HOW A CLINICAL PSYCHOLOGIST THINKS:Brianâ€™s Case; an example, PREDICTION

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Clinical Psychology (PSY401)

Lesson 03

HOW A CLINICAL PSYCHOLOGIST THINKS

Although the science and the practice of clinical psychology may sound different, they are linked by a

common way of thinking about people and the problems they experience. A series of four tasks are

central to how clinical psychologists think about people and problems, whether in generating research

and knowledge for the field as a whole or for gaining a better understanding of a given individual.

These tasks are:

1. Description,

2. Explanation,

3. Prediction, and

4. Change of human functioning.

1. Description

Accurate understanding of any individual or any psychological problem begins with a careful

description of the person and the contexts in which she or he lives. In individual cases this description

includes attention to the nature of the person's current functioning as well as a careful documentation of

his / her prior development.

In the broader field of clinical psychology, this description includes the development of systems for

classification or categorization (taxonomies) of problems that are considered the subject matter of the

field, the development of sound tools for the measurement of these problems, and documentation of the

prevalence of these problems.

Brian's Case; an example

Imagine that you are working as a clinical psychologist, and an adolescent is referred to you for help.

Brian is 16 years old. Approximately one year ago his parents went through a very difficult divorce.

Following his parents' divorce, Brian, his mother, and younger sister moved to a new town in order for

his mother to begin a new job and for the family to try to "start over". Because Brian's father did not

provide regular financial support, the family was faced with significant economic difficulties as they

tried to get by on his mother's salary. Brian did not adjust well either to his parents' divorce or to the

move to a new school and town. He had difficulty making new friends at school and became

progressively more withdrawn and lonely. Three months before coming to see you, Brian became

severely depressed and made a serious, but uncompleted, suicide attempt.

You are faced with a number of important questions in your initial meetings with him. Is there a specific

pattern of behaviors, thoughts, or feelings that characterize the difficulties that Brian is experiencing?

Are these problems unique to him, or are they similar to difficulties experienced by other people?

After some initial information has been obtained about a person, clinical psychologists must formulate a

series of questions to systematically gain more information. These questions should be guided by a

sound theory of human behavior and by research findings regarding the problems of the individual

client.

The questions may include the following:

What are Brian's strengths and competencies?

In what areas of life has he been successful?

What aspects of life are satisfying to him?

What are his future plans (regarding his suicidal tendency)?

Clinical Psychology (PSY401)

Answers to these questions are part of the task of developing a careful, detailed description of the scope

and nature of Brian's problems, his strengths and capabilities, and the environment or context in which

he lives.

Clinical science is concerned with identification of patterns of problematic behaviors, emotions, and

thoughts that can be carefully and reliably documented in more than one point in time. Accurate

description is dependent on tools for reliably measuring the behaviors, thoughts, and feelings of

individuals. The most important observations and descriptions are those that focus on consistent patterns

of problematic behaviors across individuals and within the same individual over time. For example, is

Brian representative of a large group of individuals who display a similar pattern of behaviors? If it is

the case, such description places Brian's problems into a broader context of the nature of depression

during adolescence.

2. Explanation

Description of an individual or a psychological problem is not adequate for complete understanding of

that person or problem. It is imperative that clinical psychologists develop careful models to explain

how or why the problem developed, either in an individual or in people in general.

This task includes the development and testing of models of etiology or cause, including but not limited

to the use of experimental methods to test causality. The explanation enterprise of psychological science

and of psychological practice involves the generation of hypotheses about an individual or a problem,

hypotheses that can then be carefully and rigorously tested.

Why did Brian attempt to take his life? Why has he sunk into a behavioral pattern in which he is

overwhelmed by daily responsibilities and feels that he has lost control over his own life? These

questions lead to an answer: "because of his parents' divorce". But this answer again leads to more

general questions such as "what are the psychological consequences of the parental divorce and the

losses and stresses that are associated with divorce?" and "what is the relationship between such a loss

and later depression, suicidal ideation, or suicide attempts?"

