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ContemporaryClinical

Psychology

CONTEMPORARY CLINICAL

PSYCHOLOGYSecond Edition

Thomas G. PlanteSanta Clara University and Stanford University

JOHN WILEY & SONS, INC.

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Library of Congress Cataloging-in-Publication Data:

Plante, Thomas G.Contemporary clinical psychology / Thomas G. Plante — 2nd ed.

p. cm.Includes bibliographical references (p. ) and indexes.ISBN 0-471-47276-X (cloth)1. Clinical psychology. 2. Psychotherapy. I. Title.

RC467.P56 2005616.89—dc22

2004042232

Printed in the United States of America.

10 9 8 7 6 5 4 3 2 1

➇

www.wiley.com

For Lori and Zachary,who make everything worthwhile

PREFACE TOTHE SECOND

EDITION

vii

The goals, activities, and contributions of contemporary clinicalpsychology are very appealing to many who are fascinated byhuman behavior and relationships. The enormous popularity of psy-chology as an undergraduate major; of clinical psychology as a ca-reer option; and of popular press psychology books, movies, andtelevision shows is a testament to the inherent interest of clinicalpsychology. The goal of clinical psychology is noble: to use the prin-ciples of psychology and our understanding of human behavior topromote health, happiness, and quality of life.

Contemporary clinical psychology is changing and growing at arapid pace. The advent of managed health care, the changing needsof a multicultural society, changes in training models, the shift fromprimarily a male to a female profession, technological and other sci-entific advances, complex problems in today’s culture, all havegreatly impacted both the science and practice of contemporary clin-ical psychology. Some of these changes are very positive; some arenegative. Despite the challenges confronting clinical psychology, thefield remains a fascinating and exciting endeavor with tremendouspotential to help individuals, groups, and society.

As more research evidence emerges concerning the interplay of bi-ological, psychological, and social influences on behavior, contempo-rary clinical psychologists must incorporate new knowledge todevelop better applications in their efforts to understand and helpothers. Biopsychosocial integration in many ways best reflects con-temporary clinical psychology, expanding the range and usefulness ofits efforts.

This book provides students an overview of contemporary clinicalpsychology from an integrative biopsychosocial perspective. The bookhighlights the various activities, roles, and responsibilities of the con-temporary clinical psychologist as well as provides a foundation of thediscipline through a detailed review of its history, scientific underpin-nings, and theoretical orientations. An overview of contemporary is-sues in clinical psychology serves as a road map for those interested inpursuing clinical psychology as a career option.

Each chapter includes a highlight of a contemporary clinical psy-chologist who provides a frank reflection on the pros and cons ofcontemporary clinical psychology as well as their view of the future ofthe field. A typical schedule is also provided so that you get a sense ofwhat a day in the life of a contemporary clinical psychologist might belike. The psychologists were chosen to reflect the broad range of peo-ple who are clinical psychologists. Some of the psychologists are wellknown; others are not. Several work in colleges and universities con-ducting research and teaching. Several work in solo or group privatepractice. Some work in hospitals, government agencies, or university

viii Preface

counseling clinics. One works in the U.S.Senate. Some combine work in several di-verse settings. Some work part-time whileraising a family. Psychologists from all overthe United States, from diverse training pro-grams, from both genders, a variety of ethnicgroups, and with disabilities are represented.The range of activities, roles, and responsibil-ities of these psychologists reflects the diver-sity of careers open to the contemporaryclinical psychologist.

Each chapter includes a detailed list of keypoints and terms to help enhance under-standing. Each chapter also includes a sectionentitled The Big Picture, which provides a“bottom line” or “take home message” sum-mary of the chapter as well as a look towardthe future of the topic covered in that partic-ular chapter. Each chapter also provides sev-eral questions readers have had after readingeach chapter. Each chapter also includes oneor more Spotlights on a contemporary issuein clinical psychology.

A great deal of clinical case material is pre-sented throughout the book as well. Severalcases such as Mary, a 60-year-old womanwith a long history of panic attacks, are dis-cussed in several chapters for the reader totrace the theoretical conceptualization, assess-ment, and treatment of one case in some de-tail. All of the patients presented are based onactual clinical cases. All of the examples fromtesting, therapy, consultation, and ethics arealso based on actual cases. However, the de-tails have been altered to protect patient andpsychologist confidentiality.

This book uses an integrative biopsychoso-cial approach throughout. This approach bestreflects the perspective of most contempo-rary clinical psychologists. Less emphasis isplaced on traditional theoretical models suchas behavioral, psychodynamic, and humanis-tic approaches since most contemporary clin-ical psychologists integrate these and other

approaches and orientations rather thanusing only one. An emphasis is placed on thereal world of clinical psychology to provide awindow into how the science and practice ofclinical psychology is actually conducted. Ihave attempted to provide the reader with arealistic, practical, and current portrayal ofthe contemporary clinical psychology field inmany different settings. Finally, this bookprovides a separate chapter on ethics and aseparate chapter on the consultation, admin-istration, and teaching responsibilities ofclinical psychologists. One chapter deals with10 common questions asked about psy-chotherapy. Finally, emphasis is placed oncontemporary issues in clinical psychologysuch as diversity, empirically supportedtreatments, managed health care, and otherhot topics.

The instructor’s guide that accompanies thisbook provides faculty with a detailed bookoutline, multiple choice and essay examina-tion questions, transparencies for class use, alist of references, web sites, popular and edu-cational films, class activities, and a samplecourse syllabus. The instructor’s guide is avail-able online.

The book assumes that students have al-ready completed undergraduate courses inintroductory and abnormal psychology. Thebook is appropriate for upper division collegestudents who are likely to be psychology ma-jors or first-year graduate students in clinicalpsychology. The book might also be a helpfulreference for those who provide career guid-ance for students potentially interested in acareer in psychology or related fields.

I welcome comments about the book fromboth students and faculty. These commentswill be used to create improved future edi-tions. You can contact me at [email protected] check my web site at www.SCU.edu/tplante. Thank you for reading this book andwelcome to the exciting, fascinating, and

Preface ix

ever-changing world of contemporary clinicalpsychology.

Acknowledgments

Numerous people other than the author assistin the development and completion of a book.Some provide help in a direct and concretemanner while others provide help in less di-rect and more supportive ways. I would like toacknowledge the assistance of the many peo-ple who have helped in both ways and havecontributed to the development of the bookand of me.

First, I would like to thank the many won-derful people at John Wiley & Sons who haveenthusiastically worked to publish this book.I’d like to thank my editor for her strong in-terest in the project as well as her high levelof professionalism and vision. I would alsolike to thank the production staff led by Deb-orah Schindlar.

I thank the anonymous patients referred toin this book for allowing their life experiencesand concerns to be an instrument of learningfor others.

I would like to thank the reviewers foroffering their helpful suggestions and per-spectives on earlier drafts of the book. Theseinclude:

Alan WhitlockUniversity of Idaho

Brent WaldenUniversity of Minnesota

Marsha RuntzUniversity of VictoriaVictoria, British Columbia, Canada

I would like to thank my many studentsfor helping me better understand what isuseful, interesting, and helpful for them tolearn and for providing me with inspiration.I’d like to especially thank students who pro-vided the student questions at the end ofeach chapter.

Finally, I would like to thank friends, col-leagues, mentors, and family who have beensupportive and instructive in a variety of di-verse ways over the years. These include Eliand Marilyn Goldfarb, Fr. Sonny Manuel,Peter Merenda, John Sousa, Gary Schwartz,Judith Rodin, Peter Walker, Carl Thoreson,Anthony Davids, Chris Hayward, MarciaPlante, Mary Beauchemin, Lee Sperduti,Henry and Anna McCormick, and MargaretCondon. Most especially, I would like tothank my wife, Lori, and son, Zachary, fortheir love, support, and for making every-thing worthwhile.

