Clinical psychology

Clinical psychology is an integration of human science, behavioral 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 are psychological assessment, clinical formulation, 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 generally considered to have begun in 1896 with the opening of the first
psychological clinic at 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, three main educational
models have developed in the US—the PhD Clinical Science model (heavily focused on
research),[4] the PhD science-practitioner model (integrating scientific research and practice),
and the PsyD practitioner-scholar model (focusing on clinical theory and practice). In the UK and
the Republic of Ireland, the Clinical Psychology Doctorate falls between the latter two of these
models, whilst in much of mainland Europe, the training is at the master's level and
predominantly psychotherapeutic. Clinical psychologists are expert in providing psychotherapy,
and generally train within four primary theoretical orientations—psychodynamic, humanistic,
cognitive behavioral therapy (CBT), and systems or family therapy.

Clinical psychology is different from psychiatry. Although practitioners in both fields are experts
in mental health, clinical psychologists are experts in psychological assessment including
neuropsychological and psychometric assessment and treat mental disorders primarily through
psychotherapy. Currently, only seven US states, Louisiana, New Mexico, Illinois, Iowa, Idaho,
Colorado and Utah (being the most recent state) allow clinical psychologists with advanced
specialty training to prescribe psychotropic medications. Psychiatrists are medical doctors who
specialize in the treatment of mental disorders via a variety of methods, e.g., diagnostic
assessment, psychotherapy, psychoactive medications, and medical procedures such as
electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS). Additionally,
psychiatrists are legally authorized to prescribe psychotropic medications in all states of the
U.S. and in all provinces of Canada.[5] However, Psychiatrists are not usually used for
psychometric assessment. In education, clinical psychologists attend a graduate institution and
have a Doctor of Philosophy (Ph.D.) or a Doctor of Psychology (Psy.D.) degree, usually following
both an undergraduate and master's degree in Psychology or a related discipline. Conversely,
psychiatrists complete their studies at a medical school and hold a medical degree (M.D.) or an
osteopathic degree, Bachelor of Medicine, Bachelor of Surgery (with additional post-graduate
training), and the (D.O.), with the latter only available in the United States.

History

Many 18th century treatments for

psychological distress were based on
pseudo-scientific ideas, such as
Phrenology.

The earliest recorded approaches to assess and treat mental distress were a combination of
religious, magical, and/or medical perspectives.[6] In the early 19th century, one approach to
study mental conditions and behavior was using phrenology, the study of personality by
examining the shape of the skull. Other popular treatments at that time included the study of the
shape of the face (physiognomy) and Mesmer's treatment for mental conditions using magnets
(mesmerism). Spiritualism and Phineas Quimby's "mental healing" were also popular.[7]

While the scientific community eventually came to reject all of these methods for treating mental
illness, academic psychologists also were not concerned with serious forms of mental illness.
The study of mental illness was already being done in the developing fields of psychiatry and
neurology within the asylum movement.[6] It was not until the end of the 19th century, around the
time when Sigmund Freud was first developing his "talking cure" in Vienna, that the first scientific
application of clinical psychology began.

Early clinical psychology

Cover of The
Psychological Clinic, the
first journal of clinical
psychology, published in
1907 by Lightner Witmer
 The University of Pennsylvania was the
first to offer formal education in 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
applied psychology, the general field looked down upon this idea and insisted on "pure" science
as the only respectable practice.[6] 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.[8] 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".[9] The field was slow to follow Witmer's example, but by 1914, there were 26 similar
clinics in the US.[10]

Even as clinical psychology was growing, working with issues of serious mental distress
remained the domain of psychiatrists and neurologists.[11] 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 during World
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.[7][8] 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 with 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.[10] 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.[12] In 1945, the APA created
what is now called Division 12, the Society for Clinical Psychology, 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
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 post-traumatic stress
disorder) that were best treated as soon as possible.[8] Because physicians (including
psychiatrists) were over-extended in treating bodily injuries, psychologists were called to help
treat this condition.[13] 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.[9]
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 PhDs in psychology in 1950 being awarded in
clinical psychology.[9]
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 PhD programs in clinical psychology.[14] Clinical psychology in Britain
developed much like in the US after WWII, specifically within the context of the National Health
Service[15] with qualifications, standards, and salaries managed by the British Psychological
Society.[16]