The answers to these questions lie beyond information that you can obtain by examining a single case

such as Brian's. Here you must turn to the broader science of psychology for an explanation of the

problems that Brian is experiencing. From here, the process of research begins, that attempts to focus on

all possible dimensions of the problem. For example, what are the consequences of parental separation

and divorce on the psychological functioning of the children and adolescents? Are the effects of divorce

long term or short term? Are there other factors (biological, environmental, etc.) associated with this

problem? And so on.

The clinical psychologists develop explanations of problematic behavior using these questions as

guidelines for research. They may explain psychological problems emphasizing the role of biological

factors, cognitive schemas and networking, conditioning and learning processes, interpersonal

relationships, and an integration of one or more of these factors.

3. PREDICTION

The most stringent and necessary test of any explanation is to see if it leads to predictions that are

supported by empirical research. The importance of prediction, like description and explanation, is

evident in the work of psychologists helping individuals as well as in the work of clinical researchers

trying to understand a problem in the general population. Prediction is possible only through repeated

observations in which conditions are either controlled or well understood.

As you treat Brian's depression, you must try to predict the course of his symptoms in the initial weeks

and months of his treatment. He has made an attempt to take his own life, and you must make a

judgment about the likelihood that he will make another suicide attempt. What factors would be useful

Clinical Psychology (PSY401)

in trying to predict subsequent suicidal thinking or attempts? Even if he does not make another attempt

on his life, you must make a prediction about the likely course of his current problems. Are these

problems likely to continue? Will they remit on their own, or is psychological treatment or medication

necessary? Are there certain psychological treatments that are likely to be effective in treating his

depression?

In research, prediction is tested in two ways: (a) longitudinal studies of the course of problems as they

occur in real life; and (b) experimental studies testing specific predictions or hypotheses under

controlled circumstances. In both methods, the goal of clinical psychologist is to try to identify cause-

and-effect relationships regarding important clinical problems.

4. CHANGE

Because clinical psychology involves the application of psychological knowledge to alleviate human

problems, it is not enough for clinical psychologists to describe, explain, or predict human functioning.

Clinical psychologists must also be concerned with producing change in people's lives. Specifically,

clinical psychologists develop and carry out planned and controlled interventions for the treatment and

prevention of psychopathology, for coping with and prevention of some forms of physical illness, and

for the promotion of psychological and physiological health. Facilitating change is a goal of researchers

and practicing clinicians alike.

Efforts to change people's lives must be based on research evidence that allows the clinician to make

reasonable predictions about the effects of specific interventions. For example, what should you expect

if you encourage Brian to discuss his feelings, including both his sense of sadness and his feelings of

anger, about his parents' divorce? Is this discussion likely to lead to meaningful and lasting changes in

his behavior, thoughts, and emotions? Alternatively, what is likely to happen if you systematically

encourage and reward Brian for increasing his involvement in pleasant and constructive activities

involving school, sports and friends? Will making changes in his behavior be sufficient to alleviate his

deep feelings of loss related to his parents' divorce? And from a different perspective, it may be

important to change how Brian thinks about his parents, about himself, and about the reasons for his

parents' divorce. If Brian learns to think about his parents' divorce in a different way, will this new way

of thinking lead to meaningful changes in his emotions and behaviors?

Clinical psychologists are concerned with developing much more than a set of techniques for helping

people change. They are committed to developing a broad set of principles to understand how and why

people change. Clinical psychologists are more than technicians who can follow a set of procedures

designed to help a person deal with a problem or change some aspect of his or her behavior.

Clinical psychologists need to understand whether certain techniques work with some people or some

problems and not others, and they need to understand the reasons that these techniques work. Without

this type of comprehensive understanding of the mechanisms of how people change, psychologists

cannot continue to systematically improve the ways that they can help people, and they may be unaware

of ways to generalize their current methods to different people or problems.

