Clinical psychology

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

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

By the second half of the 1800s, the scientific study of psychology was becoming well established in university laboratories. Although there were a few scattered voices calling for applied psychology, the general field looked down upon this idea and insisted on "pure" science as the only respectable practice.[6] This changed when Lightner Witmer (1867–1956), a past student of Wundt and head of the psychology department at the University of Pennsylvania, agreed to treat a young boy who had trouble with spelling. His successful treatment was soon to lead to Witmer's opening of the first psychological clinic at Penn in 1896, dedicated to helping children with learning disabilities.[8] Ten years later in 1907, Witmer was to found the first journal of this new field, The Psychological Clinic, where he coined the term "clinical psychology", defined as "the study of individuals, by observation or experimentation, with the intention of promoting change".[9] The field was slow to follow Witmer's example, but by 1914, there were 26 similar clinics in the US.[10]

Even as clinical psychology was growing, working with issues of serious mental distress remained the domain of psychiatrists and neurologists.[11] However, clinical psychologists continued to make inroads into this area due to their increasing skill at psychological assessment. Psychologists' reputation as assessment experts became solidified during World War I with the development of two intelligence tests, Army Alpha and Army Beta (testing verbal and nonverbal skills, respectively), which could be used with large groups of recruits.[7][8] Due in large part to the success of these tests, assessment was to become the core discipline of clinical psychology for the next quarter-century, when another war would propel the field into treatment.

The field began to organize under the name "clinical psychology" in 1917 with the founding of the American Association of Clinical Psychology. This only lasted until 1919, after which the American Psychological Association (founded by G. Stanley Hall in 1892) developed a section on Clinical Psychology, which offered certification until 1927.[10] Growth in the field was slow for the next few years when various unconnected psychological organizations came together as the American Association of Applied Psychology in 1930, which would act as the primary forum for psychologists until after World War II when the APA reorganized.[12] In 1945, the APA created what is now called Division 12, its division of clinical psychology, which remains a leading organization in the field. Psychological societies and associations in other English-speaking countries developed similar divisions, including in Britain, Canada, Australia, and New Zealand.

When World War II broke out, the military once again called upon clinical psychologists. As soldiers began to return from combat, psychologists started to notice symptoms of psychological trauma labeled "shell shock" (eventually to be termed post-traumatic stress disorder) that were best treated as soon as possible.[8] Because physicians (including psychiatrists) were over-extended in treating bodily injuries, psychologists were called to help treat this condition.[13] At the same time, female psychologists (who were excluded from the war effort) formed the National Council of Women Psychologists with the purpose of helping communities deal with the stresses of war and giving young mothers advice on child rearing.[9] After the war, the Veterans Administration in the US made an enormous investment to set up programs to train doctoral-level clinical psychologists to help treat the thousands of veterans needing care. As a consequence, the US went from having no formal university programs in clinical psychology in 1946 to over half of all PhDs in psychology in 1950 being awarded in clinical psychology.[9]

WWII helped bring dramatic changes to clinical psychology, not just in America but internationally as well. Graduate education in psychology began adding psychotherapy to the science and research focus based on the 1947 scientist-practitioner model, known today as the Boulder Model, for PhD programs in clinical psychology.[14] Clinical psychology in Britain developed much like in the US after WWII, specifically within the context of the National Health Service[15] with qualifications, standards, and salaries managed by the British Psychological Society.[16]

By the 1960s, psychotherapy had become embedded within clinical psychology, but for many, the PhD educational model did not offer the necessary training for those interested in practice rather than research. There was a growing argument that said the field of psychology in the US had developed to a degree warranting explicit training in clinical practice. The concept of a practice-oriented degree was debated in 1965 and narrowly gained approval for a pilot program at the University of Illinois starting in 1968.[17] Several other similar programs were instituted soon after, and in 1973, at the Vail Conference on Professional Training in Psychology, the practitioner–scholar model of clinical psychology—or Vail Model—resulting in the Doctor of Psychology (PsyD) degree was recognized.[18] 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 program explicitly based on the PsyD model was instituted at Rutgers University.[17] Today, about half of all American graduate students in clinical psychology are enrolled in PsyD programs.[18]

Since the 1970s, clinical psychology has continued growing into a robust profession and academic field of study. Although the exact number of practicing clinical psychologists is unknown, it is estimated that between 1974 and 1990, the number in the US grew from 20,000 to 63,000.[19] Clinical psychologists continue to be experts in assessment and psychotherapy while expanding their focus to address issues of gerontology, sports, and the criminal justice system to name a few. One important field is health psychology, the fastest-growing employment setting for clinical psychologists in the past decade.[7] Other major changes include the impact of managed care on mental health care; an increasing realization of the importance of knowledge relating to multicultural and diverse populations; and emerging privileges to prescribe psychotropic medication.

