Clinical Psychologists in the 2010s: 50 Years of the APA Division of Clinical Psychology

The American Psychological Association's Division of Clinical Psychology constitutes one of the oldest, largest, and most active organizations of clinical psychologists in the world. For 50 years, beginning with E. Lowell Kelly in 1960, researchers have chronicled the evolution of its membership and the transformation of clinical psychology in the United States. In this article, we highlight the continuity and change in clinical psychologists’ demographics, educations, theories, employment, activities, and satisfactions over a 50‐year span. Results from the most recent, 2010 study (N = 588, 46% return rate) are summarized in both contemporary and historical contexts. Among the prominent trends are steady increases in the proportion of female and ethnic minority psychologists, the rise of Psy.D. graduates, the domination of the cognitive orientation, a relative decline in psychological assessment in general and projective testing in particular, the ascendancy of independent practice, and a pattern of high career satisfaction.     

Stayin’ Alive: How the Society of Clinical Psychology Can Remain Vital and Viable for the Next 20 Years

Norcross and Karpiak (2012) provide a wealth of data showing recent trends in Division 12 membership. This article provides some new data suggesting that the Division's “market share” of clinical psychologists is eroding and that the current membership of Division 12 does not adequately reflect the changing demographics in the field. In order for the division to remain a vital and viable presence within the field, I suggest that the Society of Clinical Psychology will need to intensify our efforts to recruit and retain a population of younger, more diverse, and more practice‐oriented graduate students and early career psychologists. Specific recruitment and retention initiatives are proposed, some of which are new, others of which would extend existing programs within the Division.     

A re-introduction of the psychodynamic approach to the standard clinical psychology curriculum

Objective

There is a strong evidence-base for a psychodynamic approach, supporting primary theoretical tenets as well as the treatment effectiveness. Additionally, there are increasing calls from the field for more individualized treatment for clients, and the lack of training in multiple orientations limits the ability of students in clinical psychology Ph.D. programs in the United States to personalize their treatments. The accumulated evidence-base for contemporary relational psychodynamic theory and therapy places it in good standing to return to the standard clinical psychology curriculum, along with other evidence-based approaches.

Methods

We use data from the Insider's Guide (which describes clinical Ph.D. programs in the United States) from three time points over 20 years to document the waning psychodynamic approach in clinical psychology programs. We review the scientific evidence for four primary tenets of a contemporary psychodynamic approach: three related to development—from healthy to psychopathological: (1) unconscious processes; (2) internal representations of self and other; (3) dimensional model of psychopathology, and a fourth tenet that builds on these three and is the foundation for a contemporary psychodynamic approach to psychotherapy: (4) therapeutic relationship as a primary mechanism of change.

Results/Conclusions

Based on the review of the evidence, we make specific recommendations for clinical psychology training programs about how to include a psychodynamic approach in the curriculum.     

Clinical Geropsychology and Primary Care: Progress and Prospects

This paper comments on the review by Arean & Ayalon (this issue) and on implications for the further development of clinical geropsychology in primary care. The review provides an outstanding summary of the impressive scientific progress that has occurred in this field over the past decade. Comments focus on prospects for the future of geropsychologists in primary-care settings. Psychologists have been major contributors to research in this area but are not assured of major clinical roles in behavioral healthcare delivery. As a profession, clinical psychology must attend to developing reimbursable clinical roles for psychologists and to training psychologists who are prepared for the challenges of primary-care geropsychology.     

Irish clinical and counselling psychologists' experiences and views of mandatory personal therapy during training: A polarisation of ethical concerns

Although there have been some recent changes in Ireland, the practice of mandating personal therapy during training has traditionally differed between counselling and clinical psychologists. Irish psychologists (n = 258: 170 clinical, 88 counselling) took part in a survey study of experiences and views regarding this practice. Counselling psychologists reported higher rates of lifetime and current attendance at personal therapy compared to clinical psychologists, and nearly all had experienced mandated personal therapy compared to a minority of the clinical group. However, the clinical psychologists had a high rate of attendance at personal therapy compared to that reported for their British peers, indicating a high regard for personal therapy amongst Irish clinicians despite the absence of a training mandate. Five factors were found to be independent predictors of agreement with mandating personal therapy during training—lifetime experience of personal therapy, being a counselling psychologist, experience of mandated therapy, being more recently qualified, and longer attendance at personal therapy. Thematic analysis of the psychologists' open responses regarding mandated therapy indicated that the majority believed that personal therapy was an important part of ethical, effective practice, and valuable in enhancing self‐awareness and learning from the client experience. Ethical concerns about a mandate were polarised between the two psychology specialisms, more counselling psychologists emphasising the dangers and questionable efficacy of psychologists practising psychotherapy without personal therapy experience, and more clinical psychologists questioning the efficacy and ethics of imposing a mandate on trainees. Recommendations are made regarding this issue for trainers of both specialisms.     