CLINICAL PSYCHOLOGY EMPLOYMENT SETTINGS

Clinical psychologists are found in a number of service settings, including the following:

General Hospitals and Medical Clinics;

Mental Health Clinics and Psychiatric Hospitals; Rehabilitation Hospitals and Clinics;

Community Service Agencies;

Private Practice;

Universities and Colleges;

Industry;

Clinical Psychology (PSY401)

The Military;

Prisons and Correctional Facilities;

Private and Government Research Agencies; and

Schools.

Research on the employment settings of clinical psychologists reveals that the most frequent

employment setting for clinical psychologists is private practice, while the university settings are the

second most common employment sites.

The following table shows the different employment sites for clinical psychologists in the United

States during year 1997.

Employment Site

Percentage in Year: 1997

Psychiatric hospital

05 %

General hospital

04 %

Outpatient clinic

04 %

Community mental health center

04 %

Medical school

09 %

Private practice

40 %

University settings

19 %

Other settings

11 %

PRIVATE PRACTICE

About 40% of clinical psychologists work in solo or group private practices. As a private practitioner,

the clinical psychologist offers certain services to the public, as much as a dentist or general medical

doctor does.

Office hours are established and patients (i.e. clients) are seen for assessment, diagnosis and

psychotherapy. Fees are charged for services rendered.

Many psychologists are drawn to independently providing direct clinical, consultation and other

professional services to their clients and enjoy being their own boss and setting their own hours and

policies. Research supports that, private practitioners report more job satisfaction (Norcross&

Prochaska, 1983; Norcross, Karg & Prochaska 1997a) and less job stress than other psychologists.

COLLEGES AND UNIVERSITIES

About 20% of clinical psychologists are employed in academic environments (American Psychological

Association, 1993a). Most of these psychologists work as Professors. They generally teach psychology

courses, supervise the clinical and or research work of psychology students and conduct both

independent and collaborative research.

They also typically serve on various college or university committees, providing leadership and

assistance with the academic community. Some clinical psychologists work in academic clinical

settings, such as student counseling centers, providing direct clinical services to students.

HOSPITALS

Clinical Psychology (PSY401)

Many clinical psychologists work in hospital settings. They may conduct psychological testing, provide

individual, family or group psychotherapy act as a consultant to other mental health or medical

professionals on psychiatric or general medical hospital units, and may serve in administrative roles

such as unit chief on a psychiatric ward.

Many states now allow psychologists to become full members of the medical staff of hospitals. In

California, for example, psychologists are allowed to have full admitting, discharge and treatment

privileges which allow them to treat their patients when they are hospitalized and to participate in

hospital committees.

MEDICAL SCHOOLS

Clinical psychologists serve on the faculties of many medical schools. They typically act as "clinical

faculty", which generally involves several hours (i.e., two to four) per week of pro bono time

contributed to the training of medical center trainees. These trainees might include psychiatry residents,

other medical residents (e.g., pediatric residents), medical students, nursing students or non-medical

hospital trainees such as psychology interns or postdoctoral fellows, social work interns, nursing

students etc.

These psychologists might conduct seminars & workshops or provide individual case supervision and

consultation. Psychologists may also serve as academic or research faculty at medical schools.

OUTPATIENT CLINICS

Many psychologists work in various outpatient clinics such as community mental health centers. These

psychologists often provide a range of clinical services to other professionals and organizations.

For example, these psychologists might provide psychotherapy for children who have been abused or

group therapy for adult substance abusers. They might also provide parent education classes. While

psychologists in these settings may conduct research, direct clinical service is often the primary activity

and priority of these settings.

BUISNESS AND INDUSTRY

Many clinical psychologists working in business and industry settings offer consultation services to

management, assessment and brief psychotherapy to employees, and conduct research on various

psychosocial issues important to company functioning and performance.

For example, these psychologists might consult with the human resource department, provide stress

management workshops, or conduct interpersonal skills building workshops. Psychologists might help

managers learn to improve their ability to motivate and supervise their employees. They may assist in

developing strategies for interviewing and hiring job applicants.