Development of the Doctor of

Psychology degree
By the 1960s, psychotherapy had become embedded within clinical psychology, but for many,
the PhD 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.[17] Several other similar programs were instituted
soon after, and in 1973, at the Vail Conference on Professional Training in Psychology, the
practitioner–scholar model of clinical psychology—or Vail Model—resulting in the Doctor of
Psychology (PsyD) degree was recognized.[18] 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 PsyD model was instituted at Rutgers University.[17] Today, about
half of all American graduate students in clinical psychology are enrolled in PsyD programs.[18]
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.[19] 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.[7] Other major changes include the impact of
managed care 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.

Professional practice
Clinical psychologists engage in a wide range of activities. Some focus solely on research into
the assessment, treatment, or cause of mental illness and related conditions. Some teach,
whether in a medical school or hospital setting, or in an academic department (e.g., psychology
department) at an institution of higher education. The majority of clinical psychologists engage
in some form of clinical practice, with professional services including psychological
assessment, provision of psychotherapy, development and administration of clinical programs,
and forensics (e.g., providing expert testimony in a legal proceeding).[9]

In clinical 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. Clinical psychologists who provide clinical
services may also choose to specialize. Some specializations are codified and credentialed by
regulatory agencies within the country of practice.[20] In the United States, such specializations
are credentialed by the American Board of Professional Psychology (ABPP).
Training and Clinical
psychologist
certification
Occupation
to practice
Names Clinical
Clinical psychologists study a generalist
program in psychology plus postgraduate
psychologist
training and/or clinical placement and
supervision. The length of training differs Occupation Psycholo
across the world, ranging from four years plus
type
post-Bachelors supervised practice[21] to a Mental
doctorate of three to six years which
combines clinical placement.[22] In the US, health
about half of all clinical psychology graduate
students are being trained in PhD programs—a professio
model that emphasizes research—with the
other half in PsyD programs, which has more
focus on practice (similar to professional
Activity Psychology,
degrees for medicine and law).[18] Both sectors
models are accredited by the American Medicine,
Psychological Association[23] and many other
English-speaking psychological societies. A Health care,
smaller number of schools offer accredited
programs in clinical psychology resulting in a Forensic
master's degree, which usually takes two to
three years post-Bachelors. science,
In the UK, clinical psychologists undertake a Psychologica
Doctor of Clinical Psychology (DClinPsych),
which is a practitioner doctorate with both research,
clinical and research components. This is a
three-year full-time salaried program
sponsored by the National Health Service Psychologica
(NHS) and based in universities and the NHS.
Entry into these programs is highly assessment
competitive and requires at least a three-year
undergraduate degree in psychology plus
Description
some form of experience, usually in either the
NHS as an assistant psychologist or in
academia as a research assistant. It is not Competencies Asses
unusual for applicants to apply several times
before being accepted onto a training course treatm
as only about one-fifth of applicants are
accepted each year.[24] These clinical psych
psychology doctoral degrees are accredited
by the British Psychological Society and the
Health Professions Council (HPC). The HPC is
Education Doctor o
the statutory regulator for practitioner required
psychologists in the UK. Those who
Psychol
successfully complete clinical psychology
doctoral degrees are eligible to apply for
(PsyD)
registration with the HPC as a clinical Or
psychologist.