CONTENTS

xi

About the Author xxix

PART ONEFoundations and Fundamentals 1

Chapter 1What Is Contemporary Clinical Psychology? 3

Highlight of a Contemporary Clinical Psychologist:Patrick H. DeLeon, PhD, ABPP 3

CASE STUDY: Carlos 5Definition and Inherent Intrigue 6Perspective and Philosophy 7Education and Training 9Activities 11

Research 11

Assessment 12

Treatment 12

Teaching 15

Consultation 15

Administration 16

Employment Settings 16Private or Group Practices 16

Colleges and Universities 17

Hospitals 17

Medical Schools 17

Outpatient Clinics 18

Business and Industry 18

Military 18

Other Locations 18

Subspecialties 18Child Clinical Psychology 19

Clinical Health Psychology 20

Clinical Neuropsychology 20

Forensic Psychology 21

Geropsychology 21

Organizations 21American Psychological Association 21

American Psychological Society 22

xii Contents

State and County Psychological Associations 22

American Board of Professional Psychology 22

Other Organizations 23

How Does Clinical Psychology Differ from Related Fields? 23Counseling Psychologists (PhD) 23

School Psychologists (MA or PhD) 24

Psychiatry (MD) 25

Social Work (MSW) 26

Psychiatric Nursing (RN) 27

Marriage and Family Therapists (MFT) 27

Other Counselors 27

Other Psychologists 28

The Big Picture 28Key Points 29Key Terms 30For Reflection 30Real Students, Real Questions 30Web Resources 31

Chapter 2Foundations and Early History of Clinical Psychology 33

Highlight of a Contemporary Clinical Psychologist:Rev. Gerdenio “Sonny” Manuel, SJ, PhD 33

Early Conceptions of Mental Illness: Mind and Body Paradigms 36The Greeks 36

The Middle Ages 38

The Renaissance 39

The Nineteenth Century 39

The Birth of Psychology 41

The Founding of Clinical Psychology 42The Influence of Binet’s Intelligence Test 43The Influence of the Mental Health and Child Guidance Movement 43The Influence of Sigmund Freud in America 44The American Psychological Association and Early Clinical Psychology 44The Influence of World War I 45Clinical Psychology between World Wars I and II 46

Psychological Testing 46

Psychotherapy 46

Contents xiii

Training 47

Organizational Split and New Publications 47


Chapter 3Recent History of Clinical Psychology 51

Highlight of a Contemporary Clinical Psychologist:Amy Bassell Crowe, PhD 51

The Influence of World War II 53Clinical Psychology Immediately after World War II 53

Training 56

The Boulder Conference 56

Post-Boulder Conference Events 60

The Rise of Alternatives to the Psychodynamic Approach 60The Behavioral Approach 61

The Cognitive-Behavioral Approach 62

The Humanistic Approach 62

The Family Systems Approaches 63

Psychotropic Medication 65

Community Mental Health Movement 66

The Integrative Approaches 66

The Biopsychosocial Approach 68

A New Training Model Emerges 69The Vail Conference 69

Salt Lake City Conference 70

Additional Conferences 70

Michigan Conference on Postdoctoral Training 70

Present Status 70The Big Picture 72Key Points 72Key Terms 73For Reflection 73

xiv Contents

Real Students, Real Questions 74Web Resources 74

Chapter 4Research: Design and Outcome 75

Highlight of a Contemporary Clinical Psychologist:Alan E. Kazdin, PhD, ABPP 75

Research Methods and Designs 77Experiments 79

Identifying Independent and Dependent Variables 79

Minimizing Experimental Error 79

Maximizing Internal and External Validity 80

Experimental Designs 82

True Experimental Designs 82

Quasi-Experimental Designs 83

Between Group Designs 84

Within Group Designs 84

Mixed Group Designs 85

Analogue Designs 86

Case Studies 86

Single Subject Designs 87

Multiple Baseline Designs 88

Correlational Methods 90

Epidemiological Methods 92

Cross-Sectional and Longitudinal Designs 92Treatment Outcome Research 93

Treatment Package Strategy 94

Dismantling Treatment Strategies 95

Constructive Treatment Strategies 95

Parametric Treatment Strategy 95

Comparative Treatment Strategy 96

Client-Therapist Variation Strategy 96

Process Research Strategy 96

Questions and Challenges in Conducting Treatment Outcome Research 96Is a Research Program’s Treatment Similar to the Treatment in

Actual Practice? 96

Are the Patients and Therapists Used in a Research Study Typical ofThose in Actual Practice? 97

Contents xv

What Are Some of the Ethical Problems with TreatmentOutcome Research? 97

How and When Is Treatment Outcome Measured? 98

Statistical versus Clinical Significance 99

How Can Treatment Outcome Decisions Be Made When StudiesReach Different Conclusions? 100

What Is a Program of Research and How Is It Conducted? 101

Contemporary Issues in Clinical Psychology Treatment Outcome Research 101Biopsychosocial Approaches to Psychopathology Research 102

Meta-Analysis 103

Empirically Supported Treatments 103

Comprehensive and Collaborative Multisite Clinical Trial Research Projects 106

Community-Wide Interventions 106

Cross Cultural Research 107

How and Where Is Research Conducted in Clinical Psychology andHow Is It Funded? 107

How Are Research Results Communicated and Incorporatedinto Practice? 108


Chapter 5The Major Theoretical Models: Paving the Way toward Integration 115

Highlight of a Contemporary Clinical Psychologist: Marcia J. Wood, PhD 115The Four Major Theoretical Models in Clinical Psychology 117

The Psychodynamic Approach 117

CASE STUDY: Mary 118Freud’s Psychoanalytic Perspective 118

The Revisionist or Neo-Freudian Perspective 121

The Object Relations Perspective 121

The Behavioral and Cognitive-Behavioral Approaches 122

The Classical Conditioning Perspective 124

The Operant Perspective 125

xvi Contents

The Social Learning Perspective 125

The Cognitive Perspective: Beliefs, Appraisals, and Attributions 126

The Humanistic Approach 128

The Client-Centered Perspective 129

Maslow’s Humanistic Perspective 129

The Gestalt Perspective 130

The Family Systems Approach 130

The Communication Approach 131

The Structural Approach 132

The Milan Approach 132

The Strategic Approach 134

The Narrative Approach 134

Understanding Mary from Different Theoretical Orientations 135Psychodynamic Formulation and Plan 135

Cognitive-Behavioral Formulation and Plan 135

Humanistic Formulation and Plan 136

Family Systems Formulation and Plan 136

Conclusion 136


Chapter 6Integrative and Biopsychosocial Approaches in ContemporaryClinical Psychology 141

Highlight of a Contemporary Clinical Psychologist: Paul L. Wachtel, PhD 141The Call to Integration 143

Commonalities among Approaches 144

Efforts toward Integration 145

Eclectism 146

Beyond Psychological Models 147

Biopsychosocial Integration 148Biological Factors 148

Social Factors 153

Contents xvii

CASE STUDY: Mary—Integrating Biological Factors 153Synthesizing Biological, Psychological, and Social Factors in

Contemporary Integration 155The Diathesis-Stress Perspective 155

CASE STUDY: Mary—Integrating Social Factors 157The Reciprocal-Gene-Environment Perspective 157

Psychosocial Influences on Biology 158

Development of the Biopsychosocial Perspective 158

Application of the Biopsychosocial Perspective to Contemporary ClinicalPsychology Problems 159Obsessive-Compulsive Disorder 159

Panic Disorder and Anxiety 161

CASE STUDY: Hector Experiences Obsessive-CompulsiveDisorder (Biopsychosocial) 162

CASE STUDY: Nicole Experiences School Phobia (Biopsychosocial) 165Cardiovascular Disease 166

CASE STUDY: Taylor Experiences Cardiovascular Disease, Job andFamily Stress, and Type A Personality (Biopsychosocial) 167Cancer 168

CASE STUDY: Marilyn—Biopsychosocial with Cancer 169CASE STUDY: Mary—Biopsychosocial Synthesis 171

Conclusion 172


PART TWORoles and Responsibilities 175

Chapter 7Contemporary Psychological Assessment I: Interviewing andObserving Behavior 177

Highlight of a Contemporary Clinical Psychologist: Stanley Sue, PhD 177Goals, Purposes, and Types of Assessment 179

xviii Contents

Reliability and Validity 180

Interviewing 182Rapport 183

Effective Listening Skills 184

Effective Communication 185

Observation of Behavior 186

Asking the Right Questions 186

Types of Interviews 186Initial Intake or Admissions Interview 186

CASE STUDY: Joe Experiences Depression 187Mental Status Interview 188

Crisis Interview 190

Diagnostic Interview 190

Structured Interviews 193

Computer-Assisted Interviews 195

Exit or Termination Interview 195

Potential Threats to Effective Interviewing 197Bias 197

Reliability and Validity 197

Behavioral Observations 199Naturalistic Observation 199

Self-Monitoring 201

Controlled Observations 202

Checklists and Inventories 203Beck Inventories 203

Child Behavior Checklist (CBCL) 205

The Symptom Checklist 90-Revised (SCL-90-R) 205

CASE STUDY: Jose and the BDI, CBCL, and SCL-90-R 206Other Checklists and Inventories 207

Physiological Testing 208

The Big Picture 209

Key Points 209

Key Terms 210

For Reflection 210

Real Students, Real Questions 211

Web Resources 211

Contents xix

Chapter 8Contemporary Psychological Assessment II: Cognitive andPersonality Assessment 213

Highlight of a Contemporary Clinical Psychologist:Lori Goldfarb Plante, PhD 213

Cognitive Testing 214Intelligence Testing 214

What Is Intelligence? 215

How Do Clinical Psychologists Measure Intelligence? 217

Wechsler Scales 218

CASE STUDY: Gabriel—WAIS-III (Intellectual Assessment) 221Stanford-Binet Scales 222

Other Tests of Intellectual Ability 222

CASE STUDY: Donald—WISC-IV (Intellectual Assessment) 224Other Tests of Cognitive Ability 226

Neuropsychological Testing 229

Questions and Controversies Concerning IQ and Cognitive Testing 231

Case Study: Robert Experiences a Head Injury and ResultingAntisocial Behaviors (Neuropsychological) 232

Conclusion 233

Personality Testing 234What Are Personality and Psychological Functioning? 234

Is Personality Really Enduring? 236

How Do Clinical Psychologists Measure Personality andPsychological Functioning? 236

