Clinical
psychology:-
is an integration of science, theory and clinical knowledge for the purpose of
understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development.[1][2] Central to its practice arepsychological assessment and psychotherapy, although clinical psychologists also engage in research,
teaching, consultation, forensic testimony, and program development and
administration.[3] In many countries, clinical psychology is a regulated mental health profession.
The field
is often considered to have begun in 1896 with the opening of the first
psychological clinicat
the University of Pennsylvania by Lightner
Witmer. In the first half of the 20th century, clinical psychology
was focused on psychological assessment, with little attention given to
treatment. This changed after the 1940s when World War II resulted in the need
for a large increase in the number of trained clinicians. Since that time, two
main educational models have developed—thePh.D. scientist–practitioner model (requiring a doctoral dissertation and therefore
research as well as clinical expertise); and the Psy.D. practitioner–scholar model.
Clinical
psychologists are now considered experts in providing psychotherapy,
psychological testing, and in diagnosing mental illness. They generally train
within four primary theoretical orientations—psychodynamic, humanistic, behavior
therapy/cognitive behavioral, and systems or family therapy. Many continue clinical training in post-doctoral programs
in which they might specialize more intensively in disciplines such as
psychoanalytic approaches, or child and adolescent treatment modalities.
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Contents
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History
Many 18th c. treatments for psychological distress were
based on pseudo-scientific ideas, such asphrenology.
Although
modern, scientific psychology is often dated at the 1879 opening of the first
psychological laboratory by Wilhelm
Wundt, attempts to create methods for
assessing and treating mental distress existed long before. The earliest
recorded approaches were a combination of religious, magical and/or medical
perspectives.[4] Early examples of such physicians included Patañjali, Padmasambhava,[5] Rhazes, Avicenna,[6] and Rumi.[7]
In the
early 19th century, one could have his or her head examined, literally, using
phrenology, the study of personality by the shape of the skull. Other popular
treatments included physiognomy—the study of the shape of the face—and mesmerism, Mesmer'streatment by the use of magnets. Spiritualism and Phineas
Quimby's "mental healing" were also popular.[8]
While the
scientific community eventually came to reject all of these methods, academic
psychologists also were not concerned with serious forms of mental illness.
That area was already being addressed by the developing fields of psychiatry and neurology within theasylum movement.[4] It was not until the end of the 19th century, around
the time whenSigmund Freud was
first developing the recent idea of a "talking
cure" in Vienna, that the first scientifically clinical application of
psychology began.[citation needed]
Early clinical psychology
Lightner
Witmer, the father of modern 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 an applied psychology,
the general field looked down upon this idea and insisted on "pure"
science as the only respectable practice.[4] 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.[9] 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."[10] The field was slow to follow Witmer's example, but by
1914, there were 26 similar clinics in the US.[11]
Even as
clinical psychology was growing, working with issues of serious mental distress
remained the domain of psychiatrists and neurologists.[12] 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
duringWorld 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.[8][9] 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.
Early professional organizations
The field
began to organize under the name "clinical psychology" in 1917, when J. E. Wallace Wallin led 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.[11] 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.[13] In 1945, the APA created what is now called The
Society of Clinical Psychology (Division 12), 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.
World War II and the integration of
treatment
The US
army conducts a psychological test
developed by clinical psychologists for selection purposes. The image is card
IV of the Rorschach inkblot test.
