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Clinical_Psychology_in_Practice_----_Pg_19--63.pdf
Part I
Introduction
Philosophical, Practical and Ethical Underpinnings
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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Introduction
The profession of clinical psychology has grown exponentially over the past 50 years and, as this book will show, has demonstrated its value in a wide range of clinical contexts, thereby proving itself able to make a unique and important contribution to health and social care across the lifespan. It has developed from its origins in child guidance and the provision of psychological assessment in psychiatric settings to become an independent profession providing treatment and advice to clients, carers and services in a wide range of settings including primary care, social services, and secondary and tertiary care, as well as specialist services such as forensic units, palliative care and physical rehabilitation services.
This book presents an introduction to the essential features of the work of clinical psychology in practice, and demonstrates how clinical psychologists apply their knowledge and skills in a wide range of specialist settings. It is intended that this book will be of interest to both pre- and post-qualification clinical psychologists and also to a wider audience, and will remind all its readers of the value of the particular synthesis of theory, practice, a strong ethical base and commitment to the worth of people and evidence that the discipline represents. In line with social, political and academic developments, this book will also show how much further there is still to go in ensuring that the psychological is truly embedded in health and social care, par- ticularly in the UK. Hence, the book raises questions about the future, and how important it is both that research continues to broaden and deepen the discipline theoretically and also that services continue to develop that enable users or carers in health and social care to have access to good quality psychological input, across the lifespan.
1
The Key Elements of Clinical Psychology Practice
Susan Llewelyn, Helen Beinart and Paul Kennedy
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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4 Susan Llewelyn, Helen Beinart and Paul Kennedy
Clinical Psychology and How People Are Understood: Conceptual Models
Whilst medicine conceptualises the person primarily as a biological entity, albeit with emotions and thoughts, and the law thinks of people primarily as legal entities with rights and obligations, absolutely central to clinical psychology today is the notion of the person as a holistic, meaning-seeking body living within a particular social context. This approach, sometimes described as the biopsychosocial, indicates that each individual is best understood in terms of their psychological functioning and their physical and developmental history, but should also be understood in terms of the social context in which they live. The theoretical and empirical foundations of clinical psychology originated within empirical psychology, in academic centres and univer- sities, where behavioural and subsequently cognitive models and approaches were dominant. When applied in the health context, these models fit reasonably well with an individualist medical approach, and have remained the dominant models. A more sys- temic approach has nevertheless been a consistent strand within the discipline, and community-based models have been developed which draw upon social conceptualisa- tions of the person and their distress. Psychodynamic and interpersonal models have also played a significant part. Other important influences from psychology as an academic discipline include developmental psychology, personality psychology and neuropsychology. Nowadays most psychologists work in an integrated way, calling flex- ibly on a variety of models, all more or less subsumed within the biopsychosocial understanding of the person. Indeed, clinical training is deliberately generic, enabling the competent clinical psychologist to access and apply a variety of models as appropri- ate to the needs of the client or situation, in a range of settings, across the lifespan and with a range of presentations.
Although a multitude of approaches are used in clinical practice, the dominant models will now be examined in a little more detail. The behavioural model has his- torically played a highly significant role in the development of the discipline, and con- tinues to be influential. Behavioural approaches focus primarily on changing current behaviour, and de-emphasise internal events and subjective experience. They are based on the premise that human behaviour, including various patterns of psychopathology, is learned and thus can be modified by new learning, or relearning of old patterns of behaviour. Both classical conditioning (Pavlov) and operant conditioning (Skinner) models have been applied to clinical practice (see Eysenck, 1976; Kanfer & Goldstein, 1980; O’Donohue & Krasner, 1994). Assessment and treatment aims to understand and manipulate the cues or antecedents that elicit behaviour, and the consequences or ‘rewards’ that follow it. Clinical psychologists were influential in the early application of behavioural theory and principles to a range of clinical problems. These included token economies (Allyon, 1999) for long-stay psychiatric patients, social skills training (Hollin & Trower, 1986), acquisition of speech, specific behaviours and skills in those with learning disabilities (Yule & Carr, 1980), and treatment of childhood conduct problems and parent training (Herbert, 1981). Behavioural models still flourish and
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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The Key Elements of Clinical Psychology Practice 5
are widely applied, particularly in work with children, parents, those with learning disabilities and in neuropsychological rehabilitation. Some of the core principles and strategies, for example those of reinforcement, role playing, extinction and modelling, have become embedded in everyday practice, even by those whose predominant orientation is not behavioural. Behavioural approaches continue to develop, and have recently been applied to eating disorders, psychosis, dementia care, and behavioural activation for depression, among other problems (Sturmey, 2007).
In response to behaviourism’s lack of attention to internal, mental events, the cogni- tive model has become increasingly influential, and it is now the dominant model in clinical psychology in the UK. Cognitive models focus on thinking or cognition. Cognitive events (e.g. thoughts, images) are thought to be responsible for the mainte- nance of dysfunctional behaviour and mood disturbances. Cognitive assessment and therapy thus focuses on understanding and altering the cognitions that maintain dis- turbed mood and behaviour. Ellis devised rational emotive therapy (Ellis, 1961), while Beck (1976) simultaneously developed cognitive therapy. Beck’s therapy has become particularly well known in the UK, where it is often referred to as cognitive behaviour therapy (CBT). Originally developed for depression, it has expanded to cover the range of clinical problems most typically seen by clinical psychologists, such as anxiety, trauma, obsessive-compulsive disorder (OCD) and eating disorders. It has also been adapted for use in healthcare settings, for work with children and for those with learn- ing disabilities. While much of therapy is concerned with ‘here and now’ problems, schema-focused work has also been increasingly developed (e.g. Young, 1990) in order to treat those with chronic, severe and long-standing personality problems. Therapy is formulation driven, with the construction of an idiosyncratic formulation in collabo- ration with the client. A range of cognitive and behavioural strategies can then be used to challenge or modify cognitions, including verbal restructuring and behavioural experiments.
In recent years, a number of highly specific cognitive models have been developed for a range of adult psychological problems, including panic, social phobia, bulimia nervosa and OCD (see Wells, 1997, for an overview). Some of the models and treat- ments have been manualised and also published in the form of self-help guides. These have played a key role in the development of stepped care models of service provision, with minimal interventions (e.g. self-help) being offered before more intensive inter- ventions (e.g. individual cognitive therapy). Cognitive behavioural interventions have been systematically evaluated for several disorders and shown to be highly effective (Roth & Fonagy, 2004), although, when thorough and even-handed comparisons have been made, cognitive therapy has not actually been shown to be more effective than other psychotherapies. Models for bipolar disorder, psychosis and also for personality disorders have been outlined, and preliminary treatment studies have produced encour- aging results, although further development and evaluation are needed. Guidelines in the UK (e.g. National Institute for Health and Clinical Excellence (NICE) ) and other countries strongly support the use of CBT, and a large programme to train new psycho- logical therapists (Improving Access to Psychological Therapies (IAPT) ) is under way in the UK, in order to make these therapies available to many more people.
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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6 Susan Llewelyn, Helen Beinart and Paul Kennedy
A number of other therapies also focus on cognition, many of them developed in healthcare settings to facilitate adjustment to serious illness or chronic conditions, for example coping effectiveness training (Chesney & Folkman, 1994). Specific therapies to enhance motivation, for example in those with substance abuse (Marlatt et al., 2002) or eating disorders (Geller, 2006), have been devised, with a focus on cognition. More recently, ‘third wave’ cognitive therapies have appeared, partly in response to criticisms of the proposed mechanisms of action in cognitive therapy, but also because a propor- tion of people do not improve significantly with cognitive therapy. These new develop- ments focus on both control and acceptance, and typically aim to alter the person’s relationship to their thoughts. They have been developed in a variety of formats, includ- ing mindfulness-based CBT (Segal et al., 2001), metacognitive therapy (Wells, 2008) and acceptance and commitment therapy (Hayes & Strosahl, 2004).
