Which of the following has not been an emphasis of psychology since the Second World War

Clinical Concerns

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Clinical concerns include anxiety, depression, stress reactions, adjustment reactions, phobias, substance abuse, eating disorders, and burnout; all of these can be associated with performance decrements. NCAA student-athletes may face stressors/pressures that are unique in comparison with their nonathlete peers; scheduling demands, physical stress and fatigue, stereotyping effects, and the dual role of student and athlete.

Athletes are not immune to MH issues. Survey data reflects that student-athletes struggle with anxiety and depression but may be less likely to report such issues than their nonathletic peers. Given this, athletic trainers, team physicians, and coaches can play important screening and supportive referral roles. General stress, interpersonal relationships, and sleep difficulties are associated with depression and anxiety.

Psychoeducational efforts around MH or behavioral needs by the NCAA and athletic departments provide important options for student-athletes, and such efforts can decrease the stigma associated with seeking MH treatment.

Treatment from a licensed MH professional is indicated for clinical issues; for athletes, finding a professional with sport psychology experience is preferable. If prescription medication is considered, a sport psychiatrist along with a clinical psychologist may work together and provide diagnosis, treatment goals, psychotherapy (individual or family), and/or pharmacotherapy. Treatment outcomes are optimized if there is an established referral pathway for MH issues and an interdisciplinary team approach.

Introduction

Clinical psychology is a subject that focuses on the psychological (that is, the emotional, biological, cognitive, social, and behavioral) aspects of human functioning in varying socioeconomic, clinical, and cultural groups as well as in different age groups. This life span approach necessitates a focus on developmental psychology as well as on the dynamics of change for behavior, emotion, and cognition. The aim of clinical psychology is to understand, predict, and treat or alleviate disorders, disabilities, or any kind of maladjustment. This aim involves a variety of clinical specialities and competencies, such as the assessment of problems or impairments, the formulation of problems (which is linked to clinical judgment), and the indicated treatments for these problems. A second aim is to act on a preventative level to promote human adaptation, adjustment, and personal development, thereby placing a focus also on the prevention of mental health conditions.

In relation to the type of professional work involved, “clinical psychology” is an umbrella term that defines a collection of possible but not necessary theories and activities, akin to Wittgenstein's definition of “game.” Wittgenstein argued that, although we all understand the concept, there are no essential defining criteria for “game,” because there is always an example of a game to which any individual criterion does not apply. We suggest that the theory and practice of clinical psychology also have such problems of definition. Despite the plethora of evidence that has arisen from basic psychology, clinical psychology is inherently an area of applied research, which transfers findings into practice. It refers to direct work with clients and indirect work through other professionals, carers, and policy-related constructs. The professional practice of clinical psychology has now been defined in most countries to include specified training routes, registration of practitioners, and continuing professional development.

Clinical psychologists are involved in research, teaching and supervision, program development and evaluation, consultation, public policy, professional practice, and other activities that promote psychological health in individuals, families, groups, and organizations. Clinical psychology practitioners work directly with individuals at all developmental levels (infants to older adults), as well as with groups (families, patients of similar psychopathology, and organizations), using a wide range of assessment and intervention methods to promote mental health and to alleviate discomfort and maladjustment. This work can range from prevention and early intervention of minor problems of adjustment, to dealing with the adjustment and maladjustment of individuals whose disturbance requires them to be institutionalized. In terms of work settings, these include individual practice, mental health service units, managed health care organizations, counseling centers, and different departments in hospitals, schools, universities, industry, legal systems, medical systems, and government agencies.

2.02.1 Introduction

Clinical psychology celebrated its centennial in 1996. The evolution of the field, over this 100 years plus, has reflected the historical events in each era. In particular, World Wars I and II had major influences on its growth and directions. The stresses and strains that have occurred within psychology generally have steered the profession in one direction or another. Theoretical debates, professional associations, conferences, and the initiatives of individual psychologists have been some of the pushes and pulls that have altered the course of clinical psychology.