There exist 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., consistency). Many psychological assessment measures are restricted for use by those with advanced training in mental health. For instance, Pearson (one of the many companies with rights and protection of psychological assessment tools) separates who can administer, interpret, and report on certain tests. Anybody is able to access Qualification Level A tests. Those who intend to use assessment tools at Qualification Level B must hold a master's degree in psychology, education, speech language pathology, occupational therapy, social work, counseling, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, and interpretation of clinical assessments. Those with access to Qualification C (highest level) assessment measures must hold a doctorate degree in psychology, education, or a closely related field with formal training in the ethical administration, scoring, and interpretation of clinical assessments related to the intended use of the assessment.[28]

Psychological measures generally fall within one of several categories, including the following:

• Intelligence & achievement tests – These tests are designed to measure certain specific kinds of cognitive functioning (often referred to as IQ) in comparison to a norming group. These tests, such as the WISC-IV and the WAIS, attempt to measure such traits as general knowledge, verbal skill, memory, attention span, logical reasoning, and visual/spatial perception. Several tests have been shown to predict accurately certain kinds of performance, especially scholastic.[27] Other tests in this category include the WRAML and the WIAT.
• Personality tests – Tests of personality aim to describe patterns of behavior, thoughts, and feelings. They generally fall within two categories: objective and projective. Objective measures, such as the MMPI, are based on restricted answers—such as yes/no, true/false, or a rating scale—which allow for the computation of scores that can be compared to a normative group. Projective tests, such as the Rorschach inkblot test, allow for open-ended answers, often based on ambiguous stimuli. Other commonly used personality assessment measures include the PAI and the NEO
• Neuropsychological tests – Neuropsychological tests consist of specifically designed tasks used to measure psychological functions known to be linked to a particular brain structure or pathway. They are typically used to assess impairment after an injury or illness known to affect neurocognitive functioning, or when used in research, to contrast neuropsychological abilities across experimental groups.
• Diagnostic Measurement Tools – Clinical psychologists are able to diagnose psychological disorders and related disorders found in the DSM-5 and ICD-10. Many assessment tests have been developed to complement the clinicians clinical observation and other assessment activities. Some of these include the SCID-IV, the MINI, as well as some specific to certain psychological disorders such as the CAPS-5 for trauma, the ASEBA, and the K-SADS for affective and Schizophrenia in children.
• Clinical observation – Clinical psychologists are also trained to gather data by observing behavior. The clinical interview is a vital part of the assessment, even when using other formalized tools, which can employ either a structured or unstructured format. Such assessment looks at certain areas, such as general appearance and behavior, mood and affects, perception, comprehension, orientation, insight, memory, and content of the communication. One psychiatric example of a formal interview is the mental status examination, which is often used in psychiatry as a screening tool for treatment or further testing.[27]

After assessment, clinical psychologists may provide a diagnostic impression. Many countries use the International Statistical Classification of Diseases and Related Health Problems (ICD-10) while the US most often uses the Diagnostic and Statistical Manual of Mental Disorders. Both are nosological systems that largely assume categorical disorders diagnosed through the application of sets of criteria including symptoms and signs.[29]

Several new models are being discussed, including a "dimensional model" based on empirically validated models of human differences (such as the five factor model of personality[29][30]) and a "psychosocial model", which would take changing, intersubjective states into greater account.[31] The proponents of these models claim that they would offer greater diagnostic flexibility and clinical utility without depending on the medical concept of illness.[32] However, they also admit that these models are not yet robust enough to gain widespread use, and should continue to be developed.[32]

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.[33]

Clinical assessment can be characterized as a prediction problem where the purpose of assessment is to make inferences (predictions) about past, present, or future behavior.[34] For example, many therapy decisions are made on the basis of what a clinician expects will help a patient make therapeutic gains. Once observations have been collected (e.g., psychological testing results, diagnostic impressions, clinical history, X-ray, etc.), there are two mutually exclusive ways to combine those sources of information to arrive at a decision, diagnosis, or prediction. One way is to combine the data in an algorithmic, or "mechanical" fashion. Mechanical prediction methods are simply a mode of combination of data to arrive at a decision/prediction of behavior (e.g., treatment response). The mechanical prediction does not preclude any type of data from being combined; it can incorporate clinical judgments, properly coded, in the algorithm.[34] The defining characteristic is that, once the data to be combined is given, the mechanical approach will make a prediction that is 100% reliable. That is, it will make exactly the same prediction for exactly the same data every time. Clinical prediction, on the other hand, does not guarantee this, as it depends on the decision-making processes of the clinician making the judgment, their current state of mind, and knowledge base.[35][34]

