mentally ill
schizophrenia.
throughout the United States (even more in
Europe and Asia). • He also proposed terms such as paranoia,
manic depressive psychosis, involutional
Lightner Witmer (1876-1956) and the Creation of melancholia, cyclothymic personality, and
Clinical Psychology autistic personality.
• He also set a precedent for the creation of
• Father of clinical psychology
diagnostic terms that eventually led to the
• Born in Philadelphia
Diagnostic and Statistical Manual of Mental
• Earned an undergraduate degree in business at Disorders.
the University of Pennsylvania
• Received his doctorate in psychology in 1892 in History of the DSM
Germany under Wilhelm Wundt, and also
• Original reason to categorize mental disorders
studied under James Mckeen Cattell
was to collect statistics on the population.
• In the late 1800s, psychologists didn’t practice
• In 1840, the U.S. Census Bureau included a
psychology, they studied it.
single category—“idiocy/insanity”—for this
• In 1896, he founded the first psychological
purpose.
clinic at the University of Pennsylvania
• In 1880, there were seven such categories, and
• They worked with children whose problems
soon the American Medical Association and
arose in school settings and were related to
the U.S. Army each made preliminary attempts
learning or behavior
at classifying mental illness.
• By 1914, there were about 20 psychological
• The original DSM was published by the
clinics in US, most of which were modeled on
American Psychiatric Association in 1952.
Witmer’s. In 1935, it soared to 150.
• DSM-II in 1968, not considered to be
• Witmer also founded the first scholarly journal in
significantly different from the original
the field “The Psychological Clinic” in 1907
• DSM-III in 1980, signified an entirely new way of
• “Clinical Psychology” is the title of the first
thinking about mental disorders. As it provided
article in the first issue. The first known
specific diagnostic criteria, and introduced a
publication of the term “clinical psychology”, its
multiaxial system (way of cataloguing problems
definition, and explanation of the need for its
of different kinds on different axes)
existence and growth, was on this article.
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performance scales in this test compared to

• DSM-III-R in 1987 the Stanford-Binet scale.
• DSM-IV in 1994 • Revisions include: WISC-R in 1974, WISC-III in
• DSM-IV-TR in 2000 1991, WISC-IV in 2003, and WISC-V in 2014.
• DSM-5 in May 2013 • Wechsler added an intelligence test designed for
• Most drastic change occurred with the very young children called the Wechsler
publication of DSM III in 1980, with sheer size Preschool and Primary Scale of Intelligence
being the most noticeable difference (WPPSI). The WPPSI was revised in 1989
between DSM II and DSM III (WPPSI-R), 2002 (WPPSI-III), and 2012
• In the time between the original DSM (in 1952) (WPPSI-IV).
and DSM-IV (in 1994), the number of disorders
increased by more than 300% to a total of 368 Assessment of Personality
distinct diagnoses.
• The term mental test (referring to basic tests of
• Two reasons for this increase could be: abilities during that time) was first used by
scientific discovery or social invention James McKeen Cattell in 1890 in an article
Assessment of Intelligence titled “Mental Tests and Measurements”.
• Soon, this term included not only intelligence
• Edward Lee Thorndike promoted the idea that tests but also tests of personality characteristics
each person possesses separate, independent
intelligences. Projective tests
• Charles Spearman led a group of theorists who • In 1921, Hermann Rorschach published a
argued for the existence of “g”, a general projective personality test, the Rorschach
intelligence. Inkblot Method, which was based on the
Binet-Simon Scale assumption that people will project their
personalities onto ambiguous or vague stimuli.
• In 1905, Alfred Binet with Theodore Simon • Christiana Morgan and Henry Murray then
created the first Binet-Simon scale as a published the Thematic Apperception Test
response to the French government who sought (TAT) in 1935. It was similar to the Rorschach in
help in determining which public-school students that the test taker responded to cards featuring
should qualify for special services. ambiguous stimuli. But, instead of inkblots, the
• The scale yielded a single overall score of g. TAT cards depicted people in scenes or
• It was the first to incorporate a comparison of situations that could be interpreted in a wide
mental age to chronological age as a measure variety of ways.
of intelligence. • In Draw-a-Person test, psychologists infer
• In 1937, this test was revised by Lewis Terman personality characteristics from clients’ drawings
and was named Stanford-Binet Intelligence of human figures.
Scales. • In Julian Rotter’s Incomplete Sentence Blank
(Rotter & Rafferty, 1950), psychologists assess
Intelligence tests by David Wechsler
personality by examining the ways clients finish
• In 1939, David Wechsler publicized an sentence stems.
intelligence test designed for adults, the
Objective tests
Wechsler-Bellevue Test.
