Models of Training in Clinical Psychology
The Scientific-Practitioner Model
- Boulder Model/Scientist-Practioner Model: Attempts to marry science and clinical practice and is the most popular model to this day. Skilled practitioners that could produce own research and learn from others research.
- In the past, training was not the focus of the field; clinical psychologists focused on research.
- The model sought to aid students in thinking like a scientist in whatever activities they engaged in.
- 1987—Salt Lake City, Utah: Seeking a model that deemphasized research and placed greater emphasis in clinical skills
The Doctorate of Psychology Degree (Psy.D.)
- Emphasis on the development of clinical competence, de-emphasis on research competence.
- Dissertation is about professional subject and not research contribution.
- Increasing experience in therapeutic practice (3rd year divergence)
- Differences between Psy.D. and Ph.D.
o Great Psy.D. acceptance rate
o Lower percent receive full financial assistance
o Lower percent of faculty with a cognitive-behavioral orientation
o Lower percentage obtain internships at top-facilities o Shorter period to complete degree (5.1 years).
- No affiliation with universities and they have their own financial and organizational framework.
- Free standing or free for profit schools, mostly offer Psy.D. degrees.
- There are 45 professional's schools and they offer over 60% of the clinical psychology doctorates. Greater proportion of doctorates given by professional schools today.
- Rely heavily on student-tuition (so expensive) as not fully-funded and have only parttime faculty.
- Very rare that professional schools are APA accredited
- Scientific and clinical psychology is the only acceptable form of clinical psychology
- Focused on building a science of clinical psychology, by integrating scientific principles into their work.
- Academy of Psychological Science (1995)—graduate programs and internships focused on empirical methods of research.
- Main goals:
o Training—clinical science research + scientific knowledge
o Research and Theory—advance clinical science research and theory and integration with other sciences.
o Application—broad application to human problems
o Dissemination—to foster distribution of knowledge to public in a timely manner.
Combined Professional-Scientific Training Programs
- Combined specialty in counseling, clinical and school psychology; assumes a share core knowledge based for all three areas.
- Graduates however may not develop a specific sub-specialty as an expertise for an area.
- Better suited to the future practitioner than the future clinical research scientist.
Graduate Programs: Past and Future
- 1960's: Shift from university based jobs to private practice work.
- Vail Training Conference (1973): Alternative training models to meet the needs of future practitioners. Psy.D. degree and professional school model arose from this conference.
- As a result of the excessive number of applicants, many graduate students have been unable to acquire an internship position (25%).
- Curriculum will place an emphasis on empirically supported psychological intervention and focal assessment.
- Certification and licensure can vary from state to state; but it is a weak form of regulation in most instances.
- People can't call them “psychologists” unless they have been certified; attempts to protect the public by restricting title use.
- Does not prevent anyone from offering psychological services to the public as long as the non-certified people don't use the same title.
- Stronger than certification, provides the title of “psychologist” but also defines what specific activities are offered for the public.
- APA developed a model act for licensure of psychologists.
- Applicants for licensure are required to take an exam (can be oral + written)
- May require supervised experience beyond doctorate
- Licensing boards are starting to become increasing picky about the requirements and restrictions placed on those that qualify and those that can obtain licensure.
- Some argue that both licensing and certification are invalid measures of competence, others say that regulating licensing measures will ensure competence.
- Challenges include establishment of a national standard, deciding between oral or written exams and licensing over the internet.
Requirements for Licensure
- Doctoral degree from APA accredited program (e.g. clinical)
- 1-2 years of supervised clinical experience
- Must bass Examination for Professional Practice in Psychology (EPPP); sometimes oral exam is needed.
- Must practice within the scope of the knowledge and competence, training
American Board of Professional Psychology (ABPP)
- ABPP offers certification in the field of clinical child and adolescent psychology, clinical psychology, clinical health psychology and other fields.
- Candidates are required to submit practice sample (ex: videotape sessions), provide written statement regarding professional expertise and complete a supervised oral exam.
- Provides increased mobility if one decides to move states, greater respect and more reliability.
- Clinical Psychology moving in the direction of policies, legislation and greater emphasis on practice than on research.
- A fee for private-practice service is now the past, and managed health care now dominates.
The Costs of Health Care
- Predicted that from 2009 to 2019 proportion of GDP costs devoted to health care will rise by 19.6%.
- Managed Care: Profit driven corporate approach to health care that attempts to contain costs by controlling the length and frequency of service utilization and restricting the types of services provided
o Shift in control from practitioners to those that pay the bills (employers)
- Three managed care types:
- Health Maintenance Organization (HMO's): restricted number of providers and serves those who enroll in the service plan at a fixed cost for all services.
- Preferred Provider Organization (PPO's): have contracts with outside providers at a discounted rate for membership and in exchange providers get more referrals.