What has come to be called the "clinical versus statistical prediction" debate was first described in detail in 1954 by Paul Meehl,[35] where he explored the claim that mechanical (formal, algorithmic) methods of data combination could outperform clinical (e.g., subjective, informal, "in the clinician's head") methods when such combinations are used to arrive at a prediction of behavior. Meehl concluded that mechanical modes of combination performed as well or better than clinical modes.[35] Subsequent meta-analyses of studies that directly compare mechanical and clinical predictions have born out Meehl's 1954 conclusions.[36][37] A 2009 survey of practicing clinical psychologists found that clinicians almost exclusively use their clinical judgment to make behavioral predictions for their patients, including diagnosis and prognosis.[38]

Many clinical psychologists are integrative or eclectic and draw from the evidence base across different models of therapy in an integrative way, rather than using a single specific model.

In the UK, clinical psychologists have to show competence in at least two models of therapy, including CBT, to gain their doctorate. The British Psychological Society Division of Clinical Psychology has been vocal about the need to follow the evidence base rather than being wedded to a single model of therapy.

In the US, intervention applications and research are dominated in training and practice by essentially four major schools of practice: psychodynamic, humanism, behavioral/cognitive behavioral, and systems or family therapy.[2]

The psychodynamic perspective developed out of the psychoanalysis of Sigmund Freud. The core object of psychoanalysis is to make the unconscious conscious—to make the client aware of his or her own primal drives (namely those relating to sex and aggression) and the various defenses used to keep them in check.[39] The essential tools of the psychoanalytic process are the use of free association and an examination of the client's transference towards the therapist, defined as the tendency to take unconscious thoughts or emotions about a significant person (e.g. a parent) and "transfer" them onto another person. Major variations on Freudian psychoanalysis practiced today include self psychology, ego psychology, and object relations theory. These general orientations now fall under the umbrella term psychodynamic psychology, with common themes including examination of transference and defenses, an appreciation of the power of the unconscious, and a focus on how early developments in childhood have shaped the client's current psychological state.[39]

Humanistic psychology was developed in the 1950s in reaction to both behaviorism and psychoanalysis, largely due to the person-centered therapy of Carl Rogers (often referred to as Rogerian Therapy) and existential psychology developed by Viktor Frankl and Rollo May.[2] Rogers believed that a client needed only three things from a clinician to experience therapeutic improvement—congruence, unconditional positive regard, and empathetic understanding.[41] 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.[42] 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. From 1980, Hans-Werner Gessmann integrated the ideas of humanistic psychology into group psychotherapy as humanistic psychodrama.[43] According to humanistic thinking,[44] 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.

Emotion focused therapy/Emotionally focused therapy (EFT), not to be confused with Emotional Freedom Techniques, was initially informed by humanistic–phenomenological and Gestalt theories of therapy.[45][46] "Emotion Focused Therapy can be defined as the practice of therapy informed by an understanding of the role of emotion in psychotherapeutic change. EFT is founded on a close and careful analysis of the meanings and contributions of emotion to human experience and change in psychotherapy. This focus leads therapist and client toward strategies that promotes the awareness, acceptance, expression, utilization, regulation, and transformation of emotion as well as corrective emotional experience with the therapist. The goals of EFT are strengthening the self, regulating affect, and creating new meaning".[45] Similarly to some Psychodynamic therapy approaches, EFT pulls heavily from attachment theory. Pioneers of EFT are Les Greenberg[47][48] and Sue Johnson.[49] EFT is often used in therapy with individuals, and may be especially useful for couples therapy.[50][51] Founded in 1998, Dr. Sue Johnson and others lead the International Centre for Excellence in Emotion Focused Therapy (ICEEFT) where clinicians can find EFT training internationally. EFT is also a commonly chosen modality to treat clinically diagnosable trauma.[52]