• Revisions include: Wechsler Adult Intelligence • Some focused on specific aspects of personality,
Scale (WAIS) in 1955, WAIS-R in 1981, WAIS- whereas others aimed to provide a more
III in 1997, and WAIS-IV in 2008 comprehensive overview of an individual’s
• In 1949, he released a children’s version of this personality.
test called, Wechsler Intelligence Scale for • Compared to projective tests, here clients
Children (WISC). answered multiple choice/true-false questions,
• In addition to overall IQ, there is an inclusion and scoring and interpretation were typically
of specific subtests as well as verbal and more straightforward.
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Minnesota Multiphasic Personality Inventory • In the middle of the 20th century the
(MMPI) by Starke Hathaway and J. C. McKinley psychodynamic approach to therapy
dominated
• In 1943, it originally consisted of 550 true-false
• In 1950s and 1960s behaviorism flourishes,
statements
which emphasizes an empirical method.
• Here, test takers’ patterns of responses were
• Humanistic (client-centered) therapy also
compared with those of groups in the
flourished in 1960s, which offered an
standardization sample.
alternative to both psychodynamic and
• This test also used validity scales to assess the
behavioral approaches
test taker’s approach to the test.
• In other words, it had a built-in system to detect Cognitive therapy
random responding or intentionally
misleading responses. • It has put emphasis on logical thinking as the
foundation of psychological wellness
• By 1959, there were more than 200 separate
scales consisting of combinations of MMPI • Become the most popular singular orientation
items. among clinical psychologists
• In 1989, the Minnesota Multiphasic Development of the profession
Personality Inventory-2 (MMPI-2) was
released. • In 1917, the American Association of Clinical
• Its norms were more appropriate than those of Psychologists was founded
the original MMPI, especially in terms of • In 1919 it transitioned into the Clinical Section
including minorities and individuals from various of the American Psychological Association
regions of the country in the standardization • In 1921, the Psychological Corporation was
sample. founded
• It also eliminated some of the outdated or • In 1949, the historic Boulder conference took
confusing language from the original test. place
• An adolescent version of the test, the • In 1950s therapy approaches proliferated
Minnesota Multiphasic Personality • In 1953 the American Psychological Association
Inventory-Adolescent [MMPI-A]) followed in also published the first edition of its ethical
1992. code with significant discussion of clinical
• All versions of the MMPI are easy to administer activities
and score, demonstrate reliability, validity, • In 1960s and 1970s more females and
and clinical utility. minorities are recruited into the field, and first
PsyD programs appeared
NEO Personality Inventory (NEO-PI) • In 1980s clinical psychologists gained hospital
• A personality measure less geared toward admitting privileges and medicare payment
psychopathology than is the MMPI. privileges. Psychotherapy burgeoned, but use
• Rather than diagnostic categories, its scales are of intelligence and personality testing
based on universal personality characteristics decreased.
common to all individuals. • In the late 1950s, only 14% of the U.S.
population had ever received any kind of
Beck Depression Inventory and the Beck Anxiety psychological treatment; by 2010, that number
Inventory had climbed to 50%.
• Objective tests that measure more specific
states or traits
Psychotherapy
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CHAPTER 3 CURRENT CONTROVERSIES IN • Revenue for the profession

CLINICAL PSYCHOLOGY Why clinical psychologists should not
prescribe?
Prescription privileges
• Roots were established in the 1980s, but in the • Training issues
1990s and 2000s, it rose to the level of a high- • Threats to psychotherapy
profile. • Identity confusion
• The potential influence of the pharmaceutical
Some of the prominent individuals who industry
promoted the movement were:
Evidence-Based Practice/Manualized Therapy
• Patrick H. DeLeon - former president of the • Hans Eysenck’s (1952) statement that therapy
American Psychological Association had no proof of positive outcome sparked much
• Morgan T. Sammons - widely recognized research on the topic, and this early wave of
expert on psychopharmacology and 1 of 10 research basically proved Eysenck wrong.
psychologists who took part in the first • Psychotherapy was found to be quite
experimental pilot program of psychologists efficacious.
prescribing medication • However, lack of uniformity between therapies
• Robert McGrath - training director of the would be a major problem in the type of therapy
Psychopharmacology Postdoctoral Training outcome study more common in recent years.