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 posttraumatic stress disorder) that were best treated as soon as possible.[9] Because physicians (including psychiatrists) were
over-extended in treating bodily injuries, psychologists were called to help
treat this condition.[14] 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.[10] 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 Ph.D.s in psychology in 1950 being awarded in clinical psychology.[10]
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
Ph.D. programs in clinical psychology.[15] Clinical psychology in Britain developed much like in the U.S. after WWII,
specifically within the context of the National Health Service[16] with qualifications, standards, and salaries managed
by the British Psychological Society.[17]
Development of the Doctor of
Psychology degree
By the
1960s, psychotherapy had become imbedded within clinical psychology, but for
many the Ph.D. 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.[18] Several other similar programs were instituted soon
after, and in 1973, at the Vail
Conference on Professional Training in
Psychology, thePractitioner–Scholar Model of Clinical Psychology—or Vail Model—resulting
in the Doctor of Psychology (Psy.D.) degree was recognized.[19] 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 Psy.D. model was
instituted at Rutgers University.[18] Today, about half of all American graduate students in
clinical psychology are enrolled in Psy.D. programs.[19]
A changing profession
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.[20] 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.[8] Other major changes include the impact of
managed 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. Approximately 20% of clinical health psychologists identify
themselves as counseling psychologists as well.[21]
In the UK
psychology is now one of the most popular degree subjects, and over 15,000
people graduate in psychology each year, many with the hope of developing this
into a career, although only around 600 places for doctoral training in
clinical psychology means there is intense competition for these places. There
is also fierce competition to get into US Ph.D. programs in clinical
psychology, with an average acceptance rate of 8%.[24]
Professional practice
Clinical psychologists can offer a range of professional services, including:[10]
·
Administer and interpret
psychological assessment and testing
·
Conduct psychological research
·
Consultation (especially for
multi-disclinary teams in mental health settings, such as psychiatric wards and
increasingly other healthcare settings, schools and businesses)
·
Development of prevention and
treatment programs
·
Program administration
·
Provide expert testimony (forensic
psychology)
·
Provide psychological/ mental
treatment (psychotherapy, or/and psychopharmacology "priscribing
psychologists")
·
Teach
In
practice, clinical psychologists may work with individuals, couples, families,
or groups in a variety of settings, including private practices, hospitals,
mental health organizations, schools, businesses, and non-profit agencies. Most
clinical psychologists who engage in research and teaching do so within a
college or university setting. Clinical psychologists may also choose to
specialize in a particular field—common areas of specialization, some of which
can earn board certification,[25] include:
·
Mental
disorders (e.g. psychological trauma, addiction, eating
disorders, sleep
disorders, sexual dysfunction, clinical depression,anxiety, or phobia, and psychosis
Salary and employment of clinical
psychologists
According
to BlS.gov, approximately 34% of psychologists are self-employed, mostly in
private practices. Median salary of US clinical psychologists was $64,140 in
2008 (bls.gov). The field is projected to grow at an average pace. Doctoral
degree holders from a leading university in an applied specialty will face the
best prospects. M.A. degree holders will face keen competition for jobs while
there will be very limited positions for those with B.A. degrees in the field
of psychology.[26] Average doctoral starting and post-doctoral salaries
range from $25,000–90,000.[citation needed]
Training and certification to
practice
Clinical
psychologists study a generalist program in psychology plus postgraduate
training and/or clinical placement and supervision. The length of training
differs across the world, ranging from four years plus post-Bachelors
supervised practice[27] to
a doctorate of three to six years which combines clinical placement.[28]
In the US,
clinical psychology doctoral programs typically range from five to seven years
post-college and require a one year full-time clinical internship and
dissertation. There is currently an "internship crisis" in the field
(see below). Graduates must also accrue 1–2 years of supervised training
post-Ph.D. before licensure in most states (3,000 hours) and need to pass the
EPPP (plus, other state exams). About half of all clinical psychology graduate
students are being trained in Ph.D. programs—a model that emphasizes research—with the
other half in Psy.D. programs, which has more focus on practice (similar to
professional degrees for medicine and law).[19] Both models are accredited by the American
Psychological Association[29] and
many other English-speaking psychological societies. A smaller number of
schools offer accredited programs in clinical psychology resulting in a Masters
degree, which usually take two to three
years post-Bachelors. In a 2009 survey, median debt related to doctoral
education in clinical psychology was $68,000 for clinical Ph.D. recipients and
$120,000 for clinical Psy.D. recipients.[30]
In the UK,
clinical psychologists undertake a Doctor of Clinical Psychology (D.Clin.Psych.),
which is a practitioner doctorate with both clinical and research components. This is a
three-year full-time salaried program sponsored by the National Health Service
(NHS) and based in universities and the NHS. Entry into these programs is
highly competitive, and requires at least a three-year undergraduate degree in
psychology plus some form of experience, usually in either the NHS as an
Assistant Psychologist or in academia as a Research Assistant. It is not
unusual for applicants to apply several times before being accepted onto a
training course as only about one-fifth of applicants are accepted each year.[31] These clinical psychology doctoral degrees are
accredited by the British Psychological Society and the Health Professions Council (HPC). The HPC is the statutory regulator for
practitioner psychologists in the UK. Those who successfully complete clinical
psychology doctoral degrees are eligible to apply for registration with the HPC
as a clinical psychologist.[citation needed]
The
practice of clinical psychology requires a license in the United States,
Canada, the United Kingdom, and many other countries. Although each of the US
states is somewhat different in terms of requirements and licenses, there are
three common elements:[32]
1.