Psychodynamic models have as their foundation a number of fundamental principles derived from psychoanalysis. These include the belief in unconscious material, the notion of intrapsychic conflict and mechanisms of defence to master anxiety, the presence of resistance and a developmental model which gives primacy to the oedipal conflict. As a developmental model, the psychodynamic perspective holds that infancy and childhood experience is formative for the adult personality. Initially, Freudian psy- choanalytic theory was focused on unconscious desires based on the infant as primarily pleasure-seeking. However, following the advent of attachment theory (Bowlby, 1973) greater emphasis was placed on the infant’s relational capacities. The psychodynamic infant is less pleasure-seeking than seeking the relational. This has informed the ‘object relations’ (Greenberg & Mitchell, 1983) school of contemporary psychodynamic prac- tice which has given primacy to the therapeutic relationship in clinical practice with its notions of transference, counter-transference and defence mechanisms. For a contem- porary account of the use of this in current clinical practice, see Coren (2001) and Stadter (1996). There are numerous theories which can be subsumed under the over- arching psychodynamic label, but most share an emphasis on the use and analysis of the therapeutic relationship with the therapist to understand and work through the meaning of the symptom and its relation to the client’s previous developmental, rela- tional and family history. In this sense the symptom acts as a form of communication, and its relief, while desirable, is viewed as but one aspect of the treatment aims. Mutative change happens via the therapeutic relationship which, in the case of open-ended longer-term treatments, places considerable emphasis on therapist neutrality and rela- tive passive therapeutic stance, whereby the client’s difficulties are revealed via transfer- ence as if onto a ‘blank screen’. For example, a young man presenting with social anxiety, who has experienced erratic or inconsistent parenting which may make him wary of successfully establishing relationships, may approach the clinician with the expectation that a similar response is likely from the therapist and utilise a number of defensive responses to deal with this expectation which would form the focus for the treatment. Other, more short-term, focal treatments work more collaboratively with clients using the therapeutic relationship more actively to address the current difficulty and its his- torical antecedents. Although it is sometimes claimed that this approach has less research evidence for effective outcome than CBT, for example, in fact there is good
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The Key Elements of Clinical Psychology Practice 7
evidence particularly for brief time-limited therapies, such as interpersonal therapy (IPT) (Weissman & Markowitz, 1994) and psychodynamic interpersonal therapy (PIP) (Moorey & Guthrie 2003) and for the importance of the therapeutic relationship in all therapies (Lambert & Ogles, 2004).
Alternatively, the systemic model considers that people are best understood in a rela- tional context and that any individual will be shaped and will develop in relation to their family and social context. Thus relationships, communication and interaction are central to the development of identity and experience and are the key to understanding problem development. Pathology is understood as resulting from interpersonal proc- esses. General systems theory (von Bertalanffy, 1968) holds that any system is hierar- chically organised and that change at any one point inevitably leads to disequilibrium which the system will resist in order to maintain stability. A system is understood as interacting parts structured by feedback that mutually communicate and influence one another. Fundamental to systemic family therapy are the patterns that develop which connect family members in a coherent and meaningful way (described as circularity). Within circular understandings of causality each person’s behaviour is maintained by the actions of the other, thus problems are interpersonally maintained and may be shaped by broader contexts such as dominant gender or cultural roles. The epistemo- logical basis of systemic family therapy has evolved from modernism, through post- modernism to constructionism (Dallos & Draper, 2000) and a large number of specific models have been derived from this overarching model and its evolution. These include structural family therapy (e.g. Minuchin, 1974) which focuses on boundaries and deci- sion making between parental and child subsystems within the family. The more post- modern Milan approach (Palazzoli et al., 1980) uses hypothesising, circularity and positive connotation to help families shift their underlying beliefs, and sees the thera- pist as part of the system both being influenced by it and having influence upon it. Narrative therapy (e.g. White & Epston, 1990) and solution-focused therapy (e.g. Berg, 1991) are examples of therapies where experience and meaning are constructed in the stories that people tell about their lives, often influenced by multiple layers of context. Problems are understood as arising from personal idiosyncratic perceptions and meanings held by family members and the task of the therapist is to facilitate family members to explore their individual beliefs or narratives so that more positive, less problem-focused explanations can emerge. Therapy often utilises reflecting teams in order to generate many different perspectives, meanings or possible narratives. Therapy is seen as a collaborative process involving co-constructions of new ways of approaching a problem. Applications of systemic models include work with families, individuals, therapeutic letters, systemic consultation and in understanding organisations and teams. Dallos and Stedmon (2006) show how concepts such as power, influence and hierarchy are important in understanding the functioning of all organisations, no matter the size, and suggest that psychologists must factor this into both formulation and intervention.
A large number of other models and approaches are also used within clinical psychology (for example, Gestalt therapy, transactional analysis, cognitive analytic therapy), some of which will be mentioned later in this book. Many psychologists aim
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8 Susan Llewelyn, Helen Beinart and Paul Kennedy
to work integratively across several models, and some may call upon concepts from developmental models and neuropsychology or spirituality in their work. But what most of the models noted above share in common to a lesser or greater degree is the assumption that people become who they are, and have the difficulties that they have, in part because of the context in which they develop, and in part because of what the individual brings and their ability to make unique sense of that context. In order to formulate or intervene, clinical psychologists therefore need to assess in some depth the origins of people’s difficulties, their family context and their own particular psycho- logical processing, as well as to understand the contribution of any developmental, medical, biological or physical factors to the difficulty (Johnstone & Dallos, 2006). Critical to the application of all these models is the ability to apply theory to practice, and vice versa, so that the psychologist’s work is based on evidence but also contributes to the evidence base for the future. There are, of course, many similarities and much common ground between clinical psychology and other related professions, including psychiatry and psychotherapy. What particularly distinguishes the clinical psycholo- gist, however, is this combination of the use of a range of psychological models, the scientific-practitioner stance, and an embedded emphasis on reflection and ethical awareness (see also Chapter 3).
In practice, this means that clinical psychologists need to take enough time and resources to assess people in some depth prior to reaching an adequate understanding of their difficulties, and in some cases may use detailed standardised measures to assist in the process. Their ability to conduct a thorough assessment means that the resulting formulation can be complex, and relatively time-consuming. Clinical psychologists will normally seek to address a wide range of issues, many of which may be ambiguous, and may need to call on a diverse range of theoretical understandings by which to make sense of what is presented, in order to contribute most effectively.
Clinical Examples
A good clinical example might be a man who is the survivor of a car accident in which he received a closed head injury, and who is finding it hard to readjust to work and family life post-injury. While the injury itself has physical consequences, with brain lesions linked to difficulties in memory and intellectual functioning, this will probably be compounded by a range of other factors which may well be more significant than the extent of the injury in determining the success of his recovery. These factors include the nature of his interpersonal relationships prior to the injury; the quality of support provided by his spouse and the attitude of his employers; the circumstances of the acci- dent and whether or not the man has experienced any post-traumatic distress; the man’s personality and history which will in part determine his own emotional reaction; and the man’s own attitudes and appraisal of the significance and meaning of what has happened, that is, whether he sees it as a disaster with no opportunity for rehabilitation and growth, or whether he is able to build on personal and other resources to react as positively as possible to the circumstances. All these factors will vary from person to
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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The Key Elements of Clinical Psychology Practice 9
person, which means that although broad trends can be expected in how people react to such events, large differences also occur which need to be assessed and understood. The theoretical models which may need to be drawn upon in this work might include models of coping, post-traumatic stress disorder (PTSD), neuropsychological models and an understanding of brain–behaviour links, interpersonal relationship models and cognitive models which together can build an understanding of this man’s situation and how best to intervene to help him.
Another example might be a 15-year-old girl presenting to services with depression and an eating disorder. Here it is necessary to understand both the nature of her depres- sion and the eating disorder, what triggered and maintains them both and how they relate to each other, as well as understanding her developmental stage and relationships and her current physical condition. It is likely that an adequate formulation would also need to take account of early life experiences, family relationships and circumstances, sexual and emotional development, any cultural issues and any significant life events, as well as cognitive/emotional attitudes and appraisals. A full understanding would probably only develop over time, and would probably be modified as the intervention progressed. It is also likely that the psychologist would work together with other profes- sionals, or the girl’s family. Models or theories that might be relevant here include cognitive models of eating disorders and depression, risk assessment, adolescent devel- opmental models, family systems, peer relationships, psychodynamic issues and cultural perspectives. Interventions might draw upon studies of effective treatments which relate to the chosen explanatory models, while the ability to work with and to appreciate the roles of other professionals such as psychiatrists, dieticians and family therapists would also be essential.