Clinical Psychologists in Departments of Psychiatry: Current Issues and a Look to the Future

The aim of this article is to discuss issues facing psychologists who work in departments of psychiatry. The authors both have experience in such settings and address relationships between psychologists and psychiatrists, the differences in training backgrounds and approaches to understanding and treating mental health disorders, and issues related to productivity. In many departments, clinical psychologists do not have equal standing with psychiatrists when it comes to compensation, competition for resources, and administrative representation. Nevertheless, when calls for increasingly multimodal research and treatment approaches are considered along with the requirement that psychiatry residency training programs require instruction in empirically supported psychological treatments, one recognizes that psychologists will continue to fill important roles in departments of psychiatry for the foreseeable future.     

Impact of an auditory hallucinations simulation on trainee and newly qualified clinical psychologists: A mixed‐methods cross‐sectional study

Simulation training is an effective teaching tool enabling learners to gain a subjective understanding of a range of skills. Our aim in this study was to pilot and evaluate a newly designed simulation of auditory hallucinations as a future training tool for clinicians. This was a mixed‐methods study in two parts. In Phase 1, trainee and qualified clinical psychologists (N = 25) attended the London‐based immersive art exhibition, Altered States of Consciousness, which included an auditory hallucinations simulation. The exhibition aimed to improve understanding of what it feels like to hear voices by providing members of the public with an individualized simulation of auditory hallucinations. Participants completed pre/post‐exhibition measures of their mood and attitudes towards auditory hallucinations and other unusual sensory experiences. In Phase 2, a subgroup of Phase 1 participants (N = 15) took part in a semi‐structured interview and completed the post‐exhibition questions again approximately 6 months later. Post‐exhibition, there were significant increases in understanding what it feels like to hear voices (large effect), compassion towards people who hear voices (large effect), and comfort talking to people who hear voices (medium effect). Scores were partially maintained at follow‐up. Participants reported that the simulation provided numerous benefits to their training and clinical practice, including increases in subjective understanding, compassion, and confidence, and suggested several future training applications for the simulation, including with a range of health care professionals. Therefore, we conclude that this simulation has potential for training clinical psychologists and other health care professionals who work with people who experience auditory hallucinations.     

The Present and Future of Clinical Psychology

Introduces the Special Issue of Clinical Psychology: Science and Practice , in which authors address the present and future of each of several different areas within clinical psychology. Topics include major areas of research interest (e.g., assessment, diagnostics, treatment, prevention), matters of training and credentialing, specialty topics (e.g., diversity, clinical child and adolescent psychology), and the settings in which clinical psychologists are employed (e.g., private practice, academic departments of psychology, psychiatry departments).     

Reflections on “Real‐World” community psychology

Reflections on the history of real‐world (applied) community psychologists trace their participation in the field's official guild, the Society for Community Research and Action (SCRA), beginning with the Swampscott Conference in 1965 through the current date. Four benchmarks are examined. The issues these real‐world psychologists bring to the field include academic and community legitimacy, community psychology as an interdisciplinary field, and politics and advocacy. Challenges these issues create among community psychologists—real‐world and academic—are briefly addressed. These reflections end with a vision of the future of community psychology that includes a strong recommitment to social change and social justice. © 2008 Wiley Periodicals, Inc.     

Science and Practice in Clinical Psychology Doctoral Training

I evaluate the claim by Heatherington et al. (2012) that most clinical psychology graduate students are primarily educated in cognitive‐behavioral theory and therapy. I point out some limitations with their data, in part by describing my own experience in a “CBT” training program. I further contend that even if better data are needed, there may be cause for concern, especially with reference to recent training guidelines. I believe that it is important to consider how young clinical psychology is as a profession and a science and that graduate students in clinical psychology need both pluralism and a thorough grounding in history in order to keep our field moving forward.     

Changes in clients' relational patterns with parents and therapist during psychodynamic psychotherapy: Their association and relation to treatment outcome

Objective

The study aimed to explore how changes in clients' relational patterns during psychodynamic psychotherapy relate to treatment outcomes and therapy effectiveness.