MILITARY

Many clinical psychologists are employed by one of the branches of the military such as the Navy, Air

Force, or Army. They often provide direct clinical services. Some conduct research while others act as

administrators in military hospitals and clinics. Psychologists also act as civilians working in military

hospitals. Typically psychologists working in the military hold an officer rank such as captain.

FORENSIC PSYCHOLOGIST (PRISON AND PROBATION SERVICES)

Forensic psychology is concerned with the behavior of individuals within the judicial and penal

systems, such as offenders, victims, witnesses, judges, juries, prisoners and prison staff. Much of the

work of a clinical forensic psychologist focuses on therapy in correctional settings where specific

activities include:

Clinical Psychology (PSY401)

a) Carrying out one-to-one assessments - often to assess the risk of re-offending) or to assess the risk of

suicide or self-injury;

b) Developing and evaluating the contribution of assessment techniques such as psychometrics;

c) Undertaking research projects to evaluate the contribution of specific service elements, policy

initiatives or group program developments, e.g. exploring probation 'drop-out' rates or evaluating a

group program;

d) Participating in the delivery of, or acting as coordinating 'Treatment Manager' for, nationally

recognized cognitive-behavioral group programs, e.g. Enhanced Thinking Skills or Sex Offender

Treatment Program;

e) Overseeing the training of prison/probation service staff.

f) Dedicating time to the preparation of court reports.

OTHER LOCATIONS

This category includes

Professional schools

Correctional facilities

Managed care organizations

Nursing homes

Child and family services

Rehabilitation centers

School systems

Health maintenance organizations and so on.

PROS AND CONS OF A CAREER IN CLINICAL PSYCHOLOGY

Some key points to consider in support of Clinical psychology:

Personal Fulfillment Working with and helping clients can bring a great deal of personal satisfaction.

Making a Difference Unique feelings come when you see a client make changes in their lives because

you have helped them.

Being Your Own Boss In private practice, clinical and counseling psychologists are often their own

bosses and set their own hours.

Changing Environment Each client provides different and interesting information about himself or

herself; therefore, the psychologist is rarely bored from doing routine work.

Learning Experience Clients' diagnoses and therapeutic plans tend to be at least somewhat unique,

providing ongoing learning opportunities.

Some cautions

The education and training is very demanding and prolonged.

There are cases when treatment may produce little or no improvement in the client's condition.

Paperwork associated with each client requires enormous care. Health insurance companies alone

require a lot of detailed documentation about clients.

Clinical Psychology (PSY401)

CONCLUSION

Clinical psychologists are unique from other mental health professionals in their provided services,

service settings, populations seen, and knowledge base.

Populations Seen

Clinical psychologists work with a broad range of populations, including the following: individuals

(infants, children, adolescents, adults, and the elderly); couples (regardless of gender composition);

families (traditional, multi- generational, and blended families); groups; organizations; and systems.

Service Settings

Clinical psychologists are found in a number of service settings, including the following: General

Hospitals and Medical Clinics; Mental Health Clinics and Psychiatric Hospitals; Rehabilitation

Hospitals and Clinics; Community Service Agencies; Private Practice; Universities and Colleges;

Industry; the Military; Prisons and Correctional Facilities; Private and Government Research Agencies;

and Schools.

Services Provided

The typical services provided by clinical psychologists include: assessment and measurement;

diagnosis; treatment; consultation: teaching and supervision; policy planning; research; program

evaluation; and, administration.

Knowledge Base

The knowledge base within clinical psychology is so broad that no individual clinical psychologist can

become competent in all areas of clinical psychology. Therefore, clinical psychologists must function

within the specific limits of their competence (i.e., knowledge and expertise), and are expected to

clearly acknowledge the limitations of their scope of practice. Clinical psychologists are responsible for

referring to others (either within or outside the area of clinical psychology) when they are faced with a

task outside of the limits of their knowledge and skill.

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