Cognitive behavioral therapy (CBT) developed from the combination of cognitive therapy and rational emotive behavior therapy, both of which grew out of cognitive psychology and behaviorism. CBT is based on the theory that how we think (cognition), how we feel (emotion), and how we act (behavior) are related and interact together in complex ways. In this perspective, certain dysfunctional ways of interpreting and appraising the world (often through schemas or beliefs) can contribute to emotional distress or result in behavioral problems. The object of many cognitive behavioral therapies is to discover and identify the biased, dysfunctional ways of relating or reacting and through different methodologies help clients transcend these in ways that will lead to increased well-being.[53] There are many techniques used, such as systematic desensitization, socratic questioning, and keeping a cognition observation log. Modified approaches that fall into the category of CBT have also developed, including dialectic behavior therapy and mindfulness-based cognitive therapy.[54]

Behavior therapy is a rich tradition. It is well researched with a strong evidence base. Its roots are in behaviorism. In behavior therapy, environmental events predict the way we think and feel. Our behavior sets up conditions for the environment to feedback back on it. Sometimes the feedback leads the behavior to increase- reinforcement and sometimes the behavior decreases- punishment. Oftentimes behavior therapists are called applied behavior analysts or behavioral health counselors. They have studied many areas from developmental disabilities to depression and anxiety disorders. In the area of mental health and addictions a recent article looked at APA's list for well established and promising practices and found a considerable number of them based on the principles of operant and respondent conditioning.[55] Multiple assessment techniques have come from this approach including functional analysis (psychology), which has found a strong focus in the school system. In addition, multiple intervention programs have come from this tradition including community reinforcement approach for treating addictions, acceptance and commitment therapy, functional analytic psychotherapy, including dialectic behavior therapy and behavioral activation. In addition, specific techniques such as contingency management and exposure therapy have come from this tradition.

Systems or family therapy works with couples and families, and emphasizes family relationships as an important factor in psychological health. The central focus tends to be on interpersonal dynamics, especially in terms of how change in one person will affect the entire system.[56] Therapy is therefore conducted with as many significant members of the "system" as possible. Goals can include improving communication, establishing healthy roles, creating alternative narratives, and addressing problematic behaviors.

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

• Existential – Existential psychotherapy postulates that people are largely free to choose who we are and how we interpret and interact with the world. It intends to help the client find deeper meaning in life and to accept responsibility for living. As such, it addresses fundamental issues of life, such as death, aloneness, and freedom. The therapist emphasizes the client's ability to be self-aware, freely make choices in the present, establish personal identity and social relationships, create meaning, and cope with the natural anxiety of living.[57]
• Gestalt - Gestalt therapy was primarily founded by Fritz Perls in the 1950s. This therapy is perhaps best known for using techniques designed to increase self-awareness, the best-known perhaps being the "empty chair technique." Such techniques are intended to explore resistance to "authentic contact", resolve internal conflicts, and help the client complete "unfinished business".[58]
• Postmodern – Postmodern psychology says that the experience of reality is a subjective construction built upon language, social context, and history, with no essential truths.[59] Since "mental illness" and "mental health" are not recognized as objective, definable realities, the postmodern psychologist instead sees the goal of therapy strictly as something constructed by the client and therapist.[60] Forms of postmodern psychotherapy include narrative therapy, solution-focused therapy, and coherence therapy.
• Transpersonal – The transpersonal perspective places a stronger focus on the spiritual facet of human experience.[61] It is not a set of techniques so much as a willingness to help a client explore spirituality and/or transcendent states of consciousness. Transpersonal psychology is concerned with helping clients achieve their highest potential.
• Multiculturalism – Although the theoretical foundations of psychology are rooted in European culture, there is a growing recognition that there exist profound differences between various ethnic and social groups and that systems of psychotherapy need to take those differences into greater consideration.[40] Further, the generations following immigrant migration will have some combination of two or more cultures—with aspects coming from the parents and from the surrounding society—and this process of acculturation can play a strong role in therapy (and might itself be the presenting problem). Culture influences ideas about change, help-seeking, locus of control, authority, and the importance of the individual versus the group, all of which can potentially clash with certain givens in mainstream psychotherapeutic theory and practice.[62] As such, there is a growing movement to integrate knowledge of various cultural groups in order to inform therapeutic practice in a more culturally sensitive and effective way.[63]
• Feminism – Feminist therapy is an orientation arising from the disparity between the origin of most psychological theories (which have male authors) and the majority of people seeking counseling being female. It focuses on societal, cultural, and political causes and solutions to issues faced in the counseling process. It openly encourages the client to participate in the world in a more social and political way.[64]
• Positive psychology – Positive psychology is the scientific study of human happiness and well-being, which started to gain momentum in 1998 due to the call of Martin Seligman,[65] then president of the APA. The history of psychology shows that the field has been primarily dedicated to addressing mental illness rather than mental wellness. Applied positive psychology's main focus, therefore, is to increase one's positive experience of life and ability to flourish by promoting such things as optimism about the future, a sense of flow in the present, and personal traits like courage, perseverance, and altruism.[66][67] There is now preliminary empirical evidence to show that by promoting Seligman's three components of happiness—positive emotion (the pleasant life), engagement (the engaged life), and meaning (the meaningful life)—positive therapy can decrease clinical depression.[68]