Key Qualities of Clinical Psychologists
It is possible to identify at least five equally important key qualities that characterise an effective clinical psychologist. First is an understanding of theory and research. The range of models and theories which may apply in the face of clinical complexity means that clinical psychologists need to have a good grasp of theory and evidence from within the base discipline of psychology. There is therefore a requirement that all clini- cal psychologists prior to training have a first degree in psychology, because the funda- mental approach to people is psychological, that is, it concerns how people function in terms of making sense of and processing their experiences (cognition), as well as how they react to those experiences (emotion, motivation, personality) and what influences them (social, developmental, biological and environmental factors). The clinical psy- chologist applies those understandings to solve problems in practice, using evidence and theory. The point of theory is that it guides the practitioner, and tells the practi- tioner what is likely to be going on and what is likely to work. Clinical psychology has historically positioned itself as a science-based discipline, espousing the scientific- practitioner model in training (Hall et al., 2002; and see also Chapter 3 of this book), which has meant that the aspiring clinical psychologist has had to possess a number of
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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10 Susan Llewelyn, Helen Beinart and Paul Kennedy
academic and research competencies. The current dominance in clinical practice of the therapeutic role for psychologists sometimes outweighs the scientific, research-based role; nevertheless the government’s emphasis on evidence-based practice, clearly favours the scientific stance of the profession. Hence although sometimes somewhat obscured by the exigencies of immediate clinical practice, a key quality of clinical psychologists must be their ability to utilise a broad and evidence-based psychological understanding of how people function. Related to this is their competence in applied research methods: indeed, clinical psychology provides the highest level of pre-qualification clinical research training in the UK.
The second key quality for clinical psychologists is the ability to make positive work- ing or therapeutic relationships with clients, carers or colleagues. Having emphasised the scientific and research-based competences of clinical psychologists, plenty of evi- dence also suggests that in addition to being able to draw on a range of conceptual models, and evidence about what works for whom, delivery of treatment relies very crucially on the ability of the psychologist to make good relationships with the recipi- ents of services, since psychological techniques are delivered in large part through the personal qualities of the psychologist. It is now broadly accepted, for example, that although specific theoretically based techniques do play a significant role in bringing about change in psychological therapies with adults with mental health difficulties, a large part of the variance in outcome studies can be explained by the quality of the therapeutic relationship (Lambert & Ogles, 2004; Lambert, 2007). It is, of course, neither possible nor appropriate for psychologists to attempt to deliver therapeutic relationships without techniques, and indeed specific techniques have been demon- strated to be important factors when working with specific disorders; nonetheless, the quality of the relationship between psychologist and client is both the foundation and the medium for therapeutic work. As a further example, attention specifically paid to therapeutic relationship issues following a rupture or breakdown in therapy, however minimal, leads to substantially improved outcome (Bennett et al., 2006), supporting the centrality of the personal interaction between psychologist and client in determin- ing effectiveness.
The ability to make good professional relationships requires a number of personal qualities, including the ability to listen to another person, to attempt to understand them in their own terms, to respect diversity and difference, and to communicate clearly. The value base of the profession is critical here, since a commitment to the importance of each unique individual is needed if genuine and open communication is to take place. Arguably the key tool that psychologists use in their work is their ability to influence or facilitate people to think or behave differently.
Clearly linked with this is the third key quality, an ethical approach to professional work, whereby psychologists’ ability to influence is used for the benefit of the client or colleague who seeks help or advice. All Chartered Clinical Psychologists are required to act according to the British Psychological Society’s Code of Ethics and Conduct (2005a), which promotes high standards of conduct based on the notion of ‘ethical thinking’. This document promotes an appreciation that ethical dilemmas are often complex and call for thoughtful judgements based on ethical standards, whilst also recognising that
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Beinart, H., Kennedy, P., & Llewelyn, S. (Eds.). (2009). Clinical psychology in practice. John Wiley & Sons, Incorporated. Created from brenauuniv on 2023-09-25 05:56:36.
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The Key Elements of Clinical Psychology Practice 11
there are often contextual and cultural constraints and assumptions that influence what we do and believe. Nevertheless, it also enshrines a commitment to the importance of respect for persons and evidence, and to the need for psychologists to act with integrity, primarily in the interests of the recipients of their services (see Chapter 2 for more detailed discussion).
Most health and social care is delivered through teamwork and collaboration (Health Care Commission, 2006), hence the ability to understand and work constructively with groups and colleagues is critical. This can be seen as the fourth key quality. Since clini- cal psychology as a profession is very small in comparison with other professions such as medicine and nursing, one significant way of increasing the impact of clinical psy- chological knowledge and techniques is to work through other professional groups via teaching and consultancy and being involved in multidisciplinary teams. A number of writers, for example Ovretveit (1997) and West (2004), have described the factors which promote effective team working, including trust, positive leadership, organisation, having clear objectives and role clarity. Ideally psychologists should be able to work to enhance these factors. A critical understanding of the downside of group functioning, such as group think, stereotyping, conformity and inter-group conflict, can also be helpful, since these factors can impede good team working if not checked. Awareness of group dynamics can therefore be seen as crucial (see also Chapter 30).
The final key quality is that of a reflective practitioner, who is able to think carefully and creatively about his or her professional work. Lavender (2003), drawing on the work of Schön (1987), has distinguished four types of reflection: reflection in action (where, for example, the psychologist is able to respond flexibly to a client’s particular needs); reflection on action (where, for example, the psychologist may reformulate a problem after discussing it in supervision); reflection on others (where, for example, the psychologist would consider the impact their particular gender or culture might have on a service user); and reflection on self (where, for instance, the psychologist might think carefully about how to mitigate the impact of working with sex offenders on their own sexual functioning). All these components of practice are needed for effective professional work and are implicated in ethical practice, besides contributing to the ongoing improvement of the psychologist’s own professional work. A key com- ponent here is a commitment to ongoing supervision, and the willingness to subject one’s own work to scrutiny and thought (see Chapter 28).
The Complexity of Clinical Problems
In essence, as shown in the two brief case examples above, clinical psychology is both multimodal and tailor-made in its approach to individual predicaments. Thus the practitioner has to attempt to understand and respond to the complexity of psycho- logical problems, which often necessitates making use of a multiplicity of approaches when formulating and intervening. The psychologist is, however, also a practitioner operating in real time, and hence may often have to be pragmatic and act on incom- plete evidence. Pisek and Greenhaigh (2001) suggest that most problems in health and
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12 Susan Llewelyn, Helen Beinart and Paul Kennedy
social care are complex, where change at one level will inevitably affect another, and where coordinated skills and knowledge are almost always required. They argue, however, that we may spend too much time trying to apply complex solutions, and that sometimes we should just aim for ‘good enough’ solutions. Certainly many psycho- logists are aware that they do not always have a very sound evidence base for everything they do, and that many clinical problems do not fit neatly into textbook or research categories. It is here, however, that the creativity of the profession is needed, whereby the practitioner makes use of what evidence there is, applying it as a flexible scientist- practitioner to new and untried contexts or problems. An example might be applying a CBT model developed with adults to a child presenting with similar issues, but adapt- ing the model for use in the new context. Overall there is a clear need to promote trans- lational research and to engage in studies that refine laboratory-based work for clinical application.
One critical source of the complexity inherent in most clinical problems is the importance of context in determining and maintaining people’s clinical difficulties. Appreciation of the crucial role of social and cultural issues is sometimes difficult to hold on to when focusing on individual clinical problems. Yet individuals do not live in a vacuum, and as the systemic model suggests, one of the major determinants of health problems is the social context in which people live. Smail (2005) suggests that we are often blind to macro-forces such as global economic interests and consumerism which have major and often destructive impacts on our lives, focusing instead on our own, or our clients’, apparent inadequacies. Issues such as social class and comparative wealth, status and power are often overlooked in clinical formulations, where individuals are easily seen as living outwith social and economic structures. In fact some models risk encouraging such a focus. Cultural factors apply to everyone, although they are often most starkly observed when working with particularly disadvantaged groups such as some ethnic minorities or people with disability. Conversely, it is of course also likely to be the case that individuals vary widely in how they develop, and that biological factors play a significant part in both the genesis and maintenance of most health and psycho- logical problems, and this again adds to the complexity of clinical work. Here again the value of generic training is demonstrated as it allows flexibility of response, and pro- vides a broader evidence base on which to draw.
It seems that there is no shortage of distress in current society which needs to be addressed, and that a variety of models and interventions will always be needed as a response. These issues are discussed further in Chapter 30.