Graduation from an accredited school
with the appropriate degree
2.
Completion of supervised clinical
experience or internship
3.
Passing a written examination and,
in some states, an oral examination
All US
state and Canadian province licensing boards are members of the Association of
State and Provincial Psychology Boards (ASPPB) which created and maintains the
Examination for Professional Practice in Psychology (EPPP). Many states require
other examinations in addition to the EPPP, such as a jurisprudence (i.e.
mental health law) examination and/or an oral examination.[32]Most states also require a certain number of continuing
education credits per year in order to renew a license, which can be obtained
though various means, such as taking audited classes and attending approved
workshops. Clinical psychologists require the psychologist license to practice,
although licenses can be obtained with a masters-level degree, such as Marriage
and Family Therapist (MFT), Licensed
Professional Counselor (LPC),
and Licensed Psychological Associate (LPA).[33]
In the UK,
registration as a clinical psychologist with the Health Professions Council
(HPC) is necessary. The HPC is the statutory regulator for practitioner
psychologists in the UK. In the UK the following titles are restricted by law:
"registered psychologist" and "practitioner psychologist";
in addition, the specialist title "clinical psychologist" is also
restricted by law.[citation needed]
Internship crisis in US clinical
psychology programs
In the US,
clinical psychology Ph.D. and Psy.D. programs typically require students to
complete a one-year full-time (or two-year part-time) clinical internship in
order to graduate. However, there is currently an "internship crisis"
as defined by the American Psychological Association, in that approximately 25%
of clinical psychology doctoral students are unable to find an internship each
year, and only 50% are able to attend an APA-accredited internship.[34] This crisis has led to many students (approximately
1,000 each year) re-applying for internship the following year (thus delaying
graduation) or completing an unaccredited internship, both of which can have
emotional and financial consequences.[35] This internship crisis stems from an increase in the
production of psychology students. A recent study found that ~30% of unmatched
students stem from 15 degree programs, representing only 4% of all programs
participating in the internship match. These programs enrolled larger cohorts
of students than average and 14 of the 15 were PsyD programs. All but one was
APA accredited. [36] The authors argue that it would futile to simply
increase internship slots. Internship slots already have increased over the
years and as internship slots have increased, these schools increase
production. Students who do not complete an APA-accredited internship are
barred from certain employment settings, such as with the VA Hospitals, and may
not be able get licensed in some states.[37] Additionally, the majority of post-doctoral
fellowships and other employment settings require or prefer the completion of
an APA-accredited internship.[37] The median rate of applicants accepted by
APA-accredited internship sites is 5.5%[38]and
the median internship stipend was $24,218 in 2011.[39]
Assessment
An
important area of expertise for many clinical psychologists is assessment, and
there are indications that as many as 91% of psychologists utilize this core
clinical practice.[40] Such evaluations are usually conducted in order to
gain insight into, and form hypotheses about, psychological or behavioral
problems. As such, the results of these assessments are often used to clarify a
person's diagnosis and assist in planning treatments or arranging for services.