Method

Seventy clients receiving psychodynamic psychotherapy in a university counseling center were interviewed three times and filled out the OQ-45 questionnaire five times during therapy. We used the Core Conflictual Relationship Theme (CCRT) to study clients' relational patterns. Mixed models were used to assess the interaction between clients' CCRT intensity toward their parents and toward their therapists, treatment effectiveness, and treatment outcome.

Results

First, we found that clients' relational patterns with their parents correlated with relational patterns with their therapists across several time points in therapy. Then, we found significant interactions, indicating that treatment effectiveness moderates the relationship between clients' CCRT intensity and treatment outcomes.

Conclusions

The findings suggest that the transference phenomenon is related to therapy outcomes differently in effective and less-effective therapies, depending on the transference intensity. Further research is needed to expand knowledge about the intensity of transference and its possible impact on treatment choice and management.     

Internship and postdoctoral training in pediatric and clinical child psychology: a survey

A survey was designed to obtain data from pediatric psychology,clinical child psychology, and combined training centers. Sixtyprogram directors provided identifying characteristics aboutthe facility, application information for internship and postdoctoraltraining, information on clientele and case load of trainees,and specific training information. In addition, respondentsprovided definitions of the two areas and suggested differentiatingfeatures. It was concluded that the similarities are more numerousthan are the differences in training. Definitions suggest that(a) clinical child psychology has broader application than pediatricpsychology despite the latter's broader principles of application,and (b) pediatric psychologists rely heavily on the traditionalskills and techniques of clinical child psychology. The onlydifferentiating features identified were in terms of medicallyrelated populations of children served, collaboration with healthcare disciplines, and a specialized focus of viewing psychologicaldifficulties within the medical culture by pediatric psychologists.     

Observations on Training Clinical Psychology Faculty

The rank ordering of psychology programs based on the number of "core" clinical program faculty they produce is interesting and valuable. It is important to emphasize, as the Hard! et al. (this issue) did, that this is only one measure of program quality. The study was based only on faculty of university doctoral training programs, and there are other programs and locations in which faculty are involved in training future clinical psychology program faculty. It is most interesting that even the best programs train very few future clinical program faculty per year. Because of temporal shifts in program quality, when making evaluative decisions, it is essential for consumers of rank-ordered lists to obtain the most recent and direct information regarding programs. I also discuss some future implications of these and other data for future directions in training clinical psychology program faculty.     

Clinical psychology going forward: the need to promote clinical psychology and to respond to the training crisis

To provide a context for discussing psychology going forward, this article will begin by briefly providing a historical and international context. It will then argue that establishing a database demonstrating the value of our treatments is not enough, and that we also need to promote what we can accomplish. The question will then be posed as to whether the Australian Psychological Society Colleges should be restructured for maximising the potential of clinical psychology, for example, amalgamating some of the Colleges. The need for political action with respect to national health care reform will be discussed including advocacy related to Better Access, and the need to get psychologists into the newly established Medicare Locals and Local Hospital Networks. Finally, the training crisis in clinical psychology will be discussed along with some recommendations for change, of which the one considered to be most important is getting psychology added to the list of currently five professions who can offer Masters Degrees (extended) with graduates able to use the title “Doctor of (field of study).”     

Time for Acceptance,Caution, and Concern: Similarities and Differences of Ph.D. Clinical Psychology Programs

[Clin Psychol Sci Prac 18: 17–20, 2011] With some exceptions, it is important to accept that there are clear similarities across research‐dedicated programs and those with less research emphasis at comprehensive universities. There was ill‐founded negative publicity about clinical psychology based on Baker, McFall, and Shoham (2009) and the Newsweek rendition thereof, and results regarding research emphases across programs could also be used to fuel debate regarding clinical practice. However, caution is in order because the actual behaviors of psychologists in clinical practice who completed their doctorates in these two types of clinical programs are unknown. The third type of clinical program in institutes has relatively low applicant grades and GREs, high acceptance rates, and no financial support. These are major differences that merit concern by our profession.     

What Does “Work” Mean? Reopening the Debate About Clinical Significance

[Clin Psychol Sci Prac 17: 48–51, 2010]
Researchers and practitioners have long debated the meaning and measurement of clinical significance. Shearer-Underhill and Marker (2010) offer a valuable contribution to this discussion by drawing the psychotherapy research community's attention to an additional statistical method for measuring clinical significance—the number needed to treat. After a decrease in publication rates in the last 5 years on methods for measuring clinical significance, the article by Shearer-Underhill and Marker represents a renewed interest in the construct of clinical significance of treatment outcome results. This commentary discusses the importance of the article by elaborating on the theoretical and methodological issues that cut across measures of clinical significance. Strengths and weaknesses of specific statistical methods are reviewed and a call is made for continued pursuit of conceptual clarity and methodological rigor for measures of clinical significance.     