Many of the tensions in clinical psychology today can be traced back through history. The position of psychology among academic disciplines and among professional rivals has been a continuing battle of borders and territory. The relationship between clinical psychology and other areas of psychology has similarly been one of growth, interchange, overlap, and jostling for position. The scope of clinical psychology practice has expanded in competition with neighbors outside and inside psychology. The identity of clinical psychology has evolved from these conflicts and debates. The results of all of these influences are manifest in the themes of education and training in clinical psychology today.

In this chapter, I will attempt to review some of the major events influencing clinical psychology in different eras of development (Reisman, 1991)—its beginning years, between the world wars, growth years following World War II and the modern years of professional expansion. I will try to extract some of the themes and issues of education and training that intertwine with the events of those eras.

2.39.1 Introduction

Clinical psychology's very roots were planted firmly in its science base, yet also in its promise as a profession responsive to a wide range of human needs. Its essential focus was initially, and remains, on psychological and behavioral aspects of human functioning. Although its earliest foundations lay in general psychology emanating from Wilhelm Wundt's University of Leipzig laboratories in the 1870s, several traditions within psychological thinking are credited as contributing significantly to the development of clinical psychology as it is known today, and, presumably, to directions it will take in the future.

Korchin (1976), writing about major influences on clinical psychology, supported Watson's (1953) earlier identification of two traditions, other than the early European experimental influence, which have had marked impact: psychometrics and dynamic thinking. Rotter (1963), while noting the contributions of experimental and theoretical psychology to clinical psychology, pointed out the significance of clinical psychologists' gradual move from working predominantly in the 1900s–1940s with children and with assessment activities (in particular, intelligence testing) to functioning more as therapists and case managers since the 1950s. Arguably, a time of clinical psychology's greatest consolidation occurred during and just after World War II, when clinical psychologists joined other health care providers in responding to the many psychological needs of America's service men and women. Indeed, several psychologists considering the history of clinical psychology (e.g., Korchin, 1976; Shakow, 1969) relate the evolution of three major professional activities carried out by clinical psychologists— diagnosis, psychotherapy, and research—to World War II's special psychological needs. Korchin referred to these three activities as the “holy trinity of postwar clinical psychology” (1976, p. 45).

Later, fueled by political and social forces of the 1960s, the community mental health movement underscored psychology's importance to public health needs. By that time, clinical psychology was well established as one of the nation's major mental health professions. Just as the Veterans Administration (VA) had been singularly instrumental in advancing the education and training of psychologists to meet service needs following World War II (continuing its support to the present), the National Institute for Mental Health (NIMH) provided major support for the education and training of mental health professionals, including clinical psychologists in the 1960s, 1970s, and 1980s (with decreasing support in the 1980s and 1990s). Accordingly, clinical psychology has been responding to major public needs since the 1940s and, no doubt, will continue its commitment to national needs and priorities in the future.

Parallel developments in education and training also reflected clinical psychology's science and professional bases as well as its responsiveness to public needs. The Boulder Conference, led by American psychologists representing the American Psychological Association, the VA, and the NIMH, was held in 1949 for the purpose of developing standards for educating and training clinical psychologists (Raimy, 1950). One of the most enduring outcomes of the conference was the establishment of the scientist-practitioner training model, a model reaffirmed in several subsequent conferences (Korchin, 1976). In 1973, the Vail Conference addressed a lingering and also growing concern about how psychology could best educate and train clinicians to be responsive to changing and increasing demands for psychological services in both public and private sectors. A central question was how to assure clinical as well as research expertise, and conference deliberations on this matter led to the recognition of a new training model, one that emphasized professional training (Korchin). This recognition did not eliminate the scientist-practitioner model, which, in fact, continues to be observed by many graduate programs; rather, it broadened the ways in which graduate programs in clinical psychology would be designed and implemented.