Objective Testing 237

Projective Testing 242

Case Study: Martha Experiences Severe Depression and BorderlinePersonality (Rorschach) 243

CASE STUDY: Xavier Experiences Bipolar Disorder (Rorschach) 244Questions and Controversies Concerning Personality and

Psychological Testing 248

CASE STUDY: Debbie Experiences Alcoholism, Depression, andPhobic Anxiety (TAT) 248

CASE STUDY: Xavier (Sentence Completion) 249

Case Study: Elias Experiences Anxiety and Depression(Sentence Completion) 249

xx Contents

Clinical Inference and Judgment 251

Communicating Assessment Results 254

CASE STUDY: Thomas Experiences Aggressive Behavior Associatedwith Asperger’s Syndrome (Psychological Assessment Report) 255Integrated Psychological Assessment Report 257

The Big Picture 258

Key Points 258

Key Terms 260

For Reflection 260


Web Resources 260

Chapter 9Psychotherapeutic Interventions 263

Highlight of a Contemporary Clinical Psychologist:John C. Norcross, PhD 263

Contemporary Integration in Psychotherapy 266

Goals of Psychotherapy 267

Similarities or Common Denominators in Psychotherapy 268Professional Person 268

Professional Manner 269

Professional Setting 269

Fees 269

Duration of Sessions 270

Frequency of Sessions 270

Stages of Psychotherapy 270Initial Consultation 270

Assessment 272

Development of Treatment Goals 273

Implementation of Treatment 273

Evaluation of Treatment 273

Termination 273

Follow-Up 273

Modes of Psychotherapy 273Individual Psychotherapy 275

CASE STUDY: Shawna Experiences Enuresis (Individual Child Therapy) 275Group Psychotherapy 277

Contents xxi

CASE STUDY: James Experiences Bipolar Disorder(Individual Psychotherapy) 278Couples Psychotherapy 279

Family Therapy 280

Nonpsychotherapy Approaches to Treatment: Biological andSocial Interventions 280

CASE STUDY: Inpatient Group Psychotherapy 282CASE STUDY: Hans and Marta Experience Severe Marital Discord

(Couples Therapy) 285Biological Interventions 286

CASE STUDY: The Kaplans Experience a Family Death and aSuicide Attempt in the Family (Family Therapy) 287Social Interventions 289

Contemporary Case, Contemporary Treatment 291

The Big Picture 291

CASE STUDY: Mako Experiences Anorexia Nervosa—Integration ofTheories, Techniques, Modalities, and Biopsychosocial Factors(Contemporary Psychotherapy) 294

Key Points 296

Key Terms 296

For Reflection 296


Web Resources 297

Chapter 10Ten Essential Questions about Psychotherapy 299

Highlight of a Contemporary Clinical Psychologist: Allen Sherman, PhD 299

Does Psychotherapy Work? 301

Is Long-Term Therapy Better than Short-Term Treatment? 304

Who Stays In and Who Drops Out of Psychotherapy? 305

Is One Type of Therapy Better than Another? 306

Do the Effects of Psychotherapy Last after Therapy Ends? 308

What Common Factors Are Associated with PositivePsychotherapy Outcome? 309

Why Is Change Difficult? 311

Must Someone Be a Professional to Be an Effective Therapist? 313

xxii Contents

Does Psychotherapy Help to Reduce Medical Costs? 314

Can Psychotherapy Be Harmful? 315

The Big Picture 317

Key Points 317

Key Terms 318

For Reflection 319


Web Resources 319

Chapter 11Areas of Specialization 321

Highlight of a Contemporary Clinical Psychologist: Micheline Beam, PhD 321

Clinical Health Psychology 324Smoking 325

Obesity 328

Alcohol Abuse 329

Stress Management 330

Acquired Immune Deficiency Syndrome (AIDS) 330

Chronic Pain Control 332

CASE STUDY: Celeste Experiences Type A Personality and IrritableBowel Syndrome 332Conclusion 333

Child Clinical Psychology 333

CASE STUDY: Weight Loss Treatment Program 333CASE STUDY: Joe Experiences Alcoholism 334

Attention Deficit Hyperactivity Disorder 335

Learning Disorders 338

Child Abuse and Neglect 339

Anorexia Nervosa 341

Conclusions 342

Clinical Neuropsychology 342

CASE STUDY: Sam Experiences Autism 342CASE STUDY: Zoe Experiences Acting Out Behaviors 343CASE STUDY: Sally Experiences Anorexia Nervosa 344

Epilepsy 345

Brain Injuries 346

Degenerative Diseases 346

Contents xxiii

CASE STUDY: Joseph Experiences Dementia and Depression 347Conclusions 347

Geropsychology 348Degenerative Diseases 348

Psychiatric Issues in Older Adults 349

Anxiety 349

Depression 351

Substance Abuse 351

Forensic Psychology 352Involuntary Commitment 352

CASE STUDY: Austin Experiences Substance Abuse and a SevereHead Injury 352

CASE STUDY: Margaret Experiences Problems Associated with a Stroke 353Insanity Defense 354

Child Custody 354

Violence against Women 355

Jury Selection 355

Conclusions 355

Other Subspecialties 356

CASE STUDY: The Lee Family Experiences Stress Associated withDivorce and Child Custody 357

CASE STUDY: Marie Experiences Suicidal Behaviors and Depression 357CASE STUDY: Betty Experiences Job Stress 358The Big Picture 358

Key Points 359

Key Terms 360

For Reflection 360


Web Resources 360

Chapter 12Consultative, Teaching, and Administrative Roles 361

Highlight of a Contemporary Clinical Psychologist:Julie B. (Sincoff) Jampel, PhD 361

Consultation 363Consultation Defined 364

Consultation Roles 364

xxiv Contents

Types of Consultation 367

Mental Health Consultation 367

Organizational Consultation 367

Executive Coaching 368

Stages of Consultation 368

Understanding the Question 368

Assessment 369

Intervention 370

Termination 370

Follow-Up 370

To Whom Do Clinical Psychologists Offer Consultation? 371

Consultation with Nonmental Health Professionals 372

CASE STUDIES: Consultation with Mental Health Colleagues 373Effective Consultation 374

CASE STUDIES: Consultation with Nonmental Health Professionals 375Challenges in Consultation 376

Teaching 377Teaching in Academic Settings 377

Psychology Departments 377

Other Academic Departments 379

Medical Schools and Hospitals 379

CASE STUDIES: Teaching in Academic Settings 379Teaching in Nonacademic Settings 381

Clinics 381

CASE STUDIES: Teaching in Nonacademic Locations 381Workshops 382

Business and Industry 382

General Public 382

Administration 383

CASE STUDIES: Administrators in Clinical Psychology 384

The Big Picture 385

Key Points 385

Key Terms 386

For Reflection 386


Web Resources 387

Contents xxv

Chapter 13Ethical Standards 389

Highlight of a Contemporary Clinical Psychologist:Thomas G. Plante, PhD, ABPP 389

How Do Professional Ethics Differ from the Law? 392

The Ethical Principles of Psychologists and Code of Conduct 393Fundamental Ethical Principles 394

Competence 394

Integrity 395

CASE STUDY: Dr. A Treats a Patient Although He Has InadequateCompetence to Do So 396

CASE STUDY: Dr. B Conducts Psychological Testing Less Than Rigorously 397Professional and Scientific Responsibility 398

CASE STUDY: Dr. C Misleads His Clients Regarding His Credentials 398CASE STUDY: Dr. D Participates in a Dual Relationship with Her Client 399CASE STUDY: Dr. E Treats a Client Very Different from Those with Whom

He Has Expertise 400Respect for People’s Rights and Dignity 400

CASE STUDY: Dr. F Is Concerned about Unethical Behavior in a Colleague 401Concern for Other’s Welfare 401

CASE STUDY: Dr. H Breaks Confidentiality with a Client 401CASE STUDY: Dr. I Does Not Report Child Abuse Due to Patient Pressure 402

Social Responsibility 402

CASE STUDY: Dr. J Has Strong Personal Values That Impact HisWork with Clients 402

CASE STUDY: Dr. K Experiences Personal Prejudice That ImpactsHer Work with Diverse Clients 403

CASE STUDY: Dr. L Takes Advantage of His Students for Personal Favors 403Ethical Standards 404

General Standards 404

CASE STUDY: Dr. M Is Greedy and Unwilling to Give Back to Society 404Evaluation, Assessment, or Intervention 405

CASE STUDY: Dr. N Allows Unqualified Trainees to GivePsychological Tests 406

Advertising and Other Public Statements 406

CASE STUDY: Dr. O Uses Testing Materials for Purposes for Which They Were Not Developed 407

xxvi Contents

CASE STUDY: Dr. P Does Not Protect Psychological Tests from Misuse 407Therapy 408

CASE STUDY: Dr. Q Uses His Work with a Client for His Own Advantage 408CASE STUDY: Ms. R Allows Others to Misrepresent Her Credentials 409CASE STUDY: Dr. S Misleads Others about His Training 409