Methods used to gather information include formal tests, clinical interviews,
reviews of past records, and behavioral observations.[2]
There
exist literally hundreds of various assessment tools, although only a few have
been shown to have both high statistical validity(i.e., test actually measures what it claims to measure) and reliability (i.e., consistency). These measures generally fall
within one of several categories, including the following:
·
Intelligence
& achievement tests –
These tests are designed to measure certain aspects of cognitive functioning
(often referred to as IQ)
in comparison to a group of people with similar characteristics (such as age or
education). These tests, including the WISC-IV and WAIS-IV, attempt to measure traits such as general knowledge,
verbal comprehension, working memory, attention/concentration, logical
reasoning, and visual/spatial perception.[40] Several of these tests have been shown to accurately
predict scholastic achievement and occupational performance, and help to
identify a person's cognitive strengths and weaknesses.[40]
·
Personality
tests – These tests aim to describe
patterns of behavior, thoughts, and feelings, and generally fall within two
categories: objective and projective. Objective measures, such as the MMPI-2 or the MCMI-III, are based on forced-choice responses—such as yes/no,
true/false, or a rating scale—and generate scores that can be compared to a
normative group. Projective tests, such as the Rorschach inkblot test, use open-ended responses, often based on ambiguous
stimuli, to reveal non-conscious psychological dynamics such as motivations and
perceptions of the self and the world.[40]
·
Neuropsychological
tests - Tests in this category are
often used to evaluate a person's cognitive functioning and its relationship to a person's
behavior or psychological functioning.[41] They are used in a variety of settings, for purposes
such as clarifying a diagnosis (especially in distinguishing between
psychiatric and neurological symptoms), better understanding the impact of a
person's neurological condition on their behavior, treatment planning
(especially in rehabilitation settings), and for legal questions, such as
determining if a person is faking their symptoms (also referred to as malingering) or if they are capable to stand trial.[41]
·
Clinical
interviews – Clinical psychologists are
also trained to gather data by observing behavior and collecting detailed
histories. The clinical interview is a vital part of assessment, even when
using other formalized measures, as it provides a context in which to
understand test results. Psychologists can employ a structured format (such as
the SCID or the MMSE), a semi-structured format (such as a sequence of
questions) or an unstructured format to gather information about a person's
symptoms and past and present functioning.[40] Such assessments often include evaluations of general
appearance and behavior, mood and affect, perception, comprehension,
orientation, memory, thought process, and/or communication.[40]
Diagnostic impressions
After
assessment, clinical psychologists often 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 (DSM-IV-TR). Both utilize medical concepts and terms,
and state that there are categorical disorders that can be diagnosed by set
lists of descriptive criteria.[42] 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[42][43] and a "psychosocial model," which would
place greater emphasis on changing, intersubjective states.[44] In fact, the DSM-5, which is still being edited, will be using a dimensional
approach.[45] The proponents of these models claim that they would
offer greater diagnostic flexibility and clinical utility without depending on
the medical concept of illness. However, they also admit that these models are
not yet robust enough to gain widespread use, and should continue to be
developed. Some clinical psychologists prefer not to use diagnoses and instead
use clinical formulations—an individualized map of the strengths and difficulties
that the patient or client faces, with an emphasis on predisposing,
precipitating and perpetuating (maintaining) factors.[46]
Clinical theories and interventions
Clinical psychologists work with individuals, children,
families, couples, or small groups.
Psychotherapy
involves a formal relationship between professional and client—usually an
individual, couple, family, or small group—that employs a set of procedures
intended to form a therapeutic alliance, explore the nature of psychological
problems, and encourage new ways of thinking, feeling, or behaving.[2][47]
Clinicians
have a wide range of individual interventions to draw from, often guided by
their training—for example, a cognitive behavioral therapy (CBT) clinician
might use worksheets to record distressing cognitions, apsychoanalyst might encourage free association, while a psychologist trained in Gestalt techniques
might focus on immediate interactions between client and therapist. Clinical
psychologists generally seek to base their work on research evidence and
outcome studies as well as on trained clinical judgment. Although there are
literally dozens of recognized therapeutic orientations, their differences can
often be categorized on two dimensions: insight vs. action and in-session vs.
out-session.[10]
·
Insight – emphasis is on gaining
greater understanding of the motivations underlying one's thoughts and feelings
(e.g. psychodynamic therapy)[citation needed]
·
Action – focus is on making changes
in how one thinks and acts (e.g. solution-focused
therapy, cognitive behavioral therapy)[citation needed]
·
In-session – interventions center on
the here-and-now interaction between client and therapist (e.g. humanistic
therapy, Gestalt therapy)[citation needed]
·
Out-session – a large portion of
therapeutic work is intended to happen outside of session (e.g. bibliotherapy,
rational emotive behavior therapy)[citation needed]
The
methods used are also different in regards to the population being served as
well as the context and nature of the problem. Therapy will look very different
between, say, a traumatized child, a depressed but high-functioning adult, a
group of people recovering from substance dependence, and a ward of the state
suffering from terrifying delusions. Other elements that play a critical role
in the process of psychotherapy include the environment, culture, age,
cognitive functioning, motivation, and duration (i.e. brief or long-term
therapy).[47][48]
Four main schools
The field
is dominated in terms of training and practice by essentially four major
schools of practice: psychodynamic, humanistic, behavioral/cognitive
behavioral, and systems or family therapy.[2]
Psychodynamic
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.[47] The essential tools of the psychoanalytic process are
the use of free associationand 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.[47]
Humanistic
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.[49] 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.[50] This aspect of holism links up with another common aim
of humanistic practice in clinical psychology, which is to seek an integration
of the whole person, also called self-actualization. According to
humanistic thinking,[51] 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.[citation needed]
Behavioral and cognitive behavioral
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.[52] 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 dialectical behavior therapy and mindfulness-based
cognitive therapy.[53]
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 feed 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. They have studied many areas from developmental
disabilities todepression 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.[54]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 and family training for
treating addictions, acceptance and
commitment therapy, functional analytic
psychotherapy, integrative
behavioral couples therapy including
dialectical behavior therapy and behavioral activation. In addition, specific techniques such ascontingency management and exposure
therapy have come from this tradition.