Clinical Psychology Training: The UK Example
Over the past 40 years, clinical psychology training in the UK has evolved from a fairly haphazard apprenticeship model to a carefully monitored and generic three-year post- graduate University-based doctoral training which is carried out in partnership with local services offered by the National Health Service (NHS). As described in Hall and Llewelyn (2006), the profession in the UK has sought to define itself by laying out its
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unique position in the professional marketplace, defining its intake via the British Psychological Society’s training accreditation procedures. All clinical psychology train- ing has thereby become formalised, overseen by relatively stringent external quality assurance processes, which define specified aims and competencies to be attained by all trainees. The ability of training programmes to meet these standards is regularly assessed, and only trainees who have completed accredited courses are eligible for Chartering. Additionally, in common with other NHS-funded training programmes, clinical psychology courses are subject to quality assurance assessment procedures. These apply standard criteria which evaluate the ability of training programmes to provide opportunities for students to fulfil specified educational and clinical outcomes. A regular quality assurance assessment process is now carried out by local NHS com- missioners in collaboration with local NHS service providers. The content of training is broad and competency-based, that is, it is designed to allow trainees to demonstrate competence by attaining key learning outcomes. This is discussed in much greater depth in Chapter 2. Through training, trainees are encouraged to become aware of a variety of service models and to understand and apply different ways of working. They are encouraged always to work from the evidence base where that exists, and to feed back into the evidence base by both practice-based audit and research, and also through research into basic processes. The importance of working with users is also stressed, as is the need to work in collaboration with other professional groups.
Almost uniquely amongst NHS professions in the UK, all pre-qualification clinical psychologist trainees have been fully funded by the NHS since the 1980s. In the UK, health services are publicly resourced, and the precise arrangements whereby this is achieved are therefore subject to change, since political views about the best way to organise and distribute services and resources inevitably change. The current situation is for contractual agreements to exist between Strategic Health Authorities in England, or Health Boards or their equivalent elsewhere in the UK, and Universities, to deliver training in partnership with the local NHS, to agreed numbers, for trainees in each local area. Whilst academic teaching, research supervision, professional development support, appraisal and assessment, as well as some skills training, can be provided in academic settings, the bulk of training is provided via practical clinical work carried out under supervision in local NHS or social services settings.
A critical issue is therefore the quality of the relationship between the academic and the clinical sides of the training partnership. Most programmes provide additional training and support for clinical supervisors, and this helps to build and maintain positive relationships. Most programme staff also work part-time in local clinical serv- ices. The relationships between stakeholders, including commissioners or purchasers of training, are also important, and on the whole these have been reasonably good too, in part because, in contrast to many other NHS professional groups, the retention and eventual recruitment of clinical psychology trainees as NHS employees has been out- standing (British Psychological Society, 2005b). Finally, a crucial issue is the relation- ships within and between members of the programme itself (trainees and staff). Just as individuals learn relationship patterns and self-care strategies within their family of origin, so it seems likely that trainees learn much of their professional identity and
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standards within their training environment and clinical placements. Ideally this should include an expectation of a high standard of personal conduct and a commitment to both evidence and service user welfare, while at the same time fostering a tolerance of genuine mistakes and a willingness to learn.
In the UK, the training community (staff on all University programmes) works closely together, and although there is diversity between training providers, there is also a high degree of communication and mutual help between training programmes, which has helped to ensure a reasonably consistent standard of training across the UK. This has in turn helped to build and support the wider profession’s identity and stand- ards. It is notable, for instance, how prominent training programme staff have been in the professional leadership of UK clinical psychology as a whole, and how many initia- tives for innovative services are often led by NHS and University training staff working together. These issues are discussed further in Chapter 29.
Clinical Psychology Services
Clinical psychology training covers a wide range of issues across the lifespan because clinical psychology services operate in a wide range of settings, including adult, child and family, people with learning disabilities, older people and specialist services. Clinical psy- chologists also work across social and health care, and need to work collabo ratively with management and commissioners in order to meet the needs of both service users and carers, and of other service providers, as far as is possible within existing resources. Unlike training, however, there are no accepted patterns or standards of service organisation, and so a huge variety of types of provision exist across the health and social care sector. Limitations in resources mean that many service users do not in fact have good access to clinical psychology, and one constant problem remains inequality of provision, especially for hard-to-reach groups. An important principle here is recognition that services should be provided to all populations in need. For example, learning disabled and older people have poorer access than other client groups to evidence-based psychological therapies for emotional distress, despite evidence that they may benefit from such interventions. Clinical psychologists therefore have an important function in developing such services in areas where there are none. All the qualities and competencies noted in this chapter will be needed for such service develop ment, including the establishment of good work- ing relationships, the ability to assess and formulate problems, the competence to com- municate effectively and to establish what form of intervention will be most appropriate, and the ability to implement and evaluate change. Since areas which are well researched are those most likely to receive funding, and hence better services, one important role for psychologists may well be to conduct research with under-served populations and thereby to encourage extension of good practice. In all circumstances the ability to evalu- ate the services provided will be critical. One further important issue is the dissemination of effective practices, so, for example, effective techniques in parenting can be passed on to health visitors and to families, leaving psychologists to work with more complex cases or in areas of work which have yet to be explored.
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Within the UK, a recent government initiative has been to finance a large expansion of evidence-based therapy in primary care, the Increasing Access to Psychological Therapy (IAPT) programme designed to address the substantial amount of untreated level of emotional distress (depression and anxiety) which is reported in the commu- nity. Much of this work will be provided by therapists with less training than clinical psychologists, so an important future role is likely to be the provision of supervision and training for others. This ties in closely with recent proposals to revise how psy- chologists should work, to include a greater emphasis on teamwork, leadership and collaboration (New Ways of Working, 2007); see Chapter 29 for further discussion of this initiative.
This Book: Brief Overview
This book is structured to show how clinical psychologists think and work, and hence it comprises a series of chapters which present the key elements of practice, compe- tency approaches and the conceptual base. Included is discussion of models, ethical issues and values, and the need to work in partnership with others who also provide or receive services. These discussions recognise the need for clinical psychologists to take both a reflective and a scientific stance to psychological practice, and hence to ground the discipline securely on sound empirical evidence as well as on clear ethical founda- tions. Examples of services across the lifespan will be presented in a series of short chapters by specialists in their fields, most of whom have roles as providers of services and also as educators for tomorrow’s practitioners. The breadth of clinical psychology services now available means that this cannot be comprehensive, and it is inevitable that some important innovations and areas of work will have been omitted. Nevertheless, it is hoped that a reasonably wide range of areas of practice will be covered. The final section of the book discusses contextual questions, skills-sharing and the centrality of user involvement, and also raises questions about the future of the discipline. It is hoped that this volume will thereby provide a stimulating and illuminating coverage of the practice of clinical psychology as it exists in the first part of the 21st century.
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Clinical psychologists have been grappling with how to describe effectively and to define what they do since the 1930s (Woodworth, 1937). There has been much debate about how to capture clearly the particular mix of theory, science, practice and person that embodies our profession. Some applied psychologists do not believe that the use of the language of competency does justice to the sophistication or complexity of their contribution, and that much is lost by defining the parts rather than the whole. However, the authors of this chapter are convinced by the argument that in the current context of practice, applied psychologists must be able to clearly define their professional activ- ities and that this must be understood in the light of a value base as well as a social and political context. Rather than reject competency approaches as a reductionist narrative, we argue here that it is possible to capture professional contributions through careful and detailed discussion of competence.
Competency is a much used and difficult to define construct, although widely used in the world of professional training. Up until 2002, the British Psychological Society (BPS) used an experiential model as the basis for training; for example, those learning to become clinical psychologists were expected to undergo a particular range of clinical experiences during their training. These included work with a range of clinical popula- tions, ages, complexity, service settings and contexts. However, the profession ques- tioned whether simply gaining experience was sufficient since new practitioners need to be competent and to be able to demonstrate competence, not just experience, at the end of their training. Hence the BPS thought it important to articulate the competen- cies required for the expected roles and responsibilities of a newly qualified clinical psychologist. These were documented as learning outcomes and placed in the context of knowledge, skills and values in the accreditation criteria for clinical psychology doc- toral programmes (British Psychological Society, 2002, 2007).
A similar movement has taken place in the USA and Canada where accreditation of professional education programmes in psychology is now based largely on the programme’s ability to demonstrate the competencies developed in their graduates (Kaslow, 2004). In
2
Competency Approaches, Ethics and Partnership in Clinical Psychology
Helen Beinart, Susan Llewelyn and Paul Kennedy
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Competency Approaches, Ethics and Partnership in Clinical Psychology 19
the USA, for example, the American Psychological Association (APA) has developed a Task Force on the Assessment of Competence in Professional Psychology (Kaslow et al., 2006), based on a multinational competencies conference held in 2002. Much of this work has been recently published and gives a detailed overview of the findings of the working groups, covering a broad range of competencies such as ethical and legal, individual and cultural diversity, scientific foundations and research, psychological assessment, intervention, con- sultation and inter-professional collaboration, supervision and professional development (see Professional Psychology: Research and Practice, October, 2007, for detailed reports).