Since the 1960s, as indicated previously, clinical psychology, both as a science and as a profession, has been recognized as a national player in public health, especially with regard to mental health. The NIMH, for example, has identified four disciplines as essential to addressing national mental health needs: clinical psychology; psychiatry; nursing; and social work. These four disciplines have been included in NIMH's applied and training programs, and as noted above, NIMH-supported clinical training programs provided major resources for several decades to assure an available pool of mental health service providers. Clinical training funding, divided among these four mental health professionals, was at the highest level of $93 million in FY 1967; regrettably, however, that level dropped to 10.9 million in FY 92 and to 2.9 million in FY 1993 (Callan, 1993).

Clearly, national leadership on mental health needs and services has been influenced considerably by NIMH-sponsored programs and directions. In the late 1980s, for example, NIMH in collaboration with others, including professional and advocacy groups as well as educators and trainers, identified four populations whose urgent mental health needs merited special attention: (i) seriously emotionally disturbed children; (ii) the seriously mentally ill; (iii) ethnic minorities; and (iv) the elderly. Clinical psychology was a central player in the series of conferences held between 1988 and 1992 on the education and training of health care providers for these particularly needy groups.

The mental health challenges of these groups, along with numerous other public problems, constitute a broad array of national needs to which clinical psychology has relevance. Arguably, they are apparent in all major human and social systems: in government, education, health, law and justice, transportation, environmental and community safety, communication, and in the worlds of work, art, and play. Individuals, families, and communities face myriad challenges in everyday living, ranging from meeting basic needs for food and shelter to higher order ones related more to quality of life. When special problems such as those of the underserved, under-represented, or the otherwise needy are also considered, the complexity and urgency are almost overwhelming. Identifying and addressing priorities among them, especially in the context of an increasingly complex and diverse society, are daunting tasks. Moreover, effectively responding to them on a national scale will certainly require the knowledge and skills as well as the caring of many. Not only must clinical psychology play a leadership role in this response, it must become an active, ongoing partner with other psychologists, other professions, and the public.

2.05.8 Conclusion

The field of clinical psychology can contribute greatly to reducing the burden of mental health conditions around the world. The science-based approaches developed and refined within clinical psychology provide an opportunity to prevent, identify, and treat mental health conditions (Rozensky, 2013). Providing multiple levels of education and training in the practice of clinical psychology extends the reach and benefits of science-based psychological services, increasing equitable access to mental health care. As the US begins the process of accrediting master's level programs in clinical psychology, there is also an opportunity to redefine the doctorate in light of the master's degree, and to standardize the full spectrum of education and training in clinical psychology across the world.

4.01.9.4 The Clinician as a Clinical Instrument

Clinical psychology has never been completely clear about whether it wishes to distinguish between the test—a tool—and the test-in-the-hands-of-a-user. The perspective of standardized testing implies that the test is a tool that, in the hands of any properly trained user, should produce the same results for any given examinee. Many clinical instruments, however, cannot be considered to be so tightly standardized, and it is to be expected that results might differ, perhaps even substantially, from one examiner to another, even for the same examinee. Within reason, at least, an examinee's performance on a vocabulary test or a trail-making test should be little affected by the characteristics of the examiner, nor should the scoring and interpretation of the performance. By contrast, an examinee's responses might be affected to a considerable degree by the characteristics of an examiner administering a Rorschach or a TAT, let alone the interpretation of those responses.

The field of clinical psychology abounds in tales of diagnostic acumen of marvelous proportions manifested by legendary clinicians able to use the Rorschach, an MMPI profile, or some other instrument as a stimulus. Unfortunately, no such tales have advanced beyond the bounds of anecdote, and none of these legendary clinicians appears to have been able to pass along his or her acumen to a group of students—let alone passing it along across several generations. Consequently, if clinicians are to be part of the clinical assessment equation, then it seems inevitable that individual clinicians will have to be validated individually, that is, individual clinicians will have to be shown to be reliable and valid instruments. That will not further progress in the field.