Systems or family therapy
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.[55] 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. Contributors include John
Gottman, Jay
Haley, Sue
Johnson, and Virginia
Satir.[citation needed]
Other major therapeutic orientations
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.[56] Important writers in existential therapy include Rollo
May, Viktor
Frankl, James
Bugental, and Irvin
Yalom.[citation needed]
One
influential therapy that came out of existential therapy is Gestalt
therapy, primarily founded by Fritz
Perls in the 1950s. It is well known
for techniques designed to increase various kinds of self-awareness—the
best-known perhaps being the "empty chair technique"—which are
generally intended to explore resistance to "authentic contact,"
resolve internal conflicts, and help the client complete "unfinished
business."[57]
·
Postmodern – Postmodern psychology says that the experience of
reality is a subjective construction built upon language, social context, and
history, with no essential truths.[58] 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.[59] Forms of postmodern psychotherapy include narrative
therapy, solution-focused therapy, and coherence
therapy.[citation needed]
·
Transpersonal – The transpersonal perspective places a stronger focus on the spiritual facet of human experience.[60] It is not a set of techniques so much as a willingness
to help a client explore spirituality and/or transcendent states of consciousness. It also is concerned with
helping clients achieve their highest potential. Important writers in this area
include Ken Wilber, Abraham
Maslow,Stanislav
Grof, John
Welwood, David
Brazier and Roberto
Assagioli.
Other perspectives
·
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.[48] 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 ofacculturation 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.[61] 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.[62]
·
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.[63]
·
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,[64] 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.[65][66] 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.[67]
Integration
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, 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.[68]
Professional ethics
The field
of clinical psychology in most countries is strongly regulated by a code of ethics.
In the US, professional ethics are largely defined by the APA Code of
Conduct, which is often used by states to define licensing requirements.
The APA Code generally sets a higher standard than that which is required by
law as it is designed to guide responsible behavior, the protection of clients,
and the improvement of individuals, organizations, and society.[69] The Code is applicable to all psychologists in both
research and applied fields. The APA Code is based on five principles:
Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity,
Justice, and Respect for People's Rights and Dignity.[69] Detailed elements address how to resolve ethical
issues, competence, human relations, privacy and confidentiality, advertising,
record keeping, fees, training, research, publication, assessment, and therapy.[citation needed]
The BPS Code
of Ethics and Conduct similarly sets a high standard for psychologist.
It is based on four principles: respect, competence, responsibility and
integrity.[70]
Comparison with other mental health
professions
Psychiatry
Fluoxetine hydrochloride, branded by Lillyas Prozac, is a common antidepressant drugprescribed
by psychiatrists. There is a small but growing movement to give prescription
privileges to qualified psychologists.
Although
clinical psychologists and psychiatrists can be said to share a same
fundamental aim—the treatment of mental disorders—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 rely onpsychotropic medications as the chief method of addressing the illness[71]—although many employ psychotherapy as well. Psychiatrists
and medical psychologists (who are clinical psychologists that are also licensed
to prescribe) 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.[citation needed]
Clinical
psychologists generally do not prescribe medication,
although there is a movement for psychologists to have prescribing
privileges.[72] These medical privileges require additional training
and education. To date, medical psychologists may prescribe psychotropic
medications in Guam, New
Mexico, and Louisiana, as well as United States military psychologists.[73] Psychologists usually receive more thorough training
in research methods, psychological assessment, and psychotherapeutic treatment,
compared with psychiatrists.[citation needed]
Counseling psychology
Counseling psychologists study and use many of the same interventions and tools
as clinical psychologists, including psychotherapy and assessment.
Traditionally, counseling psychologists help 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][10] Many counseling psychologists also receive specialized
training in career assessment, group therapy, and relationship counseling,
although some counseling psychologists also work with the more serious problems
that clinical psychologists are trained for, such as dementia orpsychosis.[citation needed]
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. The two professions can be found working in all the same
settings but counseling psychologists are more frequently employed in
university counseling centers compared to hospitals and private practice for
clinical psychologists.[74]
School psychology
|
Comparison
of mental health professionals in USA
|
||||
|
Occupation
|
Degree
|
Common
Licenses
|
Prescription
Privilege
|
Ave.