Teaching, Training, Supervision, Research, and Publishing 410

Forensic Activities 410

CASE STUDY: Dr. T Dates a Relative of His Patient 416CASE STUDY: Dr. U Abandons His Clients 417CASE STUDY: Dr. V Publishes Research in a Way to Help Her Career

Rather Than Doing So More Responsibly 417CASE STUDY: Dr. W Surprises His Students with Rejection without

Any Warning 417CASE STUDY: Dr. X Doesn’t Provide Full Informed Consent to His Clients 418

Resolving Ethical Issues 418

Why Would a Psychologist Behave in an Unethical Manner? 418CASE STUDY: Dr. Y Fails to Help and Support Her Students 419CASE STUDY: Dr. AA Commits Insurance Fraud 419CASE STUDY: Dr. BB Enters a Dual Relationship with His Client 420How Are Ethics Enforced? 420What Is the Process for Solving Ethical Dilemmas? 421Is Behaving in Accordance with the Ethical Principles Always Clear Cut? 422The Big Picture 423Key Points 424Key Terms 425For Reflection 425Real Students, Real Questions 425Web Resources 425

PART THREEWhere Is Clinical Psychology Going and Should I Go with It? 427

Chapter 14Current and Future Trends and Challenges 429

Highlight of a Contemporary Clinical Psychologist:Nicholas A. Cummings, PhD, ScD 429

Contents xxvii

Trends in Society 433Contemporary Changes in the American Family 433

Multicultural and Diversity Issues 434

Advances in Science, Technology, and Medicine 436

Money 439

Gender Shifts in Professions 441

Research Issues 442

Practice Issues 443Managed Health Care 443

Prescription Privileges 448

Medical Staff Privileges 452

Private Practice 453

Specialization 453

Empirically Supported Treatments 455

Reaching Beyond Mental Health in Contemporary Clinical Psychology 457

Training Issues 458

The Big Picture 459

Key Points 460

Key Terms 461

For Reflection 461


Web Resources 462

Appendix 463

Chapter 15Becoming a Clinical Psychologist: A Road Map 475

Highlight of a Contemporary Clinical Psychologist:Dianne L. Chambless, PhD 475

College 477Grade Point Average 478

Graduate Record Exam 478

Research Experience 479

Clinical Experience 480

Verbal Skills 481

Interpersonal Skills 481

Reliability and Dependability 481

xxviii Contents

Productivity 481

Letters of Recommendation 481

Motivation 482

Applying to Graduate Programs in Clinical Psychology 482Graduate School in Clinical Psychology 484

PhD or PsyD 484

University versus Free-Standing Professional Schools 485

Accreditation 485

Training Curriculum and Emphasis 486

Clinical Internship 487Postdoctoral Fellowship 489Specialization 490Certification and/or Licensure 490

The Written Examination 491

The Oral Examination 491

Employment 492Academic Positions 493

Clinical Positions 493

The American Board of Professional Psychology Diploma 494Is Clinical Psychology Right for Me? 495How to Get More Information about Current Issues in Clinical Psychology 495The Big Picture 497Key Points 497Key Terms 499For Reflection 499Real Students, Real Questions 499Web Resources 499

Glossary 501

Appendix: Ethical Principles of Psychologists and Codeof Conduct 2002 511

References 533

Photo Credits 587

Author Index 589

Subject Index 603

ABOUT THEAUTHOR

xxix

Thomas G. Plante is a professor of psychology at Santa ClaraUniversity and an adjunct clinical associate professor of psychi-atry and behavioral sciences at Stanford University School of Medi-cine. He teaches undergraduate courses in General Psychology,Abnormal Psychology, Clinical Psychology, Health Psychology, Psy-chosomatic Medicine, and Ethics at Santa Clara and Professional Is-sues and Ethics for clinical psychology interns, postdoctoral fellows,and psychiatric residents at Stanford.

He is a licensed psychologist in California and a diplomate of theAmerican Board of Professional Psychology in Clinical Psychologymaintaining a private practice in Menlo Park, California. He is a fel-low of the Academy of Clinical Psychology, the American Psycholog-ical Association, and the Society of Behavioral Medicine. He is theformer chief psychologist and mental health director of the Chil-dren’s Health Council, a private, nonprofit agency serving childrenand families with behavioral, educational, and emotional problemsaffiliated with Stanford University as well as a former staff psycholo-gist and medical staff member at Stanford Hospital.

He has published over 100 professional journal articles and chap-ters on topics such as clinical psychology training and professional is-sues, psychological benefits of exercise, personality and stress, andpsychological issues among Catholic clergy. He has published severalbooks including Bless Me Father for I Have Sinned: Perspectives on SexualAbuse Committed by Roman Catholic Priests (1999, Greenwood); GettingTogether, Staying Together: The Stanford University Course on Intimate Rela-tionships (with Kieran Sullivan, 2000, 1st Books), Faith and Health:Psychological Perspectives (with Alan Sherman, 2001, New York: Guil-ford), Sin against the Innocents: Sexual Abuse by Priests and the Role of theCatholic Church (2004, Greenwood), and Do the Right Thing: Living Eth-ically in an Unethical World (2004, Oakland, CA: New Harbinger).

Dr. Plante lives in the San Francisco Bay area with his wife, Lori(also a psychologist), and son, Zachary. He enjoys running, pianoplaying, and tending to his home vineyard.

1

FO U NDATI O N S A NDFU N DA M ENTA L S

Chapter 1 What Is Contemporary Clinical Psychology?

Chapter 2 Foundations and Early History of ClinicalPsychology

Chapter 3 Recent History of Clinical Psychology

Chapter 4 Research: Design and Outcome

Chapter 5 The Major Theoretical Models: Paving the Waytoward Integration

Chapter 6 Integrative and Biopsychosocial Approaches inContemporary Clinical Psychology

PART

O n e

3

What Is ContemporaryClinical Psychology?

Chapter Objectives1. To define clinical psychology.2. To provide a brief history of the field and put it in context

relative to similar fields and professions.3. To understand the various activities, roles, and employment

settings of clinical psychologists.

Chapter OutlineHighlight of a Contemporary Clinical Psychologist:

Patrick H. DeLeon, PhD, ABPPDefinition and Inherent IntriguePerspective and PhilosophyEducation and TrainingActivitiesSubspecialtiesOrganizationsHow Does Clinical Psychology Differ from Related Fields?

Highlight of a Contemporary Clinical Psychologist

Patrick H. DeLeon, PhD, ABPP

Dr. DeLeon uses his training and skills as a clinical psychologist by work-ing on Capital Hill. He helps shape policy and legislation that best reflectsboth the science and application of clinical psychology. He is a formerpresident of the American Psychological Association.

Birth Date: January 6, 1943

College: Amherst College (BA, Liberal Arts), 1964

Graduate Program: Purdue University (MS, Psychology), 1966; PurdueUniversity (PhD, Clinical Psychology), 1969; University of Hawaii (MPH,Health Services Administration), 1973; Catholic University, ColumbusSchool of Law (JD), 1980

Clinical Internship: Fort Logan Mental Health Center, Denver, Colorado

Current Job: Administrative Assistant (Chief of Staff), U.S. Senator D. K.Inouye, United States Senate

1C h a p t e r

4 Foundations and Fundamentals

Pros and Cons of Being a Clinical Psychologist:

Pros: “Substantive knowledge about people,systems, health care, etc.”

Cons: “Most psychologists or psychology col-leagues do not appreciate how little they knowabout public policy and national trends.”

Future of Clinical Psychology: “The knowl-edge base will continue to expand; whetherservices are provided by psychologists or otherprofessionals is an open question. Psychologycontrols its own destiny—to not seek newagendas and to not save society means to bereplaced by nursing and social work.”

Changes during the past 5 to 7 years:“We have developed a significantly broaderfocus and thus have brought the behavioralsciences to a wider range of activities, espe-cially within the generic health care arena.As our numbers have increased, we have de-veloped a greater presence (i.e., influence) indefining quality care and health care priori-ties. Significantly more colleagues are nowpersonally active within the public policy andpolitical process, thus ensuring that psychol-ogy’s voice (and values) will be heard. Thedevelopment of postdoctoral training posi-tions has resulted in society developing agreater appreciation for the importance of thepsychosocial aspects of health care. Clearly,the prescription privileges agenda is revolu-tionizing mental health care delivery.”

What do you think will be the majorchanges in clinical psychology duringthe next several years? “The prescriptionprivilege agenda will continue to expand andthereby absolutely redefine quality mentalhealth care. Advances in the technology andcommunications fields will be found to havedirect applicability to health care and psy-chology will play a major role in addressingthis challenge. Health care will become morepatient-centered and interdisciplinary in

nature. No longer will any of the health careprofessional schools be allowed to foster iso-lated or ‘silo-oriented’ training modules. Thepercentage of women in the field will in-crease to nearly 75%. And, clinical protocolswill focus concretely on special populations(such as the elderly, children, and variousethnic minority clients). Health care will be-come more accountable and data driven. Dis-tance learning and virtual training programswill become ‘the norm.’ ”

Typical Schedule:9:00 Meet with Legislative Assistants and

committee staff members concerning up-coming legislation.