The practice of clinical psychology requires a

Doctor o
license in the United States, Canada, the
United Kingdom, and many other countries. Philosop
Although each of the US states is somewhat
different in terms of requirements and (PhD)
licenses, there are three common
elements:[25] Fields of Hospita
1. Graduation employment
clinics
from an Related Psychiatris
jobs
 accredited Psychothe
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 U.S. 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.[25] Most states also require a certain number of continuing education credits per
year in order to renew a license, which can be obtained through various means, such as taking
audited classes and attending approved workshops. Clinical psychologists require the
psychologist license to practice, although other mental health provider licenses can be obtained
with a master's degree, such as Marriage and Family Therapist (MFT), Licensed Professional
Counselor (LPC), and Licensed Psychological Associate (LPA).[26]

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.
Assessment
An important area of expertise for many clinical psychologists is psychological assessment, and
there are indications that as many as 91% of psychologists engage in this core clinical
practice.[27] Such evaluation is usually done in service to gaining insight into and forming
hypothesis about psychological or behavioral problems. As such, the results of such
assessments are usually used to create generalized impressions (rather than diagnosis) in
service to informing treatment planning. Methods include formal testing measures, interviews,
reviewing records, clinical observation, and physical examination.[2]

Measurement domains
There exist hundreds of various assessment tools, although only a few have been shown to have
both high validity (i.e., test actually measures what it claims to measure) and reliability (i.e.,
consistency). Many psychological assessment measures are restricted for use by those with
advanced training in mental health. For instance, Pearson (one of the many companies with
rights and protection of psychological assessment tools) separates who can administer,
interpret, and report on certain tests. Anybody is able to access Qualification Level A tests.
Those who intend to use assessment tools at Qualification Level B must hold a master's degree
in psychology, education, speech language pathology, occupational therapy, social work,
counseling, or in a field closely related to the intended use of the assessment, and formal
training in the ethical administration, scoring, and interpretation of clinical assessments. Those
with access to Qualification C (highest level) assessment measures must hold a doctorate
degree in psychology, education, or a closely related field with formal training in the ethical
administration, scoring, and interpretation of clinical assessments related to the intended use of
the assessment.[28]

Psychological measures generally fall within one of several categories, including the following:
Intelligence & achievement tests –
These tests are designed to measure
certain specific kinds of cognitive
functioning (often referred to as IQ) in
comparison to a norming group. These
tests, such as the WISC-IV and the WAIS,
attempt to measure such traits as
general knowledge, verbal skill, memory,
attention span, logical reasoning, and
visual/spatial perception. Several tests
have been shown to predict accurately
certain kinds of performance, especially
scholastic.[27] Other tests in this
category include the WRAML and the
WIAT.
Personality tests – Tests of personality
aim to describe patterns of behavior,
thoughts, and feelings. They generally
fall within two categories: objective and
projective. Objective measures, such as
the MMPI, are based on restricted
answers—such as yes/no, true/false, or
a rating scale—which allow for the
computation of scores that can be
compared to a normative group.
Projective tests, such as the Rorschach
inkblot test, allow for open-ended
answers, often based on ambiguous
stimuli. Other commonly used
personality assessment measures
include the PAI and the NEO
Neuropsychological tests –
Neuropsychological tests consist of
specifically designed tasks used to
measure psychological functions known
to be linked to a particular brain
structure or pathway. They are typically
used to assess impairment after an
injury or illness known to affect
neurocognitive functioning, or when
used in research, to contrast
neuropsychological abilities across
experimental groups.
Diagnostic Measurement Tools –
Clinical psychologists are able to
diagnose psychological disorders and
related disorders found in the DSM-5
and ICD-10. Many assessment tests
have been developed to complement the
clinicians clinical observation and other
assessment activities. Some of these
include the SCID-IV, the MINI, as well as
some specific to certain psychological
disorders such as the CAPS-5 for
trauma, the ASEBA, and the K-SADS for
affective and Schizophrenia in children.
Clinical observation – Clinical
psychologists are also trained to gather
data by observing behavior. The clinical
interview is a vital part of the
assessment, even when using other
 formalized tools, which can employ
either a structured or unstructured
format. Such assessment looks at
certain areas, such as general
appearance and behavior, mood and
affects, perception, comprehension,
orientation, insight, memory, and
content of the communication. One
psychiatric example of a formal
interview is the mental status
examination, which is often used in
psychiatry as a screening tool for
treatment or further testing.[27]

Diagnostic impressions
After assessment, clinical psychologists may 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. Both are
nosological systems that largely assume categorical disorders diagnosed through the
application of sets of criteria including symptoms and signs.[29]