2004
Income (USD) |
|
Clinical
Psychologist
|
PhD/PsyD
|
Psychologist
|
Mostly
no
|
$75,000
|
|
Counseling Psychologist (Doctorate)
|
PhD
|
MFT/LPC
|
No
|
$65,000
|
|
Counseling Psychologist (Master's)
|
MA/MS/MC
|
MFT/LPC/LPA
|
No
|
$49,000
|
|
PhD,
EdD
|
Psychologist
|
No
|
$78,000
|
|
|
MD/DO
|
Psychiatrist
|
Yes
|
$145,600
|
|
|
PhD/MSW
|
LCSW
|
No
|
$36,170
|
|
|
PhD/MSN/BSN
|
APRN/PMHN
|
No
|
$53,450
|
|
|
DNP/MSN
|
MHNP
|
Yes
(Varies by state)
|
$75,711
|
|
|
MA
|
ATR
|
No
|
$45,000
|
|
School psychologistsare 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." They typically hold a master's degree.[citation needed] Like
clinical 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 (Ed.S.), Doctor of Philosophy (Ph.D.), and Doctor of Education (Ed.D.).[citation needed]
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.[81][82]
Clinical social work
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.
The Masters in Social Work in the US is a two-year, sixty credit program that
includes a practicum each year, totaling at least 900 hours.[83] Two additional years of supervision is required to
become a Licensed Clinical Social Worker which offers similar privileges to
that of a psychologist but cannot provide diagnosis, testing, and, in some
cases, are unable to bill for services.
Occupational therapy
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."[84] 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. In chronic
pain management, occupational therapists use the common cognitive behavioral
therapy approach, often incorporating cognitive behavioral therapy techniques
and helping clients generalize or integrate their pain management strategies
into their lives. In this way, occupational therapists both support and extend
the work that clinical psychologists carry out in a clinical setting.[85]
Criticisms and controversies
What is Occupational Therapy?
Occupational Therapy helps people to
do the everyday things that they want to do and need to do when faced with
illness, injury, disability or challenging life events.
Occupational therapy is a client
centred health profession concerned with promoting health and well being
through occupation. The primary goal of occupational therapy is to enable
people to participate in the activities of everyday life. Occupational
therapists achieve this outcome by working with people and communities to
enhance their ability to engage in the occupations they want to, need to, or
are expected to do, or by modifying the occupation or the environment to better
support their occupational engagement.
(World Federation of Occupational Therapists, 2010)
(World Federation of Occupational Therapists, 2010)
5
Key Features of Occupational Therapy:
·
The unique focus of Occupational
Therapy is on the person's occupation. Occupational therapists use the term occupation to
describe all the things we do to take care of ourselves and others; socialise
and have fun; and work and contribute to society.
·
Occupational therapists understand
how illness, injury, disability or challenging life events can affect people's
ability to do the day-to-day things that are important for them.
·
Occupational therapists are experts
at assessing how different health conditions can affect people's abilities and
helping people to overcome or work around the difficulties that are affecting
their daily occupations.
·
Occupational Therapy focuses on
people's strengths and therapy is always guided by the client's preferences (or
those of their family in the case of children).
·
By tailoring a programme that
responds to the client's unique situation and needs Occupational Therapy helps
people to live their lives in a way that is meaningful and satisfying for them.
Occupational therapists have a broad
education in the health, social, psychological and occupational sciences which
equips them with the attitudes, skills, and knowledge to work collaboratively
with people, individually or in groups, to bring about positive life changes.
Occupational therapists work with people with a wide range of health needs,
including those who have an impairment of body structure or function owing to a
health condition, those who are restricted in their participation or those who
are socially excluded owing to their membership of cultural minority groups.
Occupational therapists work in many
different practice settings including hospitals, day care facilities, nursing
homes, schools, universities, community centres and workplaces. Many also work
in private practice and provide occupational therapy in the client's home or
residential setting.
Where do Occupational Therapists work?
Occupational therapists work in many
different practice settings including hospitals, day care facilities, nursing homes,
schools, universities, community centres and workplaces. Many also work in
private practice and provide occupational therapy in the client's home or
residential setting.