10:00 Attend senate hearing on issues relatedto managed health care (Labor, House ofHuman Services Appropriations Sub-committee).

11:00 Senate hearings continue.12:00 Lunch.

1:00 Attend briefing on health care issues forthe elderly.

2:00 Meet with constituents and advocacygroups (e.g., members of APA regardingupcoming vote on legislation relevant topsychology; mental health professionalsfrom Hawaii).

3:00 Respond to e-mail and phone calls.4:00 Meet with Senator Inouye for briefing

and review of day‘s activities.5:00 Stand-by in office until Senate adjourns

to provide information to Senator Inouyefor a pending vote.

As you can tell from this example, clini-cal psychology is a complex field thatparallels the complexity of human behaviorand emotion. Just as we are defined by morethan blood and tissue, emotions and ideas, orour relationships to others, the field of clinicalpsychology is, by necessity, an integrative ef-fort to understand the interaction of biologi-cal, psychological, and social factors in making

What Is Contemporary Clinical Psychology? 5

Case Study: CarlosCarlos experiences depression, substanceabuse, attentional problems, learning dis-abilities, diabetes, and family stress.

Carlos is a biracial (part Latino and partCaucasian) 14-year-old boy who feels iso-lated, depressed, and hopeless. He has fewfriends, his school work is poor, and he feelsuncomfortable in his predominately Cau-casian high school. He is new at school, re-cently moving to a new town from out ofstate. He complains that he doesn’t fit in andmisses his old middle school, which had pre-dominately Latino and African Americanstudents. He was evaluated by a psychologistat school when he was 9 years old and wasfound to experience an attentional problemas well as a learning disability that makesreading difficult. He has taken medication inthe past for his attentional problem and healso takes insulin for his diabetes.

Carlos’ mother is Latina and works as asocial worker at a local hospital. She wasrecently diagnosed with breast cancer. Hisfather is Caucasian of German descent andworks as a clerk at a large computer com-pany. His mother is Roman Catholic andvery active in her church whereas his fatherwas raised as a Lutheran but describes him-self as an atheist. His father has had analcohol problem for many years and has suf-fered from depression as well. He has beenfired from several jobs due to his alcoholtroubles and temper. He also had attentionaland learning difficulties in school but copedfairly well with these problems and gradu-ated from community college with goodgrades.

Carlos’ parents have had a great deal ofmarital conflict and have separated on sev-

eral occasions. Their differences in faith,ethnic background, financial concerns, andhis father’s alcohol abuse, depression, andtemper have taken a toll on the family. Car-los’ younger sister is a “star” student, haslots of friends, and seems to cope very wellwith the stress in the family. Carlos feelsthat his sister makes him “look bad.”

Carlos’ mother felt that Carlos should seea clinical psychologist about his depressivemood. Her managed care health insurancewill allow Carlos and his family up to sixsessions with a local clinical psychologistwho is on the company’s list of preferredproviders. Carlos is willing to get help butfeels that there is little anyone can do forhim. He also worries about confidentialitybecause he does not want his parents toknow that he has been sexually active andhas used alcohol and drugs on occasion. Hewould like to see a Latino psychologist butthe managed care company does not haveone on their local panel of providers.

If you were the clinical psychologist Car-los and his family came to, how would youhelp them during the allotted six sessions?How would you further evaluate Carlos andhis family? What would you suggest theydo to help themselves and each other? Howwould you manage confidentiality arrange-ments? What research is available to guideyou in your work? How much can you ac-complish in six sessions? What do you do ifafter six sessions Carlos and his family stillneed your help? How do you evaluate ifyour work has been helpful? What do youdo if Carlos becomes in danger of hurtinghimself?


each of us “tick.” Furthermore, modern clini-cal psychology must respond to contemporaryissues that impact all of our lives. For exam-ple, the importance of ethnicity, culture, andgender in today’s society informs and enrichesthe field of contemporary clinical psychologyas do current issues related to economics,technology, ethics, and popular culture.

Like medicine and other fields, the rootsof clinical psychology are viewed as simplisticand narrowly conceived. However, with scien-tific advancements and collaboration betweenvarious fields and schools of thought, contem-porary clinical psychology champions a so-phisticated integration that pulls together thebest of these models for optimal treatment, as-sessment, consultation, and research.

Before describing the historical evolutionof clinical psychology into its contemporaryform, this chapter defines clinical psychologyand the varied roles and activities of today’sclinical psychologist. In addition, the integra-tive nature of contemporary clinical psychol-ogy will be highlighted. The purpose of thischapter is to examine exactly what clinicalpsychology is all about. I will define clinicalpsychology as well as outline the educationalprocess for clinical psychologists, detail theirtypical roles and professional activities, list theusual employment settings, the various sub-specialties within clinical psychology, the pro-fessional organizations of clinical psychology,and the similarities and differences betweenclinical psychology and related fields. Subse-quent chapters will highlight these issues (andothers) in much more detail. In doing so, acomprehensive and realistic view of the fieldof clinical psychology will be presented.

Throughout the course of this book, I dis-cuss the field of clinical psychology as under-stood and practiced in the United States.However, clinical psychology is recognizedand practiced in many other countries. TheAmerican Psychological Association (APA),the Canadian Psychological Association, and

the British Psychological Society for example,have more similarities than differences andoften host joint meetings and other profes-sional activities. The doctorate is the expectedlevel of training for psychologists in the UnitedStates, Canada, and the United Kingdom.Much of Europe and elsewhere do not requiredoctoral training for clinical psychologists. Un-fortunately, it is beyond the scope of this bookto detail the training, history, and activities ofclinical psychologists in other countries. How-ever, much of the information presented isuniversally relevant to clinical psychologists.

Definition and Inherent Intrigue

What could be more intriguing than humanbehavior and interpersonal relationshipsin all their complexity? A visit to any majorbookstore reveals that topics such as clinicalpsychology, self-help, and the general useof psychological principles in understandingour lives are enormously popular and perva-sive. Hundreds of books are published eachyear that focus on ways to better understandhuman behavior, replete with methods to im-prove psychological functioning as it interactswith physical well-being, emotions, and in-terpersonal relationships. Furthermore, oneof the most popular television programs dur-ing the past several years has been The Dr. PhilShow, a clinical psychologist offering adviceon numerous wide-ranging topics for willingparticipants.

Although the discipline of psychology isonly about 100 years old, psychology is one ofthe most popular current undergraduate ma-jors in most colleges and universities. Further-more, clinical psychology is the most popularspecialty area within psychology (APA, 2001;Norcross, Sayette, & Mayne, 2002). Doctor-ates in psychology are more common thanany other doctoral degree awarded in theUnited States with the majority of psychology


doctorates being awarded in clinical psy-chology (APA, 2000a, 2000b; Norcross et al.,2002). The majority of members of the APAlist clinical psychology as their area of special-ization (APA, 2001).

How is clinical psychology defined? Clini-cal psychology focuses on the assessment,treatment, and understanding of psycholog-ical and behavioral problems and disorders.In fact, clinical psychology focuses its effortson the ways in which the human psycheinteracts with physical, emotional, and socialaspects of health and dysfunction. Accordingto the APA, clinical psychology attempts touse the principles of psychology to betterunderstand, predict, and alleviate “intellec-tual, emotional, biological, psychological,social, and behavioral aspects of human func-tioning” (APA, 2000b). Clinical psychologyis “the aspect of psychological science andpractice concerned with the analysis, treat-ment, and prevention of human psychologi-cal disabilities and with the enhancing ofpersonal adjustment and effectiveness” (Rod-nick, 1985, p. 1929). Thus, clinical psychol-ogy uses what is known about the principlesof human behavior to help people with thenumerous troubles and concerns they experi-ence during the course of life in their rela-tionships, emotions, and physical selves. Forexample, a clinical psychologist might evalu-ate a child using intellectual and educationaltests to determine if the child has a learningdisability or an attentional problem thatmight contribute to poor school performance.Another example includes a psychologist whotreats an adult experiencing severe depres-sion following a recent divorce. People expe-riencing substance addictions, hallucinations,compulsive eating, sexual dysfunction, physi-cal abuse, suicidal impulses, and head in-juries are a few of the many problem areasthat are of interest to clinical psychologists.

Who is a clinical psychologist? Many people with different types of training and

experience are involved with helping under-stand, assess, and treat people with problemsin living. Counselors, nurses, psychiatrists,peer helpers, and others are involved with theareas of concern already listed. Clinical psy-chologists “have a doctoral degree from a re-gionally accredited university or professionalschool providing an organized, sequentialclinical psychology program in a departmentof psychology” (APA, 1981, p. 641). Althoughmany universities offer master’s degree train-ing programs in clinical psychology, the doc-torate is considered to be the minimal level oftraining to be considered a clinical psycholo-gist. Clinical psychology is not so much a spe-cialty separate from psychology, but is more aunique application of psychology to the realmof emotional and behavioral problems(Matarazzo, 1987).