- Point of Service Plan (PPO's): managed members have more choices at their health care choices but may more for non-managed features (incorporates HMO and PPO features)
- Two Models of Health Care
o Consumer-Directed Health Care Plan: Shift cost and responsibility to consumer o Performance Disease Management Models: Pay for performance incentives to clinicians to provide high-quality effective services (fewer sessions).
- Self-help methods may increase—books, pamphlets, handouts, computer/internet therapy.
- Argument that it will allow for autonomy of clinical psychologists as health service providers
- Help with continuous care from one physician
- Argument of professional boundaries and bridging the gap between psychology & psychiatry.
Pro Arguments for Prescription Privileges
- Enable practitioners to provide a wider variety of treatments to a wider number of people.
- Increase in efficiency and cost-effective of care for patients who need psychological treatment and medication.
- Provide clinical psychologists an advantage in the marketplace (e.g. over social workers)
- May be more qualified to consider psychopharmacological treatment due to them spending longer sessions with clients.
- Better able to offer combined treatment (psychosocial + psychopharmacological).
Con Arguments for Prescription Privileges
- De-emphasis on psychological forms of treatment as medication is faster and brings more money.
- May result in conflict between members of the fields of psychology and psychiatry.
- May lead to more drug-company sponsored research.
Implications for Training
- Ad Hoc Task Force for Psychopharmacology—three levels of competence and training.
- Level 1—Basic Pharmacology Training: knowledge of medication and substances that may be addictive. Recommended: a course on psychopharmacology.
- Level 2—Collaborative Practice: Psychopharmacology consultant with knowledge as well as diagnostic assessment skills. Recommended: coursework and practical exposure.
- Level 3—Prescription Privileges: Practice independently and prescribe medication. Recommended: Intensive science based coursework, 2 years of graduate training in psychopharmacology and postdoctoral residency in psychopharmacology.
- Only Level 3 individuals are qualified to prescribe.
- Additional course requirements would make it longer to complete graduate school; prescription privilege programs may thus only be offered at the post-doctoral level.
- Delivery and oversight of health services using telecommunication technologies (ex: websites, email, videoconferencing).
- Increased accessibility to services, efficiency, reducing stigma.
- Involves assessing the emotions, behaviors and cognitions of individuals as they are interacting with their environment in real time.
- Requires very little retrospection of the client (reflection).
- More ecologically valid (ex: tracking mood via phone throughout the day).
- Multiple assessments on the same client are possible; multiple forms of ambulatory assessment focusing on different response across domains can also be done.
- Clients who don't have access to mental health professionals for face-to-face time or embarrassment may choose to use this method.
- If mental health services are accessible through telephone, internet or videoconferencing it could aid those that have lack of accessibility, inconvenience or fear treatment.
- Electronic health records can be maintained and clinicians can view clients Web-based homework's.
Culturally Sensitive Mental Health Services
- Given the plurality of U.S. culture, mental health services need to serve ethnically diverse populations.
- Clinical psychologists must demonstrate cultural competence—knowledge and appreciation of other cultural groups and the skills to deal with other cultures.
o Dynamic sizing; when to generalize vs. when to individualize
o Culture specific expertise; have knowledge of the groups that they work with
- 1953: Publication of the Ethical Standards of Psychologists
- General principles of ethical standards:
o Beneficence and non-maleficence (strive to benefit others and do not harm)
o Fidelity and responsibility: professional and scientific responsibility to society
o Integrity: strive to accurate, honest and truthful
o Justice: all people are entitled to access and to benefit from knowledge generated by psychology
o Respect for people's rights and dignity: enact safeguards and protection measures.
- Specific ethical standards underlined under APA membership are enforceable rules, the general principles are not.
Rule 1: Competence
- Clinicians must only provide services within the boundaries of their training.
- Clinicians should not provide treatment for assessment procedures of which they have no knowledge.
- Tool kits to ensure competence: performance reviews, case presentation reviews, client outcome data.
Privacy and Confidentiality
- Respect and protect confidentiality of their patients.
- Clinicians should be clear about confidentiality and the conditions under which it can be broken.
- Tasaroff Case: A 1976 case in which California Supreme Court deemed that therapist was remiss for not informing all parties of the clients intention to harm his girlfriend.
- Being aware that confidentiality may need to be broken in certain instances (e.g. child abuse, potential suicide or murder).
- Jaffe vs. Redmond: 1996 Supreme Court case that permits communication between licensed mental health professionals and individual adult patients in psychotherapy.
- Client-Welfare: The best interests of the client and as such this condones relations of a sexual nature, relationships, sexual harassment.
- Most common ethical dilemma for psychologists—confidentiality (breach of potential risk due to abuse or other reasons).