The
following are just some of the areas where Occupational Therapists work:
·
Child and Adolescent Mental Health
·
Adult Mental Health
·
Old Age Psychiatry
·
Alcohol and Addiction Services
·
Neurology
·
Stroke Rehabilitation
·
Brain Injury Rehabilitation
·
Hand Therapy and Rehabilitation
·
Older Persons Healthcare
·
Paediatric Healthcare and
Rehabilitation
·
Intellectual Disability
·
Palliative Care and Oncology
·
Orthopaedics
·
Musculoskeletal Disorder
·
Rheumatology
·
Pain Management
·
Housing Adaptations
·
Specialist seating
·
Ergonomics
·
Vocational Rehabilitation
·
Acute Hospital Healthcare
·
Nursing Home and Residential Care
·
Primary and Community Care
·
Private Healthcare
·
Schools and Universities
·
Healthcare Management
Clinical psychology is a diverse
field and there have been recurring tensions over the degree to which clinical
practice should be limited to treatments supported by empirical research. Despite
some evidence showing that all the major therapeutic orientations are about of
equal effectiveness,[87][88] there remains much debate about the efficacy of
various forms treatment in use in clinical psychology
It has
been reported that clinical psychology has rarely allied itself with client groups and tends to individualize problems to the neglect of
wider economic, political and social inequality issues that may not be the
responsibility of the client.[86] It has been argued that therapeutic practices are
inevitably bound up with power inequalities, which can be used for good and
bad.[90] A critical psychologymovement
has argued that clinical psychology, and other professions making up a
"psy complex," often fail to consider or address inequalities and
power differences and can play a part in the social and moral control of disadvantage,
deviance and unrest.[91][92]
An October
2009 editorial in the journal Nature suggests that a large
number of clinical psychology practitioners in the United States consider
scientific evidence to be "less important than their personal—that is,
subjective—clinical experience."[93]
Accessing
an OT in the public service
Occupational therapists work
in a variety of settings in the community, voluntary organisations and public
health services including hospitals, primary care, community, child and family
services, disability services, mental health and older people's services. You
can access an occupational therapist publicly through your HSE Local Health
Office or request a referral from your GP..
Your Local Health Office is your entry point to
community health and personal social services. The wide range of services that
are provided through Local Health Offices and from Health Centres include
general practitioner services, public health nursing, occupational therapy, child
health services, community welfare, chiropody, ophthalmic, speech therapy,
social work, addiction counselling and treatment, physiotherapy, psychiatric
services and home help.
Accessing an OT privately
If you are unable to access an OT
publicly or would prefer to source an OT privately, you can search for a
private OT on our database by specialty or location depending on your
preference. Private OTs may work within a number of specialties or across a
number of geographical locations in Ireland. To find an OT best suited to your
needs you should contact them directly via their contact details as listed on
the website.
You
can use the Search option on the right to find a private occupational
therapist. Alternatively, please click on the Word document, located on the
right hand side of this page, to find an OT near you.
It
is recommended that OTs in Private Practice have:
·
Minimum 5 years clinical experience
·
Have specialised in the area in
which they wish to practice
·
Provide details of experience to
clients, as well as a clear schedule of fees, in advance
·
If you require more information than
is listed on this website please contact the OT directly
Private
OTs are listed under the following specialties
1. Accessible accommodation
2. Physical intervention/treatment (Neurological, Older
people, Orthopaedic)
3. Paediatric - developmental, intellectual disability, sensory
integration
4. Psycho social - mental health
5. Vocational/employment
6. Education/management
7. Medico/legal assessment/reports
Please
read 'What
to expect' for further information on
what to expect when meeting an OT in private practice or the health service
What to expect
Any person using the title
'Occupational Therapist' has completed specialised training in occupational
therapy resulting in a DipCOT/BSc/MSc in Occupational Therapy. Although
statutory registration is not currently in place in Ireland, an OT who is a current
member of AOTI will practice ethically and professionally being mindful of AOTI
Code of Ethics.
If
attending an OT privately, the AOTI Private Practice Advisory Group have
devised the following guidelines in standards of practice:
·
An Occupational Therapist in Private
Practice is a self employed professional, a partner in a company or principal
in his/her own company.
·
An Occupational Therapist in Private
Practice is self governing and accepts clients according to his/her
professional knowledge and experience.
·
Fees for Occupational Therapy
Services are set by individual therapists with regard to “The Competitions Act
2002”.