This chapter will define competence, and place the development of the centrality of competence within a professional and ethical context. It will then discuss models of competence, articulate the competences required for clinical psychology in the UK, and raise some of the complex issues in the development, training and assessment of professional competence.
What Is Competence?
Competence is defined by the Concise Oxford English Dictionary (1995) as ‘ability or skill’, while competent is defined as ‘adequately qualified, capable or effective’. Clearly the literal definition is not particularly helpful in understanding professional training since it assumes an end-state, whereas professional learning and development are con- tinuous and ongoing throughout a professional career. Competence is variously defined in professional writings, and in the context of applied psychology, it involves the com- plex interaction of four major components: knowledge, skills, judgement and diligence (for example, New Zealand Psychologists Board, 2006). Knowledge involves having absorbed and comprehended a body of information sufficient to understand and con- ceptualise a range of professional issues. It is a necessary, but not sufficient, foundation for competence. Skill is the ability to apply knowledge effectively in actual practice. Judgement involves knowing when to apply which skills under what circumstances. It also includes a self-reflective element, including awareness of personal values, attitudes and context, and to know how these may influence actions. Diligence suggests a con- sistent application of knowledge, skills and judgement in professional activities, giving careful priority to client needs, and aiming to provide the highest quality of care.
Epstein and Hundert (2002) in their discussion of medical education have devel- oped a broadly accepted definition of professional competence:
Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a founda- tion of basic clinical skills, scientific knowledge and moral development. It includes a cognitive function – acquiring and using knowledge to solve real life problems; an integra- tive function – using biomedical and psychosocial data in clinical reasoning; a relational function – communicating effectively with patients and colleagues; and an effective moral function – the willingness, patient and emotional awareness to use these skills judicially and humanely. Competence depends on habits of mind, including attentiveness, critical
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curiosity, self-awareness, and presence. Professional competence is developmental, impermanent and context dependent. (p. 227)
Professional competence as thus defined by Epstein and Hundert is clearly applicable to clinical psychology. It suggests the capability of critical thinking and analysis, the use of professional judgement based on applied knowledge to make assessments and deci- sions and, through reflective practice, to evaluate and change decisions as needed. It clearly identifies competence as a developmental construct which is context-depend- ent, and which changes as the psychologist continues to develop over their professional lifetime. It also places competence within the context of moral decision making, which links closely with ethical values, as exemplified by the BPS Code of Ethics and Conduct (British Psychological Society, 2006).
The BPS’s Code of Ethics and Conduct is based on four core ethical principles of respect, competence, responsibility and integrity. Each ethical principle includes a statement of values which describes a fundamental set of beliefs guiding ethical reasoning, decision making and behaviour, and a set of standards which clarify the ethical conduct expected from members of the Society. Interestingly, competence is seen as a core ethical principle within clinical psychology, both in the UK and USA, and is embedded within both the BPS and APA ethical codes. The BPS statement of values associated with competence is described as follows: ‘Psychologists value the continuing development and maintenance of high standards of competence in their professional work, and the importance of preserving their ability of functioning optimally within the recognised limits of their knowledge, skill, training, education and experience’ (British Psychological Society, 2006, p. 14). This value sits alongside respect for the dignity and worth of all people, responsibility to clients, the general public, the profession and commitment to promoting integrity in all professional interactions. The other overarching and widely accepted professional stance of clinical psy- chology is that of working collaboratively. This is an attitude and approach which encour- ages the individual psychologist to work with the client, be they individual, group, team, wider organisation or community, in partnership. Hence, our understanding of compe- tence needs to be placed within ethical frameworks and a collaborative stance.
It is probably clear from the discussion thus far that although there are many com- petencies required by a clinical psychologist (for example, relationship formation, assessment, formulation, intervention, research and evaluation, consultation and edu- cation, management and supervision), these individual areas form only part of the building blocks of professional competence. Nonetheless, professional competence is a much broader term which cuts across the various competency areas listed above, and reflects the integration of knowledge, skills and attitudes with professional practice and the science of psychology. Professional competence also involves meta-knowledge, knowledge about knowledge: knowing what you know and what you don’t know. Hence, meta-knowledge includes being aware of the range and limits of what you know: knowing your own strengths and weaknesses, how to apply available skills and knowledge to a variety of tasks, how to acquire new or missing skills, or being able to judge when not to intervene due to lack of knowledge or competence. The develop- ment of meta-knowledge and meta-competencies therefore depends on self-awareness,
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self-reflection and self-assessment (Weinert, 2001). Schön (1983) has contributed to our understanding of this discussion by suggesting that, in addition to ‘technical ration- ality’ (understanding of basic science, its application and the skills and attitudes required), competence develops through ‘reflection on action’ and develops in a mature professional to ‘reflection in action’. This is understood as moment-to-moment self- supervision which involves the practitioner reflecting during practice in order to make decisions about how best to proceed in each individual context. Reflective practice thus involves meta-cognitive and self-awareness as well as interpersonal awareness.
A final consideration in thinking about what we mean when we are discussing compe- tence must include some clarification of the terms used in this area. In general, compe- tencies usually refer to an area or domain such as assessment or intervention, both of which are components of competence. Normally, competencies are observable and measurable and can be evaluated against accepted standards (Kaslow, 2004). ‘Competence’ usually refers to a level of attainment or minimum threshold an individual has acquired such as the development of basic competence in, for example, assessment, while ‘compe- tent’ is a description of a particular level of skill. However, a ‘competency-based approach’ can also refer to a more aspirational striving towards excellence and in this context all competence is developmental in nature. Perhaps it is most helpful to use the minimum threshold understanding in a professional training context and the more aspirational interpretation in an ongoing professional development context. However, Erault (2008) stresses that competence should be understood in terms of the context, prevailing condi- tions and situation. He also distinguishes the term capability which emphasises personal knowledge and lifelong learning rather than expected standards or qualifications.
Models of Competence
Several authors have attempted to develop models to account for the development of professional competence. For example, Roe (2002) developed the Competence Architecture Model (Figure 2.1) where he depicts competence as a building which has, as its foundation layers, abilities and personal attributes that are supported by pillars of acquired learning, such as knowledge, skills and attitudes. The roof of the model is made up of the competencies essential to practice, such as assessment and intervention skills, which are thought to be learnt largely through the integration of practical learn- ing through supervised practice and knowledge, skills and attributes.
One of the most widely used schemes for describing the development of competence is that of Dreyfus and Dreyfus (1986), who define five stages: Novice, Advanced Beginner, Competent, Proficient and Expert. Their main thesis suggests that as the learner becomes more familiar with the analytic and practical tasks required of the profession, performance becomes more integrated, flexible, efficient and skilled. Patterns and actions that have to be carefully considered or supervised become inter- nalized and increasingly automatic. Stoltenberg et al. (1998) in their Integrated Developmental Model of Supervision (see Chapter 28 for a detailed discussion) describe the journey of development from a novice to competent professional which they
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22 Helen Beinart, Susan Llewelyn and Paul Kennedy
suggest involves the development of competence, professional identity and maturity. The main developmental tasks involved are self-awareness and awareness of others, motivation and autonomy. The model identifies eight domains reflecting professional competence: intervention skills, assessment techniques, interpersonal assessment, client conceptualisation, individual differences (including impact of difference and diver- sity), theoretical orientation, treatment plans and goals, and professional ethics.
Skovholt and Ronnestad (1992) interviewed and qualitatively analysed interviews with a range of therapists and counsellors across the professional lifespan. They devel- oped a model which suggests that the evolving professional self follows a series of stages in development which include: untrained/intuitive and common sense (prior to train- ing), transition to professional training, imitation of experts and conditional autonomy (towards the end of training), exploration (as a newly qualified professional), integra- tion and individuation (as a mature professional).
Rodolfa et al. (2005) developed a competencies cube model (Figure 2.2) to describe the development of competencies throughout a professional career. The model is seen as developmental and interactional, and will vary according to clinical context and set- ting, such as the populations and problems served and the theoretical models used. The foundation competencies, or building blocks, are conceptualised as reflective practice and self-assessment, scientific knowledge and methods, relationships, ethical and legal standards, individual and cultural diversity and interdisciplinary systems. The func- tional competencies are seen as the knowledge, skills and values to perform the work of a psychologist, and these areas of professional functioning include: assessment, diagnosis, conceptualisation (formulation), intervention, consultation, research/evaluation, super- vision/teaching and management/administration. The cube model assumes that the relationship between the functional and foundation competency domains is ortho- gonal, that is, each of the foundation domains has implications for the functional com- petencies. Additionally, stages of professional development are also represented in the
Competencies
Abilities
Sub-competences
Personal characteristics and qualities
S ki
lls
K no
w le
dg e
A tti
tu de
s
Figure 2.1 Competence Architecture Model. Source: Adapted from Roe (2002).