Perspective and Philosophy

Clinical psychology uses the scientific methodto approach and understand human problemsin behavior, emotions, thinking, relationships,and health. Rigorous scientific inquiry is usedto select and evaluate assessment and treat-ment approaches and activities. Treatmentoutcome research helps to determine whichtreatments might be most effective for peopleseeking help with particular clinical problems.However, clinical psychology is both a scienceand an art. Findings from scientific investi-gations must be applied to the unique andspecial needs of an individual, group, or orga-nization. What might be helpful to one personmay not be to another even if they both expe-rience the same diagnosis or problems. The sci-ence of clinical psychology informs the artwhile the art also informs the science. For ex-ample, research findings from experiments onpsychotherapy outcomes are used to deter-mine which type of psychotherapy is mostuseful with people experiencing depression


whereas clinical experience working withpeople struggling with depression is used tobetter design and implement psychotherapyoutcome research.

Contemporary clinical psychology uses in-tegrative approaches to understand and ad-dress problems in human behavior. While awealth of individual perspectives contributeimportant pieces of understanding to the puz-zle of human behavior, these pieces mustoften be joined in novel ways to provide themost complete and holistic perspective. Forexample, advances in biology have providedimportant knowledge about the role of neuro-transmitters in depression. Similarly, personalvariables such as history of loss and trauma, aswell as sociocultural factors such as poverty,discrimination, and community support in de-pression, are well appreciated. Ultimately, anintelligent melding of these biological, psycho-logical, and social factors leads to interventionstrategies that best address the complex needsof depressed individuals. Therefore, this bookemphasizes integrative efforts to addresshuman behavior, referring to biopsychosocialfactors throughout.

Although individual clinical psychologistsmay be closely aligned with particular theo-retical perspectives on human behavior, mostcontemporary clinical psychologists also ap-preciate the integral roles of biopsychologicalfactors in health and illness. The biopsycho-social perspective, an example of an integra-tive approach, will be more fully described inChapter 6. To understand psychology’s rootsand gradual development into its presentform as an integrative endeavor, it is impor-tant to keep in mind the impact of biopsy-chosocial issues simply as the interplay ofrelevant biological, psychological, and socialfactors in human behavior.

Research and practice in clinical psychologyhas found that certain approaches to under-standing and treating problems may be espe-cially useful for certain people and problems

while different approaches might be mosthelpful for others. For example, some peoplewho experience depression respond well tomedication while others respond to cognitive-behavioral psychotherapy. Others respondwell to supportive therapies such as the hu-manistic approach. Still others respond to acombination of these and other approaches.Although medication might be useful to treatsomeone with depression, family therapy, vo-cational counseling, and group social skillstraining may enhance treatment success.

Many people who seek the services of aclinical psychologist often have several prob-lems or diagnoses occurring at the same time.For example, the person who experiencesdepression may also suffer from a chronic ill-ness, a personality disorder, a learning dis-ability, and marital discord. Furthermore,stressful life events, intellectual functioning,ethnic background, religious orientation, andother factors contribute to the manifestationof the depressive disorder and other prob-lems. One theoretical orientation alone maynot address the complexity of the personseeking help. Although various clinical psy-chologists may be closely aligned with oneparticular theoretical or philosophical ori-entation, most contemporary clinical psy-chologists believe that problems in humanbehavior are multidimensional. They use anintegrative approach that suggests that inter-acting causal factors generally contribute tohuman problems and that a multidimen-sional approach is usually needed to tacklethese issues. Thus, many factors may con-tribute to human problems and a selection offactors must be utilized to help alleviate theseconcerns. Today, many clinical psychologistsuse an integrative perspective that maintainsa biopsychosocial orientation.

The biopsychosocial perspective em-phasizes the interaction of biological, psy-chological, and social influences on behaviorand psychological functioning. Each must


be carefully considered and the individualviewed in a broader biopsychosocial contextin order to best understand the complexities ofhuman behavior and the most effective meansof intervention (Engel, 1977, 1980; N. John-son, 2003; G. E. Schwartz, 1982, 1984). Al-though clinical psychologists may not be ableto intervene at the biological, psychological, orsocial level, they must take into considerationthese influencing factors in understanding andtreating people who seek their services. Forexample, psychologists cannot prescribe med-ication in most states, conduct physical exam-inations, or offer surgery to their patients.They cannot alter ethnic, religious, socioeco-nomic, or cultural backgrounds. However,clinical psychologists can work to understandthese influences on behavior and clinical prob-lems and can consult with others who canprovide additional services such as medicationmanagement and surgery.

The biopsychosocial approach is a systemicperspective (G. E. Schwartz, 1982, 1984), thatis, changes in one area of functioning willlikely impact functioning in other areas. Thefluid and systemic nature of the biopsychoso-cial approach highlights the mutual interde-pendence of each system on each of the othersystems. For example, feelings of depressionmay be associated with brain neurochemicals,interpersonal conflicts, disappointments inlife, stresses at home and at work, unrealisticexpectations, cultural context, and manyother interacting factors. Someone might begenetically or biologically vulnerable to de-pression due to brain chemistry. Stressful lifeevents such as a divorce, illness, or job lossmay trigger a depressive episode. Feelings ofdepression may result in poor work perfor-mance, social isolation, feelings of hopeless-ness, and lower self-esteem that may deepenthe depression as well as trigger brain chem-istry that, in turn, further worsens the depres-sion. Educational, cultural, socioeconomic,and other factors might influence whatever

treatment, if any, is pursued by the depressedperson. Treatment success may be influencedby both patient and therapist motivation, ex-pectations, and comfort with the treatmentplan. The biopsychosocial model has been en-dorsed as the preferred approach to under-standing and treating health-related problemsand issues by the APA (N. Johnson, 2003) andother organizations (Institute for the Future,2000).

Details on theoretical orientations and thebiopsychosocial perspective will be discussedmore fully in Chapters 5 and 6.

Education and Training

Few people are aware of the long and in-tensive training process that is involvedin becoming a clinical psychologist. Most donot realize that the training process includesexperimental research as well as clinical train-ing in psychological testing and psychotherapy.Although master’s degrees are awarded inclinical psychology as well as other areas ofapplied psychology (e.g., school psychology),the doctorate is considered the minimal edu-cational requirement to become a clinical psy-chologist (APA, 1987b). Finally, mandatorytraining continues even beyond the doctorate.The road to becoming a clinical psychologist isa long one divided by a number of distinctstages and phases that include college, gradu-ate school, clinical internship, postdoctoralfellowship, licensure, and finally employment,continuing education, and advanced certifica-tion. Although a brief overview of the trainingprocess is presented here, details of the train-ing of clinical psychologists are outlined inChapter 15.

Students interested in becoming clinicalpsychologists and gaining admission to qualitygraduate programs must take their college ex-perience very seriously. Completing coursesin psychology, research design, and statistics


as well as having excellent grades, GraduateRecord Examination (GRE) scores, and high-quality research and clinical experience dur-ing the college years are important.

Graduate training in clinical psychologyinvolves course work as well as clinical andresearch experiences and training. Graduateschool in clinical psychology takes at leastfive years to complete, including a one-yearclinical internship. However, many studentsfind that they need more than five years tocomplete their graduate education. Disserta-tion projects and other factors often extendthe training process to an average of six to

eight years. A student interested in obtain-ing a doctorate in clinical psychology canchoose between two types of degrees: thetraditional PhD (Doctor of Philosophy)or the PsyD (Doctor of Psychology). Al-though the APA recommends a core curricu-lum of courses and activities (APA, 1987b),each program maintains its own unique ori-entation based on the faculty and traditionsof the program. In researching graduate pro-grams, you will find that each program hasits own unique balance on emphasizing theroles of biological, psychological, and socialfactors in human behavior.

SPOTLIGHT

Dr. Phil and Other Psychology Celebrity PersonalitiesPhillip McGraw (aka Dr. Phil) has received a great deal of attention in re-cent years due to his highly successful television show. Started in Septem-ber 2002, it quickly became the highest rating new syndicated televisionshow in 16 years. Prior to The Dr. Phil Show, he regularly appeared on theOprah Winfrey Show starting in 1998 acting as an expert on relationships,life strategies, and behavior. Dr. Phil, unlike many other well-known“psychology” celebrity personalities such as Dr. Laura (Schlessinger) andDr. John Gray, is a clinical psychologist and licensed as a psychologist inTexas. He obtained his PhD in clinical psychology from the University ofNorth Texas and opened a clinical practice in 1979. Dr. Phil is a clinicalpsychologist who uses his professional training and skill to host his popu-lar television show and write popular books on relationship issues, weightloss, and so forth.

Unlike Dr. Phil, Dr. Laura (Laura Schlessinger) is not a clinical psychol-ogist or a psychologist at all. Her PhD degree is in physiology from Co-lumbia University. Although she has received training in marriage andfamily therapy at the University of Southern California, she is not a li-censed psychologist. The same is true for John Gray, PhD. He is the well-known author of the popular Men Are from Mars and Women Are from Venusbooks published by HarperCollins. He is not a clinical psychologist or a li-censed psychologist either.

Regardless of what you think about these well-known psychology per-sonalities, their popularity speaks to the remarkable interest the generalpopulation has on the use of applied psychology to help people solve lifeproblems, improve relationships, and live better lives.