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[29][30]) and a
"psychosocial model", which would take changing, intersubjective states into greater account.[31]
The proponents of these models claim that they would offer greater diagnostic flexibility and
clinical utility without depending on the medical concept of illness.[32] However, they also admit
that these models are not yet robust enough to gain widespread use, and should continue to be
developed.[32]

Clinical psychologists do not tend to diagnose, but rather use formulation—an individualized map
of the difficulties that the patient or client faces, encompassing predisposing, precipitating and
perpetuating (maintaining) factors.[33]

Clinical v. mechanical prediction

Clinical assessment can be characterized as a prediction problem where the purpose of
assessment is to make inferences (predictions) about past, present, or future behavior.[34] For
example, many therapy decisions are made on the basis of what a clinician expects will help a
patient make therapeutic gains. Once observations have been collected (e.g., psychological
testing results, diagnostic impressions, clinical history, X-ray, etc.), there are two mutually
exclusive ways to combine those sources of information to arrive at a decision, diagnosis, or
prediction. One way is to combine the data in an algorithmic, or "mechanical" fashion.
Mechanical prediction methods are simply a mode of combination of data to arrive at a
decision/prediction of behavior (e.g., treatment response). The mechanical prediction does not
preclude any type of data from being combined; it can incorporate clinical judgments, properly
coded, in the algorithm.[34] The defining characteristic is that, once the data to be combined is
given, the mechanical approach will make a prediction that is 100% reliable. That is, it will make
exactly the same prediction for exactly the same data every time. Clinical prediction, on the
other hand, does not guarantee this, as it depends on the decision-making processes of the
clinician making the judgment, their current state of mind, and knowledge base.[35][34]
What has come to be called the "clinical versus statistical prediction" debate was first described
in detail in 1954 by Paul Meehl,[35] where he explored the claim that mechanical (formal,
algorithmic) methods of data combination could outperform clinical (e.g., subjective, informal,
"in the clinician's head") methods when such combinations are used to arrive at a prediction of
behavior. Meehl concluded that mechanical modes of combination performed as well or better
than clinical modes.[35] Subsequent meta-analyses of studies that directly compare mechanical
and clinical predictions have born out Meehl's 1954 conclusions.[36][37] A 2009 survey of
practicing clinical psychologists found that clinicians almost exclusively use their clinical
judgment to make behavioral predictions for their patients, including diagnosis and
prognosis.[38]

Intervention
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][39]

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, a psychoanalyst 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.[9]

Insight – emphasis is on gaining a

greater understanding of the
motivations underlying one's thoughts
 and feelings (e.g. psychodynamic
therapy)
Action – focus is on making changes in
how one thinks and acts (e.g. solution
focused therapy, cognitive behavioral
therapy)
In-session – interventions center on the
here-and-now interaction between client
and therapist (e.g. humanistic therapy,
Gestalt therapy)
Out-session – a large portion of
therapeutic work is intended to happen
outside of session (e.g. bibliotherapy,
rational emotive behavior therapy)
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).[39][40]

Four main schools

Many clinical psychologists are integrative or eclectic and draw from the evidence base across
different models of therapy in an integrative way, rather than using a single specific model.

In the UK, clinical psychologists have to show competence in at least two models of therapy,
including CBT, to gain their doctorate. The British Psychological Society Division of Clinical
Psychology has been vocal about the need to follow the evidence base rather than being
wedded to a single model of therapy.

In the US, intervention applications and research are dominated in training and practice by
essentially four major schools of practice: psychodynamic, humanism, 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.[39] The essential tools of the psychoanalytic process are
the use of free association and 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.[39]
Humanistic/Experiential
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.[41] 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.[42] 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. From 1980, Hans-Werner Gessmann integrated the ideas of humanistic
psychology into group psychotherapy as humanistic psychodrama.[43] According to humanistic
thinking,[44] 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.