·
Therapists employed by a principal
therapist in providing Private Occupational Therapy services are not considered
to be an “Occupational Therapist in Private Practice”.
The
purpose of this Standard in Practice document is to provide a set of principles
that apply to all members of the Association working in “Private Practice”.
·
It is a statement of the values used
in promoting and maintaining professional behaviour among Occupational
Therapists in Private Practice in Ireland.
·
It is also to promote consistency in
the delivery of Occupational Therapy provided by Occupational Therapists
working in Private Practice nationally.
The
Practitioner
·
The Occupational Therapy
Practitioner in this context will be a member of the Association of
Occupational Therapists Ireland and other related
Clinical Specialist groups as appropriate.
Clinical Specialist groups as appropriate.
·
A minimum of 5 years clinical
experience post graduation in a particular area of practice is advised and
strongly recommended before commencing employment in private practice.
·
A Practitioner should adopt and
follow the “Code of Ethics” of the AOTI and the requirements of state
registration when it becomes law.
·
The Practitioner should be aware
that in law holding oneself as a Specialist in any area of work requires a
higher degree of skill than one who does not profess to be so qualified by
special training and ability.
·
Each Practitioner has a duty to be
aware of the limits of his/her expertise or competence.
·
Public Liability and Professional
Indemnity Insurance Scheme is essentialbefore starting work in
Private Practice.
Case Studies
The following Case studies and
examples give you an idea of what to expect from OT's in different settings.
Role
of Occupational Therapy in Mental Health
Occupational Therapists are health professionals who work
with you to increase your independence in and satisfaction with the everyday
activities and roles that give meaning to your life. Occupational Therapists
work as part of a team of mental health multididciplinary professionals.
An occupational therapist will help
you to develop personal goals and to understand what is preventing you from
reaching these goals. Your occupational therapist will then support you,
using your strengths, to achieve these goals. You might see the
occupational therapist individually, as part of a group or both. Your plan may
include some of the following:
Gaining a better understanding of
your mental health so you can take an active part in your wellness and recovery
·
Developing the skills you need to
live more independently such as shopping, cooking, budgeting, using public
transport and home management.
·
Finding a routine that allows you to
do everything you want or need to do in your life.
·
Learning how to cope with stress or
anxiety.
·
Taking part in enjoyable activities.
·
Making friends and finding social
support
·
Returning to or staying in work or
education
·
Taking part in the life roles that
are important to you and define who you are
·
Getting in touch with community
groups or organisations
Because you are a unique person your
occupational therapy plan will be designed with you taking into account what is
important for your mental health and the quality of your life.
Mental Health Advisory Group,
Association of Occupational Therapists of Ireland (September 2011)
Benefits of Occupational Therapy
Anyone, of any age, can benefit from
occupational therapy if they are unable to, or find it difficult to participate
in a desired activity. Occupational therapists have training and knowledge in
physical and psychosocial development and disorders and therefore look at the
whole person, not just the physical aspects of the person’s problem. They also
look at these problems or risks in terms of how they affect someone’s function.
By seeing an occupational therapist,
people develop the skills for the job of living so they are able to participate
more fully in the life they choose, or to prevent a disruption in their
day-to-day living. Occupational therapy benefits the individual and those
around them such as teachers, employers, parents, spouses and other family
members.
For
example
Occupational
therapy can help overcome and/or develop strategies to cope with:
·
Mobility and seating problems due to
developmental disorders, arthritis, a spinal cord injury or simply the aging
process.
·
Managing pain due to an automobile
accident, burns, incorrect lifting, arthritis, repetitive strain injuries such
as carpal tunnel syndrome and fibromyalgia.
·
Fatigue due to a heart condition,
multiple sclerosis, depression, stress, strokes, etc.
Returning to work after an injury or prolonged illness.
Returning to work after an injury or prolonged illness.
·
Relearning and finding new ways to
manage home-making activities after a brain injury or acute mental illness.
·
Discovering memory aids and other
tricks for people who complain of poor memory due to aging, Alzheimer’s,
stress, etc.
Occupational
therapy can help prevent:
·
Unnecessary hospital stays or
premature nursing home admissions.
·
Work injuries due to poor work
station positioning, unrealistic pacing and other organizational and
psychosocial strains.
·
School dropouts due to poor
attention spans, or reading and writing difficulties.
·
Unemployment among people with a
developmental disability or people with a mental illness.
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