Almost all graduate training programs inclinical psychology require that studentscomplete a one-year, full-time (or two-year,part-time) clinical internship prior to beingawarded the doctorate. The internship is themost focused clinical training experience gen-erally available during graduate training.The training usually occurs in hospitals, clin-ics, or various clinical settings throughout theUnited States and Canada. The activities dur-ing the clinical internship focus specifically onclinical training, such as the practice of psy-chotherapy, psychological testing, and consul-tation activities with a variety of patient orclient populations.

Almost all states now require one to twoyears of postdoctoral training and supervisionbefore you are eligible to take the nationaland state licensing examinations. Postdoctoraltraining occurs in a wide variety of settings in-cluding hospitals, clinics, counseling centers,universities, and even private practices. Post-doctoral training can include clinical work aswell as research, teaching, and other profes-sional activities.

Each state offers appropriately trainedpsychologists an opportunity to acquire alicense to practice psychology and offer pro-fessional services to the public. Licensing at-tempts to protect the public from untrainedor unethical practitioners and helps to pro-tect the integrity of the profession by offer-ing minimum standards of care. All statesuse the same national written examinationfor licensing (i.e., the Examination for Pro-fessional Practice in Psychology, EPPP). Aftersuccessful completion of the written exami-nation, many states then require an oral (orsometimes an essay) examination before ob-taining the license. Following licensure, moststates require continuing education in orderto renew the psychology license.

After being awarded the doctorate, a clinicalpsychologist is eligible to become a diplomate,an advanced level of certification. This diplomais an optional post-licensing certification that

reflects advanced competency in a subspe-cialty area of professional practice. TheAmerican Board of Professional Psychology(ABPP) acts as the credentialing agency forpsychology diplomates in a variety of spe-cialty areas (e.g., clinical psychology, coun-seling psychology, neuropsychology, schoolpsychology, health psychology).

Activities

Clinical psychologists certainly do more thantalk to people who are distressed about per-sonal matters. Clinical psychologists often dovastly different types of activities from teach-ing to psychotherapy to laboratory research.Clinical psychologists also may be involved ina wide range of professional activities includ-ing teaching at the college or university level,conducting independent and/or collaborativeresearch, providing consultation to a varietyof professionals and organizations, conductingpsychotherapy, and providing psychologicalassessment and diagnostic services. Clinicalpsychologists work in a plethora of environ-ments such as universities, hospitals, clinics,schools, businesses, military institutions, andprivate or group practices. These varied rolesand settings often assist the clinical psycholo-gist in appreciating multidimensional factorsand integrating key approaches into his orher work.

Research

Research is at the foundation of all clinicalpsychology activities. Research conducted bypsychologists or others in the behavioral sci-ences provides the basis and direction for allprofessional activities. Clinical psychologistsoften conduct and publish a wide variety ofresearch studies. Research programs helpto determine which assessment or treatmentapproach might be most effective for a partic-ular clinical problem such as depression,


anxiety, eating disorders, or substance abuseproblems. Projects may help identify those atrisk for the development of certain psycho-logical problems. Other projects might evalu-ate methods to better determine clinicaldiagnoses. The types of research activitiesconducted by clinical psychologists are ex-tremely diverse.

Most psychologists who are actively en-gaged in research are faculty members at col-leges, universities, or medical schools. They,like faculty in other academic disciplines, mayconduct research on a wide range of subjectareas, publish their findings in professionaljournals, and present their research at na-tional and regional professional conferences.Psychologists who are not academic facultymembers at colleges or universities might alsoconduct research at their hospitals, clinics,government agencies (e.g., National Instituteof Mental Health), industry (e.g., pharmaceu-tical companies, psychological testing com-panies, managed care insurance companies),or private practices. Research in clinical psy-chology encompasses biological, psychologi-cal, and social aspects of human behavior,from research exploring neuroimaging tech-niques, to ethnic factors in hypertension, tospiritual aspects of love and intimacy.

Although not all clinical psychologists con-duct and publish their own research, all areexpected to be constant consumers of researchin order to inform their professional activities.Clinical psychologists must understand theresearch findings of others in order to improvetheir own clinical practice activities. Manyregularly read professional journals that covertopics of special interest.

Assessment

Many clinical psychologists use psychologi-cal tests and procedures to assess or diag-nose various psychiatric (e.g., depression,psychosis, personality disorders, dementia) as

well as nonpsychiatric issues (e.g., relation-ship conflicts, learning differences, educa-tional potential, career interests, and skills).Generally, psychologists are the only mentalhealth professionals who administer psycho-logical tests. In fact, clinical psychologists notonly conduct psychological evaluations withindividuals to assess intellectual, educational,personality, and neuropsychological func-tioning, but also assess groups of people (e.g.,families) and even organizations.

There are numerous components to psy-chological assessment, including cognitive,personality, behavioral, neuropsychological,and observational measures. For example,a neuropsychologist may be called on to eval-uate an urban Latino adolescent boy fortemporal lobe epilepsy, which often resultsin impulsive behavior and aggression. Neu-roimaging techniques conducted by a physi-cian will augment the findings, as well as adevelopmental history, to rule out personalityor environmental factors such as trauma ascausal in the behavioral manifestations of thedisorder. Thus, while focusing on neuropsy-chological measures, the psychologist needs tobe keenly aware of medical, psychological, andsocial factors that may contribute to or other-wise explain “seizure-like” symptomology.

Integration in assessment will be more fullyexplored in conjunction with its componentelements in Chapters 7 and 8. An extremelychallenging and exciting area of clinical psy-chology, assessment requires the psychologistto be something of a psychological sleuth, uti-lizing an arsenal of tools in determining subtleand often hidden problems and syndromes inthe context of biological, psychological, andsociocultural factors.

Treatment

Contemporary psychological interventionsaddress a tremendous range of human problems through a diversity of approaches.


SPOTLIGHT

TerrorismThe horrific terrorist events of September 11, 2001, in the United Statesthat claimed the lives of approximately 3,000 people have enormous im-plications for life in America and elsewhere. In many ways, life in theUnited States is very different after September 11 than before. The newU.S. Department of Homeland Security and Congress have altered theway foreign students and visitors are screened and evaluated. Laws havebeen changed in an attempt in increase security. Wars in Afghanistan andIraq commenced with thousands of military young people being shippedoverseas. Many people from Islamic countries or religious traditions haveexperienced prejudice and suspicion.

Clinical psychology has been involved with the response to terrorism inthe United States in a number of different ways. Immediately following theterrorism events and since, psychologists have counseled those who lostloved ones in the tragedy as well as those terribly stressed by the events. Forexample, airplane phobias have always been treated by clinical psycholo-gists. Yet, following the terrorism events, the need for this type of special-ized counseling increased a great deal. Children and others in the New Yorkand Washington areas (as well as elsewhere), experienced posttraumaticstress symptoms such as anxiety and sleep disturbances that needed treat-ment and consultation. Furthermore, clinical psychologists and others havebeen involved in research to help better understand the causes and risk fac-tors for terrorist acts (Eidelson & Eidelson, 2003; Moghaddam & Marsella,2004; Pyszczynski, Solomon, & Greenberg, 2003).

For example, Eidelson and Eidelson (2003) have examined research thatpropels groups toward conflict and violence that have many useful implica-tions for understanding and hopefully preventing terrorism. They havehighlighted five “dangerous ideas [that include] superiority, injustice, vul-nerability, distrust, and helplessness” (p. 182) that act as risk factors forconflict and violence.

Superiority refers to the belief and conviction that a person or group isbetter than everyone else in a variety of important ways. For example,someone might believe that they (or their group) are the only ones whohave a clear understanding of God’s will and plan. This belief has certainlycaused wars, terrorism, mass killings, and so forth for thousands of year.This perspective is rather narcissistic in that someone or a group believesthat they have some special information, entitlement, or gifts that othersdo not have or can’t have access to obtain. Injustice and victimization referto the belief that the person or group has been badly mistreated by

(continued)


Psychotherapy may involve individuals, cou-ples, families, and groups, and address an end-less array of target problems. Anxiety,phobias, depression, shyness, physical illness,loss, trauma, drug addiction, eating difficul-ties, sexuality concerns, hallucinations, rela-tionship problems, and work difficulties mayall prompt individuals to seek psychologicaltreatment. Furthermore, it has become in-creasingly incumbent upon psychologists tobecome educated and sensitized to culturalfactors in treating clients, as well as the entirespectrum of individual differences (e.g., sex-ual preference, religious faith, disabilities,economic status) that comprise today’s mosaicsociety.

Various treatment approaches and theoreti-cal models are utilized to treat psychologicaland behavioral problems. Most psychologists

use an eclectic strategy, defined as integratinga variety of perspectives and clinical ap-proaches in their treatment (Norcross, Karg, &Prochaska, 1997; Weston, 2000). Others tendto specialize in one of a number of treatmentapproaches, such as psychoanalysis, familytherapy, or hypnosis. The major theoreticalschools of thought in psychology are psycho-dynamic, cognitive behavioral, humanistic/existential, and family systems. Each of thesetheoretical orientations or perspectives arediscussed in detail in Chapter 4, leading to ourcurrent understanding of integrative models.