Emotion focused therapy/Emotionally focused therapy (EFT), not to be confused with Emotional
Freedom Techniques, was initially informed by humanistic–phenomenological and Gestalt
theories of therapy.[45][46] "Emotion Focused Therapy can be defined as the practice of therapy
informed by an understanding of the role of emotion in psychotherapeutic change. EFT is
founded on a close and careful analysis of the meanings and contributions of emotion to human
experience and change in psychotherapy. This focus leads therapist and client toward strategies
that promotes the awareness, acceptance, expression, utilization, regulation, and transformation
of emotion as well as corrective emotional experience with the therapist. The goals of EFT are
strengthening the self, regulating affect, and creating new meaning".[45] Similarly to some
Psychodynamic therapy approaches, EFT pulls heavily from attachment theory. Pioneers of EFT
are Les Greenberg[47][48] and Sue Johnson.[49] EFT is often used in therapy with individuals, and
may be especially useful for couples therapy.[50][51] Founded in 1998, Sue Johnson and others
lead the International Centre for Excellence in Emotion Focused Therapy (ICEEFT) (https://iceeft.
com/) where clinicians can find EFT training internationally. EFT is also a commonly chosen
modality to treat clinically diagnosable trauma.[52]
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.[53] 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 dialectic behavior
therapy and mindfulness-based cognitive therapy.[54]

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 feedback 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 or behavioral
health counselors. They have studied many areas from developmental disabilities to depression
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.[55] 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 approach for treating addictions,
acceptance and commitment therapy, functional analytic psychotherapy, including dialectic
behavior therapy and behavioral activation. In addition, specific techniques such as contingency
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.[56]
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.

Other therapeutic perspectives

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.[57]
Gestalt – Gestalt therapy was primarily
founded by Fritz Perls in the 1950s. This
therapy is perhaps best known for using
techniques designed to increase self-
awareness, the best-known perhaps
being the "empty chair technique." Such
techniques are intended to explore
resistance to "authentic contact",
resolve internal conflicts, and help the
client complete "unfinished
business".[58]
Postmodern – Postmodern psychology
says that the experience of reality is a
subjective construction built upon
language, social context, and history,
with no essential truths.[59] 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.[60] Forms of postmodern
psychotherapy include narrative therapy,
solution-focused therapy, and coherence
therapy.
Transpersonal – The transpersonal
perspective places a stronger focus on
the spiritual facet of human
experience.[61] It is not a set of
techniques so much as a willingness to
help a client explore spirituality and/or
transcendent states of consciousness.
Transpersonal psychology is concerned
with helping clients achieve their highest
potential.
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.[40] 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
of acculturation 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.[62] 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.[63]
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.[64]
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,[65] 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.[66][67] 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.[68]
Community psychology approaches are often used for psychological prevention of harm and
clinical intervention.[69][70][71]

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, behavioural 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.[72]

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.[73] 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.[73] Detailed
elements address how to resolve ethical issues, competence, human relations, privacy and
confidentiality, advertising, record keeping, fees, training, research, publication, assessment, and
therapy.

The Canadian Psychological Association ethical code principle's are: Respect for the Dignity of
Persons and Peoples, Responsible Caring, Integrity in Relationships, and Responsibility to
Society. It is considered very similar to the APA's Code.[74]

In the UK the British Psychological Society has published a Code of Conduct and Ethics for
clinical psychologists. This has four key areas: Respect, Competence, Responsibility and
Integrity.[75] Other European professional organizations have similar codes of conduct and
ethics.

The Asian Federation for Psychotherapy published a code of ethics in 2008 with the following
principles: Beneficence, Responsibility, Integrity, Justices, and Respect. Similar to the APA code,
it provides detailed instructions for the conduct of psychologists, specifically
psychotherapists.[76] Russia, India, Iran, Kazakhstan, China, Malaysia, and Japan are member
countries.[77]

The National Latina/o Psychological Association adopted their current ethical guidelines in
2018, stating that "the traditional Eurocentric foundations in mainstream psychology have
provided culturally bound knowledge about worldviews, ways of living, and cultural practices."
Their principles are: Respect and Responsibility, Ethical Dilemmas, Ethical Decision-Making and
Legal Responsibility, Consultation, Justice and Advocacy, Self-Awareness and Social-
Consciousness, Action and Accountability, Training and Creating Infrastructure, and
Mentorship.[78]
Comparison with other
mental health professions

Psychiatry

Fluoxetine hydrochloride, branded

by Lilly as Prozac, is an
antidepressant drug prescribed by
physicians, psychiatrists, and
some nurses.