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Competency Approaches, Ethics and Partnership in Clinical Psychology 23
model such as doctoral training, post-doctoral supervision and continuing professional development, suggesting that psychologists gain and enhance competencies throughout their professional careers. Rodolfa et al. (2005) suggest that functional competencies will develop according to the speciality or context within which the psychologist works and that this further specialisation will usually take place post-qualification.
Core Competencies, Ethics and Partnership in Clinical Psychology
One of the challenges in dissecting professional competence into its component compe- tencies is that they inevitably become reductive since they lose the overall purpose and integration, ethical stance and value of partnership which is central to good practice. Hence it is perhaps worth restating the overall aims of UK professional clinical psychology here:
Clinical psychologists aim to reduce psychological distress and to enhance and promote psychological well-being by the systematic application of knowledge derived from psy- chological theory and research. Clinical psychology services aim to enable service users to have the necessary skills and abilities to cope with their emotional needs and daily lives in order to maximise psychological and physical well-being; to develop and use their capac- ity to make informed choices in order to enhance and maximise independence and auton- omy; to have a sense of self-understanding, self-respect and self-worth … (British Psychological Society, 2007, p. 8)
Additionally, clinical psychologists work with colleagues, teams and services to enhance and promote psychological understanding of human distress. This latter point is particularly important in certain clinical settings where more medically focused models
Assessment
Intervention
Consultation
Research/Evaluation
Supervision/Teaching
Management/Administration
P re
-q ua
lif ic
at io
n ex
pe rie
nc e
D oc
to ra
l t ra
in in
g
N ew
ly q
ua lif
ie d
C on
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ng p
ro fe
ss io
na l d
ev el
op m
en t
Reflective practice Scientific knowledge and methods
Relationships Ethical & legal standards/policy issues
Individual & cultural diversity
Foundational competencies
Stages of development
Functional competencies
Interdisciplinary systems
Figure 2.2 Cube model describing competency development in professional psychology. Source: Adapted for the UK from Rodolfa et al. (2005).
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24 Helen Beinart, Susan Llewelyn and Paul Kennedy
of care may pathologise rather than empower service users. Psychologists have an important role to support their colleagues and teams to use normative lifespan develop- mental and psychological models to work in partnership to understand and enhance people’s psychological well-being (see Chapter 30 for further discussion of teamwork).
The training accreditation criteria for UK clinical psychology courses (British Psychologi- cal Society, 2007) couch competencies in the language of skills, knowledge and values, and emphasise the capability to combine knowledge and competencies to achieve a set of learn- ing outcomes by the end of training. The summary learning outcomes are noted below:
The skills, knowledge and values to develop working alliances with clients, including indi- viduals, carers and/or services, in order to carry out psychological assessment, develop a formulation based on psychological theories and knowledge, carry out psychological interventions, evaluate their work and communicate effectively with clients, referrers and others, orally, electronically and in writing;
The skills, knowledge and values to work effectively with clients from a diverse range of backgrounds, understanding and respecting the impact of difference and diversity upon their lives;
The skills, knowledge and values to work effectively with systems relevant to clients, including for example statutory and voluntary services, self-help and advocacy groups, user-led systems and other elements of the wider community;
The skills, knowledge and values to work in a range of indirect ways to improve psycho- logical aspects of health and healthcare;
The skills, knowledge and values to conduct research that enables the profession to develop its knowledge base and to monitor and improve the effectiveness of its work;
and
High level skills in managing a personal learning agenda and self-care, and in critical reflection and self-awareness that enable transfer of knowledge and skills new settings and problems. (British Psychological Society, 2007, p. 9)
The Health Professions Council which now regulates the profession in the UK uses the format of statements of proficiency to highlight required competencies. These pro- ficiency statements can be mapped onto the learning outcomes noted here, although they are less specifically clinical, since they apply to all branches of psychology eligible for regulation. In a similar vein the APA has also developed a Competency Benchmarks Document (2007) applicable to all health service providers in professional psychology. The common competencies are listed as follows:
Reflective practice self-assessment, which includes practicing within the boundaries of competence, being committed to lifelong learning and scholarship, engaging in critical thinking, and being dedicated to the development of the profession;
Scientific knowledge and methods, including a respect for scientifically derived know- ledge, the ability to understand research methods, data collection and analyses, and the capacity to appropriately evaluate and judge the quality of research. This area also includes specific knowledge of psychological models of behavior, as well as lifespan development;
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Competency Approaches, Ethics and Partnership in Clinical Psychology 25
The capacity to have meaningful and productive professional relationships with individu- als, groups, and communities including core relationship skills such as empathy, warmth and genuineness.
Individual-cultural diversity, which includes awareness of self within the cultural context and sensitivity when working with individuals, groups and communities with diverse cul- tural backgrounds and unique personal characteristics;
Ethical-legal standards-policy, which involves the appropriate application of ethical stand- ards as well as an awareness of legal issues associated with professional activities and advo- cacy for the profession; and
Interdisciplinary systems, including teamwork and appropriate professional involvement with colleagues and the ability to interact knowledgeably with professionals in related fields.
The working group of the APA tasked with developing basic clinical competencies in intervention (Spruill et al., 2004) built on the foundation competencies above, and divided intervention into intervention planning (including assessment and formula- tion), implementation (building the relationship, choice and timing of intervention, endings and communication) and evaluation competencies (monitoring client progress and therapist reactions). Additionally, they suggested that competent clinicians must be able to deal with the unexpected or with clinical emergencies or crises (for example, abuse, risk or self-harm issues) without rupturing the therapeutic relationship. The role of supervision and consultation is seen as essential in this context both to enhance learning and competence and also to allow for scrutiny and clinical governance.
For more specific detail, the core competencies for clinical psychologists outlined by the BPS (2007) can be seen in Box 2.1 (overleaf).
The Training, Development and Assessment of Competence
Competency-based education is challenging in that it needs to straddle the training of competence and capabilities alongside facilitating the learning of specific competen- cies. In other words, specific, clearly articulated competencies such as specific assess- ment techniques need to be learnt together with the ability to adapt to change, be flexible, and show sound judgement and decision making in complex and changing environments. It is essential therefore that competency-based education is develop- mentally informed and incorporates progressively more complex and sophisticated content (Kaslow, 2004). It could be argued that training should begin with foundation competencies and develop to training core competencies, and then move to more spe- cific speciality-related competencies. However, many of the foundation competencies are more complex to learn, and also somewhat more difficult to teach. For example, teaching of ethics, reflective practice or cultural diversity is perhaps not as straightfor- ward or indeed measurable as teaching interviewing skills. Many of the models of com- petence development suggest a linear developmental pathway, but experienced trainers will be aware of competence fluctuating depending on many factors such as familiarity
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26 Helen Beinart, Susan Llewelyn and Paul Kennedy
Box 2.1 Summary of learning outcomes for UK clinical psychology training (BPS, 2007)
Psychological assessment includes the ability to:
● develop and maintain effective working alliances with clients ● choose, use and interpret a broad range of appropriate assessment methods
(standardised psychometric measures, clinical interviews, structured observation) ● assess social context and organisations ● conduct appropriate risk assessment and using this to guide practice.
Psychological formulation includes the ability to:
● develop formulations of presenting problems or situations ● integrate information from assessments using psychological theory and evi-
dence, incorporating interpersonal, societal, cultural and biological factors ● use formulation to facilitate clients’ understanding of their experience ● collaboratively plan appropriate interventions ● revise as necessary as understanding deepens ● assist inter-professional communication and understanding.
Psychological intervention includes the ability to:
● implement psychological therapy or interventions appropriate to the present- ing problem and to the psychological and social circumstances of the client(s)
● collaborate with the client (individual, couple, family, group, team, service) ● be proficient in at least two evidence-based models, one of which is cognitive
behaviour therapy ● work with and through others ● recognise when intervention is unlikely to be helpful ● manage caseload and handle endings sensitively and effectively.
Evaluation includes the ability to:
● select and implement appropriate methods to evaluate the effectiveness, acceptability and impact of interventions
● devise innovative procedures and audit clinical effectiveness. (Continued)
with the clinical context, client group and complexity of the work, as well as personal factors such as confidence and life stresses. Thus an interactional, developmental model, such as the Competency Cube Model (Rodolfa et al., 2005) introduced above, may be most helpful in this area.