Efforts to develop empirically supported orevidence-based treatments to assist cliniciansand researchers in providing structured treat-ments and the use of treatment manuals thatare based on treatment outcome researchfindings has received a great deal of attention

specific others or the world in general. Although injustice and victimiza-tion have been common human experiences since the dawn of time, thisperspective can lead (and has) to retaliatory acts and rage against others.Vulnerability refers to the notion that a person or group is highly likely toexperience danger or further victimization and that hypervigilance andpreemptive acts are needed to reduce the risk of further harm. Distrustrefers to the belief that very few people can be trusted and that only theinner circle of true believers can be considered appropriate and trustwor-thy group members. This point of view leads to paranoia and potentialmisunderstandings attributing benign others as hostile and malevolent. Fi-nally, helplessness refers to feelings of powerlessness and dependency thatoften becomes overly pessimistic and negative. This perspective can leadto extreme measures to help feel more in control and more powerful.These five dangerous beliefs can be applied to the actions of many con-flicts between nations and peoples as well as to the terrorism experiencedin America on September 11, 2001, and elsewhere.

Many countries have been dealing with terrorism for a long time. Forexample, Ireland, Israel, and many other areas of the world have regularlyhad to deal with terrorism for many years. Lessons learned from thesecountries can be applied to the current concerns in the United States. Psy-chologists in these other locations have studied and counseled those af-fected by terrorism for many years.

Clinical psychology has much to offer in our efforts to help thosetouched by terrorism as well as to help us better understand the factors thatcontribute to such horrific violence perpetrated against others.


and support from the APA and others (Addis,2002; APA, 1995f; Chambless & Ollendick,2001; Crits-Christoph, D. Chambless, Frank,Brody, et al., 1995; W. Sanderson, 1994; W.Sanderson & Woody, 1995). Empirically sup-ported treatments hinge on the notion thatpsychological treatment approaches should al-ways be based on solid empirical research dataand supported by professional organizationssuch as the APA (D. Chambless & Hollon,1998). Empirically supported treatment ap-proaches are manualized treatments and havebeen developed for a variety of clinical prob-lems such as depression (Cornes & Frank,1994; Hollon & Beck, 1994), anxiety (M.Newman & Borkovec, 1995), conduct disor-dered children (Feldman & Kazdin, 1995;Schmidt & Taylor, 2002), and pain control(R. M. Hawkins, 2001). For example, cogni-tive and interpersonal psychotherapy havebeen determined to be empirically supportedtreatments for both depression and bulimiawhile exposure and response prevention havebeen found to be an empirically supportedtreatment for obsessive-compulsive disorder(D. Chambless & Ollendick, 2001; Crits-Christoph et al., 1995). While many treatmentapproaches are based on research support, theconcept of empirically supported treatments isthe most recent effort to systematize servicedelivery to carefully studied populations andproblems (D. Chambless & Hollon, 1998;Nathan & Gorman, 2002). Controversy existsover the development of “approved” treat-ment approaches for various clinical problems(B. Cooper, 2003; Ingram, Hayes, & Scott,2000). These issues will be further discussedin detail in Chapter 14.

Teaching

Clinical psychologists teach in a variety ofsettings. Some are full-time professorsin colleges and universities across the UnitedStates and elsewhere. These professionalsteach undergraduates, graduate students, and/

or postgraduate students. Other psycholo-gists might teach on a part-time basis at localcolleges and universities as adjunct profes-sors or lecturers. Still others might teach byproviding one-on-one clinical supervision ofgraduate students, interns, or postdoctoralfellows. During supervision, psychologistsdiscuss the trainees’ clinical cases in depthwhile providing therapeutic guidance as theylearn psychotherapy or psychological testingskills. Teaching may also occur in hospitals,clinics, or business environments. For ex-ample, a clinical psychologist might offer astress management course for attorneys,business executives, nurses, clergy, police of-ficers, or others. A psychologist might alsoteach a workshop on intimate relationshipsto young couples about to be married. A psy-chologist might teach other professionalssuch as doctors or clergy how to better main-tain professional boundaries or understandpsychopathology among the persons theycounsel. As in psychological treatment facili-ties, there are numerous examples and op-portunities for psychologists to teach in awide variety of professional settings.

Consultation

Many clinical psychologists provide consulta-tion to churches, health care professionals,business persons, schools, lawmakers, organi-zations, and even to other mental health pro-fessionals. Consultation might involve aninformal discussion, a brief report, or a moreongoing and formal consultation arrangement.For example, companies might consult with apsychologist to help reduce coworker conflictsor provide stress management strategies forhigh stress employees such as business execu-tives, fire fighters, police officers, or prisonguards. Consultation might involve helping aphysician to better manage patient noncom-pliance with unpleasant medical procedures.Consultation could include working with areligious superior in helping to better select


applicants who wish to enter a religious order.Consultation might include working withlaw enforcement professionals on violenceprevention or screening applications for thepolice academy. Clinical psychologists provideprofessional consultation in a wide variety ofsettings using a range of techniques. Consulta-tion might also include assessment, teaching,research, and brief psychotherapy activities.

Administration

Many clinical psychologists find themselves(intentionally or unintentionally) in adminis-trative positions. Administrative duties mightinclude serving as chairperson of a psychologydepartment, or dean, provost, or even presi-dent of a college or university. Other psychol-ogists might hold administrative positions inhospitals, mental health clinics, or other agen-cies. They may act as a unit chief directing apsychiatric hospital unit or ward, or directmental health services for a community men-tal health clinic. They may act as directors oftraining in numerous clinical settings. In ad-ministration, these psychologists generallymanage a budget, lead a multidisciplinary pro-fessional and support staff, make hiring andfiring decisions, and develop policies and pro-cedures for clinical or research operations.

Employment Settings

Clinical psychologists work in many differentemployment settings including hospitals,medical schools, outpatient clinics, collegesand universities, businesses and industry, andprivate or group practices. Many clinical psy-chologists work in some type of part-time orfull-time private practice as well (Norcross,Hedges, & Castle, 2002). Following privatepractice, teaching in colleges and universitiesis the second most common employmentchoice for clinical psychologists (APA, 2000a;

Norcross et al., 1997; Norcross, Sayette, et al.,2002). Many psychologists work in morethan one setting, combining various positionsand activities. For example, it is common fora clinical psychologist to work at a hospital orclinic several days a week, teach a course ortwo at a local college or university, and con-duct a private practice one or more days eachweek. A clinical psychologist may be a full-time professor teaching and conducting re-search while also operating a small privatepractice and offering consultation services tovarious clinics, hospitals, or businesses. Thediversity of experiences available to psychol-ogists is quite appealing and offers tremen-dous flexibility and options.

Private or Group Practices

About 35% of clinical psychologists primarilywork in solo or group private practices (APA,1997, 2000a; Norcross, Karpiak, & Santoro,2004; Norcross et al., 1997; Norcross, Pro-chaska, & Gallagher, 1989). Professionals inprivate practice may provide clinical servicesin their own solo practice or in conjunctionwith other mental health or health carepractitioners in a multidisciplinary setting.However, clinical psychologists who offerpsychotherapy service tend to do so in privatepractice environments (Norcross, Sayette,et al., 2002; Norcross et al., 2004). Many psy-chologists are drawn to independently pro-viding direct clinical, consultation, and otherprofessional services to their own patientsand clients and enjoy being their own bossand setting their own hours and policies. Infact, private practitioners report more jobsatisfaction (Norcross & Prochaska, 1988;Norcross et al., 1997) and less job stress thanpsychologists employed in other settingssuch as academia (e.g., Boice & Myers, 1987).However, significant changes in managedhealth care and insurance reimbursement forpsychological services are likely to alter this


rosy view of private practice for many profes-sionals. Many private practice psychologists,along with other mental and health care pro-fessionals operating practices, have experi-enced reductions in profits and freedoms as aresult of the changing health care industry.In fact, some authors have suggested that soloprivate practice (as commonly providedby clinicians in the 1980s and 1990s) willno longer exist during the coming years (N.Cummings, 1995). Cummings predicted thatthese clinicians will be employed primarily inmultidisciplinary health settings such ashealth maintenance organizations (HMOs) orvery large and comprehensive medical grouppractices. Others disagree with Cummings’pessimistic view concerning the future of pri-vate practice, stating that managed care stillaccounts for only about 23% of the fees col-lected by private practitioners (Kanapaux,2003). Furthermore, the percentage of psy-chologists engaged in at least part-time pri-vate practice has not decreased even 20 yearsafter the onset of managed health care (APA,2000a, Norcross et al., 2002, 2004).

Colleges and Universities

About 20% of clinical psychologists areemployed in academic environments (APA,1993a, 1997, 2000a; Norcross et al., 1997;Norcross et al., 2002). Most of these psycholo-gists work as professors at colleges and uni-versities across the United States and Canada.They generally teach psychology courses, su-pervise the clinical and/or research work ofpsychology students, and conduct both inde-pendent and collaborative research. Theyalso typically serve on various

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