Although clinical psychologists and psychiatrists can be said to share a same fundamental aim
—the alleviation of mental distress—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 can use psychotropic medications as a
method of addressing the illness[79]—although some also employ psychotherapy as well.
Psychiatrists 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.
Conversely, clinical psychologists conduct specialist assessment and psychometric testing.
Such assessments and tests would not normally only be administered and interpreted by
psychologists due to their advanced training in psychometric assessment. As standard clinical
psychologists also usually possess more advanced training and specialist knowledge in psycho-
social development and psychological therapies.
Clinical psychologists generally do not prescribe medication, although there is a movement for
psychologists to have prescribing privileges.[80] These medical privileges require additional
training and education. To date, medical psychologists (prescribing psychologists) may
prescribe psychotropic medications in Colorado, Guam, Iowa, Idaho, Illinois, New Mexico,
Louisiana, the Public Health Service, the Indian Health Service, and the United States Military.[81]

Counseling psychology
Counseling psychologists undergo the same level of rigor in study and use many of the same
interventions and tools as clinical psychologists, including psychotherapy and assessment.
Traditionally, counseling psychologists helped 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][9] However, that distinction has faded over time, and of the
counseling psychologists who do not go into academia (which does not involve treatment or
diagnosis), the majority of counseling psychologists treat mental illness alongside clinical
psychologists. Many counseling psychologists also receive specialized training in career
assessment, group therapy, and relationship counseling.

Counseling psychology as a field values multiculturalism[82] and social advocacy, often

stimulating research in multicultural issues. 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. Counseling psychologists tend to be more frequently
employed in university counseling centers compared to hospitals and private practice for clinical
psychologists.[83] However, counseling and clinical psychologists can be employed in a variety of
settings, with a large degree of overlap (prisons, colleges, community mental health, non-profits,
corporations, private practice, hospitals and Veterans Affairs).

School psychology
School psychologists are 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
"educ
ationa Comparison of mental health professionals in the US
l Mean
psych Prescription 2022
Occupation Degree Common licenses
ologis privilege income
ts". (USD)
Like
Varies by
clinic Clinical psychologist PhD/PsyD/EdD Psychologist $90,130
state
al
Counseling
(and
psychologist PhD/PsyD/EdD Psychologist No $65,000
couns
(doctorate)
eling)
psych Counselor (master's) MA/MS/MEd MFT/LPC/LHMC/LPA No $49,710
ologis School psychologist PhD/EdD/MS/EdS School psychologist No $81,500
ts,
Psychiatrist MD/DO Psychiatrist Yes $226,880
schoo
l Clinical social
PhD/DSW/MSW LCSW No $55,350
worker
psych
ologis Psychiatric nurse MSN/BSN RN No $75,330
ts
Psychiatric and
with Yes (varies
mental health nurse DNP/PhD/MSN APRN/APN/PMHNP $121,610
docto by state)
practitioner
ral
Expressive/Art
degre MA ATR No $55,900
therapist
es are
eligibl
e for Sources: [84][85][86][87][88][89]
licens
ure 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
(EdS), Doctor of Philosophy (PhD), and Doctor of Education (EdD).

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.[90][91]

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.

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."[92] 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.
Criticisms and controversies
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.[93]
Despite some evidence showing that all the major therapeutic orientations are about of equal
effectiveness,[94][95] there remains much debate about the efficacy of various forms of treatment
in use in clinical psychology.[96]

See also

Anti-psychiatry
Applied psychology
Clinical Associate (Psychology)
Clinical neuropsychology
Clinical trial
List of clinical psychologists
List of credentials in psychology
 List of psychotherapies
Outline of psychology
Psychiatric and mental health nursing
Psychoneuroimmunology

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