Additionally, adult learning models, such as that proposed by Kolb (1984), may be helpful in supporting adult learners who will start their professional careers with an
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Competency Approaches, Ethics and Partnership in Clinical Psychology 27
Box 2.1 (Cont’d)
Psychological research includes the ability to:
● identify, review and critically appraise the research evidence ● understand techniques for clinical research, including quantitative and quali-
tative approaches ● collaborate in small-scale and service-related research ● conceptualise, design and conduct independent, original research ● identify research questions ● demonstrate an understanding of ethical issues ● choose appropriate research methods and analysis ● report outcomes and disseminate findings.
Personal and professional skills and values include the ability to:
● understand ethical issues and apply in complex contexts ● appreciate the inherent power imbalance between practitioners and clients
and the impact of difference, diversity and social inequalities on people’s lives ● be aware of the impact of one’s own value base ● work effectively at an appropriate level of autonomy ● work within the limits of one’s own competence, and accept accountability ● use supervision and manage learning needs ● reflect on practice and the emotional impact of the work ● maintain the health, safety and security of self and others.
Communication and teaching include the ability to:
● communicate psychological information effectively ● adapt the style of communication to people with a range of cognitive ability,
sensory acuity and modes of communication ● take into account the needs and goals of the participants ● attend to the supervision process for both supervisee and supervisor roles ● provide psychological advice and consultation.
Service delivery includes the ability to:
● adapt practice to a range of different organisational contexts ● provide supervision, consultancy and leadership ● work effectively with formal service systems, procedures, legislative and
national planning contexts ● work with users and carers to facilitate their involvement in service planning
and delivery ● work effectively in multidisciplinary teams and understand how to support change ● understand quality assurance, management roles and organisational policies.
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28 Helen Beinart, Susan Llewelyn and Paul Kennedy
existing wealth of previous personal and professional experience as well as preferred styles of learning. Training is clearly most effective when it occurs in a respectful, sup- portive and facilitative learning environment where adult learners are encouraged to hold or at least share responsibility for their learning. In the UK, clinical training includes parallel streams of academic teaching (usually a mix of didactic and experien- tial learning), research training (learnt through a combination of teaching, mentoring or supervision and application), clinical placements where the focus is on competence development in a range of contexts supported by clinical supervision, and personal, professional development and reflective, ethical practice which are developed across all spheres. Following its successful development in medical education, problem-based learning has been recently introduced into clinical training and appears to be a promis- ing strategy for the development of competencies (Stedmon et al., 2005).
In the UK, each clinical training course has a slightly different emphasis, although through the rigorous BPS accreditation systems as well as NHS quality control mecha- nisms most newly qualified psychologists have roughly comparable competencies after taking into account individual differences. To our knowledge, we do not yet know which elements of training are most effective in the development of competent and capable professionals, so most courses have developed their own preferred method of competence development. In Oxford, for example, following a competencies conference with supervisors, trainees and tutors, we produced a developmental guide to the assess- ment of clinical competence to help supervisors to make informed judgements about the development of clinical competence over the three years of training, and this is out- lined here as an illustration. We emphasise needs-led supervision which takes into account individual learning needs and goals, since all trainees join the programme with a range of different experiences and abilities. Additionally, case complexity, level of risk, familiarity with the client group and service context all influence the development of competence. These general guidelines therefore need to be interpreted and applied in the light of individual trainee needs and experience, and specific service issues such as complexity. The specific competencies we assess are: use of supervision, therapeutic relationships, assessment, formulation, intervention, communication, teaching, research and evaluation, multidisciplinary working, services, contexts and organisa- tion, personal/professional practice and cultural competence.
As a general framework we would expect the following:
● In year 1, trainees will show basic knowledge and skills, emergent competencies and awareness of learning needs. They will show flexibility and capacity to learn from feedback. They are likely to require structured and detailed guidance from their supervisors.
● In year 2, trainees will show basic applied skills and knowledge and a greater level of maturity in their competence development. General engagement and relationship skills are in place and formulation and intervention skills are developing but will still require some structured guidance from supervisors, particularly in new, complex or high-risk situations. A more collaborative approach will facilitate supervision.
● In year 3, trainees will show the majority of competencies with the exception of highly specialist or complex issues. Trainees will show appropriate strategies to
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manage high complexity/risk. They will show clear application of theory, ongoing development of knowledge and an ability to explain and teach others. They will show an increasing integration of ideas and approaches as they consolidate their clinical skills and develop an autonomous professional style. They will show a commitment to ongoing professional development post-qualification. A collabo- rative style will facilitate supervision. (Oxford Doctoral Course in Clinical Psychology, 2006)
Assessment of competence needs to take into account developmental factors, and will usually include both formative (feedback aimed at developmental needs) and summative (evaluation based on whether expected level of competence is reached, and gate keeping) feedback. Kaslow, Bebeeau et al. (2007) argue that in keeping with the common Zeitgeist, psychologists have embraced competency-based training but still have much work to do to develop competency-based assessment. They have therefore developed some guiding principles for the assessment of competence and suggest that: assessment of competence requires a major cultural shift towards the assessment throughout professional life, and also that competencies should be con- ceptualised as generic, holistic and developmental. Assessment of competence should reflect fidelity to practice and incorporate reliable, valid and practical methods. Self- reflection and self-assessment are seen as key components in the assessment of com- petence, and a comprehensive assessment should include a focus on interpersonal functioning and professional development, highlight the importance of individual and cultural diversity and the development and maintenance of ethical practice. Additionally, it is suggested that it is important to assess capability as well as compe- tence, where capability refers to the extent to which competent individuals can adapt their skills to new contexts, generate new knowledge and continue to improve their competence through lifelong learning.
Leigh et al. (2007) argue that the multidimensional nature of competence requires a multifaceted approach to assessment. Assessment should be viewed as a continuum from early stages of professional training through continued learning and professional development in practice (Bashook, 2005). A variety of models of assessment may be used which include measures of knowledge (e.g. multiple choice questionnaires), meas- ures of professional decision making (e.g. case-based oral examinations), measures of performance (e.g. portfolios) and integrated assessment of practice-based skills and tasks (e.g. through observation or simulation of practice). Leigh et al. conclude that good assessment is expensive to develop and maintain and that psychology lags behind many other healthcare professions in the development of reliable and valid methods to assess competence. Bashook (2005) recommends that best practice in the assessment of competence should be grounded in a conceptual model and include multiple assess- ment methods tailored to the competencies to be measured which take into account credibility, feasibility and career stage of the practitioner.
Barber et al. (2007) distinguish global competence from limited-domain compe- tence and argue that most empirical investigations of competence have assessed lim- ited-domain competence, for example in randomised control trials investigating the
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outcome of specific therapies. They report that the majority of therapy outcome stud- ies show a small but positive correlation between competence and outcome in several limited domains. In the UK, much new financial investment has occurred on the basis of these studies and limited-domain competencies in, for example, cognitive behaviour therapy have been developed (Roth & Pilling, 2007). Barber et al. (2007) argue that while it is conceivable that therapy outcome may result from competence demonstrated within a single domain, it is likely that global competence, in particular the ability to deal with the unexpected, is more likely to predict therapy outcome, but that this requires further empirical study.
Problems in the Development of Professional Competence
When problems with competence are identified, it is important to have strategies in place for their remediation and management. Professional psychology has struggled with how and when to intervene when behaviour or performance does not meet expected levels of competence (Elman & Forrest, 2007). This is a challenging area and trainers, supervisors and managers need to be trained in effective methods for ongoing assessment of competence and how to manage poor performance. Identifying learning needs, feedback and constructive challenge are normally the first steps in supporting learning and managing difficulties (Scaife, 2001). Additionally, training programmes need to foster an ethos of openness and acceptance of feedback so that any problems are brought to light early. If one accepts a developmental model of competence devel- opment, then much work can be done preventatively by clearly identifying what needs to change. However, it is also essential that training programmes have clear written and transparent policies and procedures regarding remediation, failure and, if necessary, dismissal. These are best couched in a terminology which clearly describes the compe- tencies and standards required and hence emphasises the ongoing need for definition, assessment and ethical practices. Kaslow, Rubin et al. (2007) propose several methods for recognising, assessing and intervening with problems of professional competence. These include clear definitions of the competence required, preparing the system to ensure that policies and procedures for assessment are in place, encouraging self-assess- ment and learning from feedback, considering cultural diversity and the impact of beliefs and values in the identification, assessment and resolution of problems, and maintaining clear communication at all times (including transparent discussions of confidentiality and limitations to the individual’s rights to privacy bearing in mind ethical and regulatory principles).