10.02.12 Summary

Clinical psychology has suffered from an ethnocentric approach blinded by culture-bound assumptions. Early research in cross-cultural psychopathology was borrowed from cultural psychiatry which has focused its interest on the identification of culture-bound syndromes. In this chapter, an alternative approach to study the interplay of cultural dynamics in the manifestation of these “culture-bound syndromes” is illustrated through the discussion of Koro, neurasthenia, and somatization. The transplantation and transformation of neurasthenia from a Western diagnostic category to a culture-related syndrome in Chinese societies demonstrate the fluidity of diagnostic labels in incorporating cultural meanings. By reexamining somatization as an illness experience and narratives of suffering, a more useful framework for studying the relationship between culture and psychopathology is also identified.

Culture affects psychopathology by producing stress, creating specific problems, predisposing vulnerability, and selecting the form of psychopathology. It also provides folk explanations of the nature and cause of aberrant behavior. Earlier research methods have adopted either the emic or the etic approach. The emic approach focused on the relativistic aspects of culture such as culture-bound syndromes. The etic approach, on the other hand, assumes that Western-based constructs are applicable in other cultures and attempts to replicate these constructs in cross-cultural studies. Recent studies attempt to incorporate the emic–etic approaches. For example, the development of an emic–etic instrument such as the CPAI has introduced new dimensions of the personality structure to Western models of psychopathology. Other work such as that by Draguns (1989) are uses multicultural studies to formulate functional relationships between cultural characteristics and psychopathology. These new developments have pointed to the importance of the interpersonal dimension in psychopathology which has often been neglected in Western models of psychopathology. Future directions for study in cross-cultural psychopathology need to bring culture from its marginal status into the mainstream of clinical psychology.

7.20.11.4.1 Development of clinical geropsychology

Clinical psychology with older people has had contrasting histories in the two countries. In the UK, in the 1960s and 1970s contact of clinical psychologists with older people concerned assessment, usually to attempt to answer the depression vs. dementia question. Very few psychologists specialized in aging. This changed during the 1970s when a small group developed a special interest in the field and explored a much broader range of roles, including treatment approaches to depression and dementia. By 1980, a formal interest group was formed and membership has continued to grow dramatically. The training of all clinical psychologists in the UK now requires experience in working with older adults, which includes working with people with depression and dementia and with family caregivers.

In the US, specialization in aging within clinical psychology developed later and more slowly. The first meeting on training psychologists to work with the elderly was held in 1981 (Santos & VandenBos, 1982). A follow-up conference in 1992 provided mixed impressions of the growth of the specialty during the 1980s (Knight, Santos, Teri, & Lawton, 1995); university-based training showed little expansion although internship training, especially in the Veterans Affairs hospital system, had expanded (Cooley, 1995). The national organization for clinical geropsychology in the US was formed in 1992 (Knight, Santos et al., 1995). Training for psychologists in aging is not widespread in the US and not a requirement for all psychologists as in the UK. The training models in the US emphasize university teaching and research, Veterans Affairs or university medical center employment, or independent practice as eventual employment opportunities in clinical psychology. Training and working within community-based mental health programs has been relatively ignored, except for the use of community practica in training geropsychologists (Qualls, Duffy, & Crose, 1995). Few psychologists with expertise in clinical geropsychology are found in community settings (Knight, Rickards et al., 1995; Qualls et al., 1995). Psychologists in the US are also facing increased competition from master's level providers not identified with psychology (e.g., clinical social work, marriage and family therapists). These other mental health professionals are employed as a less expensive provider of psychological services, especially under managed care approaches.