Program in the School of Psychology at Fairleigh • Now, rather than broadly instructing the study’s
Dickinson University and former president of the therapists to practice therapy, or providing a
American Society for the Advancement of vague description of the category of therapy to
Pharmacotherapy practice, you would provide a therapy manual.
• New Mexico, Louisiana, and Illinois—granted • One purpose is to keep variability among
prescription privileges to appropriately trained therapists to a minimum.
psychologists in 2002, 2004, and 2014, • Researchers tested exposure and response
respectively prevention (behavior therapy) for the treatment
Other significant steps: of obsessive-compulsive disorder; dialectical
behavior therapy (DBT) for the treatment of
• Creation of the American Society for the borderline personality disorder; and specific
Advancement of Pharmacotherapy (APA cognitive therapy techniques for the treatment
division 55) in 2000 of depression.
• Psychopharmacology training programs • Division 12 (Clinical Psychology) of the
available for psychologists in the U.S. military American Psychological Association created
a task force to compile specific therapies into a
Why clinical psychologists should prescribe?
list to serve as a reference for therapists
• Shortage of psychiatrists • The therapies on this list were originally called
• Clinical psychologists are more expert than “empirically validated” and soon changed to
primary care physicians “empirically supported” and eventually
• Other nonphysician professionals already have “evidence-based practice”.
prescription privileges • Evidence-based practice, incorporates not only
• Convenience for clients the particular treatment itself but also factors
• Professional autonomy related to the people providing and receiving it.
• Professional identification • Evidence-based practice is defined as “the
• Evolution of the profession integration of the best available research with
clinical expertise in the context of patient
characteristics, culture, and preferences”
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• The first list of empirically validated • “There has been no real epidemic of mental
treatments was published in 1995, and updates illness, just a much looser definition of sickness,
appeared in 1996 and 1998 making it harder for people to be considered
• Guide to Treatments That Work – a landmark well.”
book with more detailed information about these • “The danger of DSM-5 ideology is that it extends
therapies the scope of mental disorder to a point where
• psychologicaltreatments.org - a site almost anyone can be diagnosed with one.”
maintained by Division 12 (Clinical • “The more that psychiatric diagnoses appear to
Psychology) of the American Psychological encroach on the boundaries of normal behavior,
Association, where visitors can search for the more psychiatry opens itself to criticisms that
treatments of disorders there is no validity to the concept of mental
• effectivechildtherapy.org – a similar site for disorders.”
treatments for kids offered by Division 53 • In a 2014 survey of over 500 therapists from
(Clinical Child and Adolescent Psychology) eight countries around the world, over 60% of
participants identified at least one disorder that
Advantages of Evidence-Based
should be completely removed from DSM.
Practice/Manualized Therapy
• Most common reasons were unclear
• Scientific legitimacy boundaries between the disorder and either
• Establishing minimal levels of competence another disorder or normalcy
• Training improvements New Disorders and New Definitions of Old
• Decreased reliance on clinical judgement Disorders
Disadvantages of Evidence-Based • Expansion of the scope of mental disorders
Practice/Manualized Therapy happens in at least two ways: introduction of
• Threats to the psychotherapy relationship new disorders to capture experiences once
• Diagnostic complications considered normal, and “lowering the bar”
for existing disorders such that more people
• Restrictions on practice
meet the criteria
• Debatable criteria for empirical evidence
• A diagnosis can help some people with problems
Overexpansion of Mental Disorders get treatment they need, but a diagnosis can
also help some people with problems get
• Half of the U.S. population is diagnosable at treatment they don’t need
some point in their lifetime, and 11% of the • Other effects of a mental illness diagnosis
population is currently taking antidepressant include: affect a person’s self-image via the
medication stigma that some people attach to mental illness
• This climb in mental disorder rates goes by many and subsequently the person’s self-efficacy and
names: overdiagnosis, diagnostic expansion, overall wellness; influence how health insurance
diagnostic inflation, diagnostic creep, companies consider the person as a potential
medicalization of everyday problems, false enrollee; and affect how a court of law views the
positives, and in severe cases, false person.
epidemics • There is some truth to the notion that practicing
• There are those who believe that many of clinicians make diagnoses without detailed
today’s disorders actually describe normal life consideration of the precise definition of a mental
experiences—unfortunate or unpleasant disorder, and offer treatments whether or not a
experiences, certainly, but nothing that warrants diagnosis has been made at all.
