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).

Professional Schools

  • 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

Clinical Scientist-Model

  • 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.

Professional Regulation

Certification

  • 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.

Licensing

  • 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.

Private Practice

  • 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:
  1. 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.
  2. Preferred Provider Organization (PPO's): have contracts with outside providers at a discounted rate for membership and in exchange providers get more referrals.
  3. 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.

Prescription Privileges

Background

  • 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.

Technological Innovations

Telehealth

  • Delivery and oversight of health services using telecommunication technologies (ex: websites, email, videoconferencing).
  • Increased accessibility to services, efficiency, reducing stigma.

Ambulatory Assessment

  • 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.

Computer-Assisted Therapy

  • 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 Scientific-mindedness

o Dynamic sizing; when to generalize vs. when to individualize

o Culture specific expertise; have knowledge of the groups that they work with

Ethical Standards

  • 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.

Human Relations

  • 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).
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