Training programs need to rethink their goals to train psychologists for the jobs of the twenty-first century. Clinical geropsychology tends to be progressive in its emphasis on the interface between medicine and mental health, between social services and mental health, and placing psychologists into nontraditional settings. The future of clinical geropsychology depends upon developments in public policy and in the management of health care services over the next several decades. Certainly, it would be helpful for clinical geropsychologists to study the successes and failures of colleagues in other countries.

2.36.1 Introduction

Clinical psychology has flourished over the past two decades. The number of psychologists in the health service provider subfields has tripled during this time, from approximately 20 000 in 1975 to almost 70 000 by 1995 or about 2500 new doctorates in the health service provider subfields each year (National Science Foundation [NSF], 1996). Equally striking are changes in the “face” of professional psychology. In the 1970s, a newly minted doctorate in clinical psychology would have been white, male, and in his late twenties. More often than not he would have earned a Ph.D. and would be headed, after licensure, toward academic employment or into independent practice. In contrast, today the new doctorate is likely to be a woman and white, although the representation of persons of color has inched up over time. Graduates today are somewhat older than their colleagues two decades ago, with the median age of new Ph.D.s in 1995 at just over 33 years (Henderson, Clarke, & Reynolds, 1996). Increasingly, new graduates may have earned a Psy.D. degree. The new doctorate is less likely to find as many opportunities for academic employment and independent practice as was the case in the 1970s. In fact, clinical psychology may be faced with some tough decisions as it heads toward the twenty-first century, finding work in a system that is searching for the means to confront worsening social problems in light of shrinking financial resources and shifting national priorities.

This chapter begins by discussing the current supply of clinical psychologists and attempts to answer the question “How many are there?” For the most part, this chapter focuses on doctoral-level psychologists, and in some cases, due to limitations of a vailable data, is forced to narrow its focus further on Ph.D. psychologists. However, no discussion of supply or demand can occur without some reference to the supply of master's-level psychological personnel or to the supply of professionals in mental health fields outside psychology.

The next section addresses the demographic characteristics of clinical psychologists, including the gender, racial/ethnic distributions, age, and types of degrees. One of the largest shifts, that of the changing gender composition or the gender “tip” and the implications for the field is given particular attention.

The third section of this chapter presents information about the employment and geographic distributions of clinical psychologists in the USA. What are clinical psychologists doing, in what types of settings and where?

Fourth, the issue of supply and demand is raised. The question of balance is not reducible simply to provider–client ratios but must consider the many recommendations that have urged psychologists to “shift and expand their focus” (Fox, 1994); look at “systems of delivery” (Kiesler & Morton, 1988; Schneider, 1990); explore a “universe of alternatives” (Sarason, 1981); and conduct a “cognitive reappraisal” (Humphreys, 1996). Discussion is worthwhile and, ultimately, encouraging.

The final section incorporates information on the social, economic, and legal milieus in which psychology is embedded and to which the field must respond, and suggests possible future directions for this major subfield of psychology as it moves into its second century. The chapter concludes with a short summary.

2.18.11 Summary

Clinical psychology training in Australia is entering an exciting phase of its development. The number of programs has increased dramatically and new types of degrees have burst on to the scene. Australia now has a larger number of programs and diverse offerings that are characterized internationally by a strong emphasis on research training. The APS has developed its accreditation principles and processes to the point where they could have an important influence on clinical training, and the advent of mandatory professional development will impact on postqualification clinical training. State and territory legislation related to registration of psychologists needs revision to keep pace with these developments but there are encouraging signs that this process has begun.

The above developments will lead to many challenges. How will an adequate number of clinical supervisors be found given the contraction of the public sector on the one hand and the increased number of trainees needing supervision on the other? Who will employ the expanded group of graduates from these programs? Will the increased financial pressures on students encourage training programs to make changes that will attract students but have detrimental effects such as minimizing training in areas associated with great social need but low financial rewards for clinical psychologists?

The 1990s have been characterized by marked change for clinical training in Australia. The next decade will be even more interesting.