Manual-Based Treatment: An Essential Ingredient of Clinical Practice in the 21st Century

Wilson (this issue) raises several thought-provoking issues pertaining to the use of manual-based treatments (MBTs) in clinical practice. Based on my experiences as a researcher of manual-based treatments for social phobia and as a clinical psychologist in independent practice, I share my perspective on several of Wilson's points. Comorbid conditions do not appear to hinder the outcomes of MBTs for social phobia, and participants in controlled clinical trials do not appear very different from persons who refuse or are excluded from participation. Manuals can be written in a manner that retains a great deal of flexibility for the clinician, and these manuals may be productively employed in clinical settings. Proper implementation of MBTs requires experience with the disorder of interest and a strong background in theories of psychopathology and therapy technique.     

Ethical beliefs and behaviors of pediatric psychologists: a survey.

There is an absence of data concerning the beliefs about and compliance with ethical principles of pediatric psychologists. Survey data were collected from 169 psychologist members of the Society of Pediatric Psychology (Division 12, Section 5 of APA) regarding the degree to which they engaged in each of 101 behaviors and the degree to which they considered each behavior ethical. The data were categorized and examined in terms of the APA Ethical Principles. Results indicated that pediatric psychologists show significantly different beliefs and behavior comparing children, adolescents, and their parents. A "majority belief" scale was developed where 80% of pediatric psychologists agreed that a clinical behavior was ethical or not ethical. Female pediatric psychologists, compared to males, more strongly endorsed the majority belief items (p less than .01). In addition, psychologists who graduated from APA-approved graduate programs more strongly endorsed the majority belief items than did psychologists from non-APA programs (p less than .05). Increased awareness of ethical issues is hoped to improve self-regulation by psychologists.     

Between a rock and a hard place: Associations between Mentzos' “dilemma”, self‐reported interpersonal problems,and psychosocial functioning in individuals with non‐affective psychoses

Primary aim of this study was to determine the extent and type of self‐reported interpersonal problems in patients with non‐affective psychoses and their impact on psychosocial functioning. Furthermore, we aimed to explore potential links with the psychodynamic construct of Stavros Mentzos' “psychotic dilemma”, which describes an insufferable inner tension caused by an individual's struggle of being torn between “self‐oriented” and “object‐oriented” tendencies. In a cross‐sectional study among 129 patients with non‐affective psychoses, measures of cognition, symptom load and social functioning as well as a tentative, psychodynamic assessment of Mentzos' “dilemma” were obtained during a clinical research visit. Self‐report data on interpersonal problems were gathered using the Inventory of Interpersonal Problems (IIP‐64D) and compared with a German representative standard sample. Second, IIP‐64D scores were compared between groups with or without Mentzos' “dilemma”. Hierarchical regression analyses were performed to test for the impact of interpersonal problems on psychosocial functioning, while controlling for cognitive deficits and psychopathology. Results showed that IIP‐64D scores differed significantly from healthy controls, except for “self‐centred” and “intrusive” interpersonal styles. Participants with a potential “psychotic dilemma” scored significantly higher on the subscales: “domineering”, “self‐centred”, “cold”, and “socially avoidant” than the group without a “psychotic dilemma”. The total amount of interpersonal problems, and particularly high scores on the IIP‐64D “socially avoidant” subscale, predicted psychosocial dysfunction, whereas a “cold” interpersonal style had an opposite effect. In conclusion, specific interpersonal problems may predict psychotherapeutic outcome measures like psychosocial functioning and are partly compatible with the psychodynamic construct of Stavros Mentzos' “psychotic dilemma”.     

Overcoming Barriers to Increase the Contribution of Clinical Psychologists to Work With Persons With Severe Mental Illness

Psychosocial treatments for persons with severe mental illness (SMI) have been developing rapidly over the past decade. Despite the fact that people with SMI are often in the greatest need of care, clinical psychologists are not currently playing a major role in their treatment and are underrepresented compared to other disciplines in this area such as nursing, social work, and psychiatry. In this article, we present possible reasons for clinical psychologists' underrepresentation and discuss motivators, potential opportunities, and ways for clinical psychologists to take a greater role in the provision of services for persons with SMI. Implications for the training of clinical psychologists are discussed.