Community psychology approaches are often used for psychological prevention of harm and clinical intervention.[69][70][71]

In the last couple of decades, there has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of cultural, gender, spiritual, and sexual-orientation issues. Clinical psychologists are beginning to look at the various strengths and weaknesses of each orientation while also working with related fields, such as neuroscience, behavioural 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.[72]

Fluoxetine hydrochloride, branded by Lilly as Prozac, is an antidepressant drug prescribed by physicians, psychiatrists, and some nurses.

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 licensed physicians. As such, psychiatrists often use the medical model to assess psychological problems (i.e., those they treat are seen as patients with an illness) and can use psychotropic medications as a method of addressing the illness[75]—although many also employ psychotherapy as well. Psychiatrists are able to conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning.

Clinical psychologists generally do not prescribe medication, although there is a movement for psychologists to have prescribing privileges.[76] These medical privileges require additional training and education. To date, medical psychologists may prescribe psychotropic medications in Guam, Iowa, Idaho, Illinois, New Mexico, Louisiana, the Public Health Service, the Indian Health Service, and the United States Military.[77]

Counseling psychologists undergo the same level of rigor in study and use many of the same interventions and tools as clinical psychologists, including psychotherapy and assessment. Traditionally, counseling psychologists helped people with what might be considered normal or moderate psychological problems—such as the feelings of anxiety or sadness resulting from major life changes or events.[3][9] However, that distinction has faded over time, and of the counseling psychologists who do not go into academia (which does not involve treatment or diagnosis), the majority of counseling psychologists treat mental illness alongside clinical psychologists. Many counseling psychologists also receive specialized training in career assessment, group therapy, and relationship counseling.

Counseling psychology as a field values multiculturalism[78] and social advocacy, often stimulating research in multicultural issues. There are fewer counseling psychology graduate programs than those for clinical psychology and they are more often housed in departments of education rather than psychology. Counseling psychologists tend to be more frequently employed in university counseling centers compared to hospitals and private practice for clinical psychologists.[79] However, counseling and clinical psychologists can be employed in a variety of settings, with a large degree of overlap (prisons, colleges, community mental health, non-profits, corporations, private practice, hospitals and Veterans Affairs).

School psychologists are primarily concerned with the academic, social, and emotional well-being of children and adolescents within a scholastic environment. In the UK, they are known as "educational psychologists". Like clinical (and counseling) psychologists, school psychologists with doctoral degrees are eligible for licensure as health service psychologists, and many work in private practice. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning. Common degrees include the Educational Specialist Degree (EdS), Doctor of Philosophy (PhD), and Doctor of Education (EdD).

Traditional job roles for school psychologists employed in school settings have focused mainly on assessment of students to determine their eligibility for special education services in schools, and on consultation with teachers and other school professionals to design and carry out interventions on behalf of students. Other major roles also include offering individual and group therapy with children and their families, designing prevention programs (e.g. for reducing dropout), evaluating school programs, and working with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically.[86][87]

Social workers provide a variety of services, generally concerned with social problems, their causes, and their solutions. With specific training, clinical social workers may also provide psychological counseling (in the US and Canada), in addition to more traditional social work.

Occupational therapy—often abbreviated OT—is the "use of productive or creative activity in the treatment or rehabilitation of physically, cognitively, or emotionally disabled people."[88] Most commonly, occupational therapists work with people with disabilities to enable them to maximize their skills and abilities. Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the physical, emotional, psychological, sociocultural, cognitive and environmental components of illness and injury. They commonly work alongside clinical psychologists in settings such as inpatient and outpatient mental health, pain management clinics, eating disorder clinics, and child development services. OT's use support groups, individual counseling sessions, and activity-based approaches to address psychiatric symptoms and maximize functioning in life activities.