a label of mental disorder, which was particularly • 72% of people who receive a prescription for an
true with DSM-5 antidepressant medication do not receive any
Among the criticisms about DSM-5 were: mental health diagnosis
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• Many rely more on professional experience, • From the psychologists’ point of view, the
intuition, and “gut feelings” than symptom downside of working with managed-care
checklists to guide diagnostic decisions companies include: lower pay than from
clients who pay directly; taking time away
The Influence of the Pharmaceutical Industry
from direct clinical work to spend on
• Big drug companies have a stake in the way paperwork, phone calls, and other interaction
mental disorders are defined, and to them, the with the managed-care company; denial of
broader the better. care that the psychologist believes is
• Cosgrove, Krimsky, Vijayaraghavan, and necessary; and numerous other frustrations
Schneider (2006) found that of the 170 panel • An empirical study indicated that when clients
members of DSM-IV, 95 of them, or 57%, had learned about psychologists’ negative reactions
financial ties to the major pharmaceutical to managed care, many individuals thought more
companies. negatively about therapy than they had before.
• Work Groups for mood disorders and These individuals also felt entitled to have this
psychotic disorders, for which medication is information before beginning therapy.
extremely common, the number was 100%. • Drawbacks of paying without using
• It was also high for other work groups in which insurance/managed-care benefits include:
medication is common including, anxiety struggling of individuals to pay therapy out
disorders (81%), eating disorders (83%), and of pocket without reduced fees/services from
childhood disorders (62%) low-cost community clinics, self-pay as an
• But lower for work Groups in which medication is unaffordable option.
uncommon, such as substance-related • For those who can afford, self-pay does allow
disorders (17%). the therapist and client to make important
• In 2012, this research was repeated for those decisions.
working on DSM-5 and the results indicated that Effect on Diagnosis
the relationship between industry and
authors remained. • How clients pay for therapy not only influences
• Carey and Harris (2008) studied the prescribing therapy but also influences the diagnostic
habits of psychiatrists in Minnesota and found process
that those who had received at least $5,000 • They will not pay for the treatment of issues that
from pharmaceutical companies had written a client brings to therapy if those issues do not
three times as many prescriptions for qualify for a diagnosis.
antipsychotic medication as doctors who • Clients whose symptoms are not severe enough
had received none. to be diagnosable may find that treatment will not
be covered.
Payment Methods: Third-Party Payment Versus
• Psychologists diagnose clients differently
Self-Payment Effect on Therapy
depending on how the clients pay for therapy
• According to a survey by Murphy et al. (1998), • The specific choice of diagnosis depended
psychologists in private practice describe somewhat on payment method as well.
managed care as having a negative impact on
The Influence of Technology: Cybertherapy and
their practices and, more specifically, on the
More
quality of therapy they provide.
• Managed-care companies’ emphasis on • The use of technology, and particularly the
financial concerns often made it difficult for Internet, by clinical psychologists often goes by
them to provide appropriate, ethical the name cybertherapy but is also called
psychological services. With confidentiality telehealth and telemental health.
as one specific noted ethical concern. • Cybertherapy and other recent applications of
technology in clinical psychology and related
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professions have generated both enthusiasm
and skepticism

• Maheu, Pulier, Wilhelm, McMenamin, and

Brown-Connolly (2005) summarize the benefits
of these technologies as “accessibility,
affordability, anonymity, acceptability, and
adaptability”
How well do cybertherapy and other applications
of technology work?

• Reviews and meta-analyses suggest that

cybertherapy works as well as more
traditional, face-to face forms of
psychotherapy for a variety of disorders
• Several studies have found that cognitive-
behavioral treatment of anxiety disorders was
equally effective whether the treatment was
delivered in person or via computer, a meta-
analysis of Internet-based therapy for PTSD
produced similarly favorable results
• The use of a smartphone app designed to deliver
attention-bias modification significantly reduced
stress and anxiety in highly anxious people
• Numerous technological components––like
videoconferencing, Internet-delivered treatment
elements, and texting between therapist and
client––enhanced the effectiveness of cognitive
behavioral treatment of binge eating disorder
and bulimia.
• An Internet-based intervention designed to
increase optimism reduced depression in people
high in pessimism.
• Internet-guided programs designed to improve
mood decrease were effective in decreasing
depression symptoms.
• Although evidence indicates that cybertherapy
can be quite successful, it is important to
remember that the effectiveness of a
cybertherapy treatment can depend on a number
of factors related to the intervention including the
delivery mode and setting in which it is used.
• Along with these new technologies have come
corresponding ethical and professional issues,
including informed consent, laws and ethics,
confidentiality, and effectively managing client
emergencies from a distance.