Conclusion
This chapter has focused on understanding the competency approach in clinical psy- chology by discussing the meaning of competence and competencies, exploring models of competency development, articulating the competencies required in the training of
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Competency Approaches, Ethics and Partnership in Clinical Psychology 31
clinical psychologists both in the UK and USA and raising issues concerning the train- ing and assessment of professional competence. It is evident that defining and assessing competence in clinical psychology is a challenging task and psychology has lagged behind other professions in defining what professional psychologists know and can contribute, resulting in a possible failure to communicate the nature of their compe- tence to the public and policy makers (Kaslow, 2004). This is not entirely surprising in an area where the meaning of competence can range from an ethical principle to a specific definition of a technical skill. In the current Zeitgeist of evidence-based, com- petency approaches, there is a danger of defining competencies as a collection of spe- cific skills which may lead to a focus on training technicians rather than competent and capable professionals who have the capacity to think critically, evaluate and develop new and innovative methods. Despite these challenges, there is an opportunity for the profession to develop a developmentally informed competency-based model and methods of training and assessment that reflect the diversity, creativity and flexibility of the profession across the professional lifespan.
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Leigh, I., Smith, I., Bebeau, M., Lichtenberg, J., Nelson, P., Portnoy, S. et al. (2007). Competency assessment models. Professional Psychology: Research and Practice, 38, 463–473.
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3
The Conceptual Base
Paul Kennedy, Susan Llewelyn and Helen Beinart
To introduce this discussion of the conceptual base of clinical psychology, we will start by briefly outlining some of the historical context. Lightner Witmer established the first psychological clinic in the USA, coining the term ‘Clinical Psychologist’ as long ago as 1896 (Strickland, 1988). Following this, professional development for the next fifty years or so was variable, being particularly slow in the UK although a little more focused in Germany and the USA (Hall & Llewelyn, 2006). Yet despite this unpromising start, the expansion of the profession in the subsequent fifty years or so has largely confirmed Woodworth’s (1937) prediction that ‘the number of Clinical Psychologists would be very great’. So how and why did this happen?
This chapter aims to suggest some answers to these questions and explores the scien- tist-practitioner model underpinning the profession. In it we include an examination of pre- and post-Second World War developments, which highlight the links between research and professional practice, and examination of some of the risks, biases, con- straints and contradictions associated with this model, particularly as practice and research has developed into the 21st century. Finally, we discuss the integration of reflective practice, as well as the need and strategies for managing the potentially uncomfortable disconnect between practice and research.
Historical Perspectives
In the early days of the profession in the USA, the US Public Health Service (USPHS) and the Veterans Administration (VA) appropriated funds to support University train- ing programmes to deliver accredited training of graduate psychologists in clinical psy- chology. Part of the impetus behind this was the US government’s wish to avoid a repeat of blunders following the First World War that led to significant dissatisfaction amongst veterans with the then available mental health care. The federal Government wanted to take proactive measures to ensure that the mental health needs of the veterans
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34 Paul Kennedy, Susan Llewelyn and Helen Beinart
would be better addressed following the Second World War. Some graduate (academic) psychology departments, however, feared the expansion within their programmes, and were concerned about the possible domination of clinical psychology within their departments. Doubts were also expressed (see Benjamin & Baker, 2000) about whether a psychologist could be both a practitioner and a researcher.
The Boulder Conference of 1949 (reported by Raimy in 1950) was arguably a defin- ing event for the status of the profession; its legacy included the rapid expansion of US government-funded training places in clinical psychology (the UK was to follow a decade later), the adoption of the scientist-practitioner model of training in profes- sional psychology, and a strong endorsement of the belief that the professional psy- chologist could and should be both researcher and practitioner. Despite the anxiety of the Universities noted above, the decision of the Boulder Conference was to recom- mend the training of clinical psychologists for research and practice, with equal emphasis placed on both, and to suggest that this synthesis should chart major policies in training institutions for some time to come (Raimy, 1950, p. 79). The Boulder Conference also delivered the most comprehensive statement of training for clinical psychology ever written, detailing recommendations on achieving competence and diagnosis, therapy and research. It thereby brought together opinion from practitioners, researchers, fed- eral funders and professional bodies, and was successful in achieving a level of consen- sus that was considered way beyond the dreams of many of those in attendance (Benjamin & Baker, 2000).
The successful advance of clinical psychology today and its cognate practitioners (specialists, counsellors, etc.) owes much to the early vision and pragmatism of the architects at Boulder. The widespread endorsement of the scientist-practitioner model confirmed it as the core conceptual base for clinical training in the USA, while in the UK the creation of the National Health Service in 1948 provided a framework for the expansion of clinical psychology as a scientific profession, since many of the early clinical psychologists were appointed and paid as scientists, primarily concerned with the provision of assessment and research advice. Courses based loosely on this notion were set up in a few institutions in the fifties, namely the Maudsley, Tavistock and Creighton Royal, while the National Health Service began to formally approve training for clinical psychologists, leading to significant expansion in the sixties.
Also at around this time, Raimy (1950) suggested that the basic needs of our society for the services of clinical psychology could be understood using two dimensions:
a) Provision of professional services to i. individuals through corrective and remedial work, as well as diagnostic and
therapeutic services; ii. groups and social institutions needing positive mental hygiene programmes
in the interest of better community health; iii. students in training, members of other professions and the public through
systematic education and general dissemination of information.
and
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The Conceptual Base 35
b) Research contributions designed to i. develop better understanding of human behaviour; ii. improve the accuracy and reliability of diagnostic procedures; iii. develop more efficient methods of treatment; iv. develop methods of promoting mental hygiene and preventing maladjustment.
In these early days, and notwithstanding Boulder, many doubted the sustainability of maintaining both dimensions of this model. Indeed, Eysenck, rather than emphasising the need to combine research and clinical intervention, proposed a British scientist- practitioner model that diminished the role of therapeutic practice. Eysenck (1949) believed that the profession should concern itself solely with research and diagnosis, and should be removed from the social needs that could interfere with scientific require- ments. Despite Eysenck’s opinion, however, Shapiro in the Maudsley (Institute of Psychiatry, London) applied the methods of experimental psychology and learning theory to the clinical management of individual cases, which Hall (2007) has argued provided the effective basis for clinical psychology in the UK as it is today.
While the architects at Boulder established a formal template for scientist-practitioner programmes, in fact North American clinical psychology training programmes estab- lished prior to Boulder had already included many of the elements that later became identified with the Boulder model (Routh, 2000). If science and practice were the bride and groom, was it a marriage of convenience, a shotgun wedding or a joint partnership based on mutual respect, love and admiration? Despite the affirmation of scientific values at Boulder, it is impossible not to consider the historical context within which Boulder occurred. The pressure applied to address the mental health needs of a nation in the post-war atmosphere at the time created a cultural expectation that compelled the various stakeholders at Boulder to agree on a model of training and practice, more or less in line with the profession’s aspirations. If the quality of the science and practice at the time were scrutinised using current standards of evidence, one could reasonably raise questions about generalisability, reliability and validity. Nevertheless, the aspira- tions at the time created conditions which, we wish to argue, have enabled the profession’s continued enhancement, credible scientific advancement and recognition to the present day, despite any reservations we may currently have.
The Nature of Scientific Enquiry
To explore these issues further, it is helpful to review the scientific basis of clinical psy- chology today. O’Donohue et al. (2007) believe that science (which they describe as an applied epistemology or approach to knowledge) features specialised ways of forming beliefs, and is the safest way to minimise error in our methods. They suggest that science is the best safeguard we have at our disposal against commonplace biases and lapses in reasoning to which we all are prone. It thereby provides the most trustworthy basis for solving the myriad of problems we confront in psychological phenomena related to what causes disorders, and how we can measure and treat them.
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36 Paul Kennedy, Susan Llewelyn and Helen Beinart
The struggle for developing the science of the mind is, of course, not new. While ancient Greeks may have made many profound statements which appear to set the context of our current understanding of the functioning of the human mind, it was 18th-century empiricists who began to understand the importance of doing this in a systematic way, using emerging scientific methodologies. The 18th-century empiricist Thomas Reid, in his enquiry into the human mind on the principles of common sense, commented that ‘all the knowledge we have in agriculture, gardening, chemistry and medicine is built upon the same foundation and if ever our philosophy concerning the human mind is carried so far as to deserve the name of science, which ought never to be despaired of, it must be by observing facts, reducing them to general rules and drawing just conclusions from them’ (1764, p. 113).
Scientific method involves a) observation: a constant feature of scientific inquiry; b) description: information must be reliable, i.e. replicable (repeatable) as well as valid (relevant to the inquiry); c) prediction: information must be valid for observations, past, present and in the future of a given phenomenon; d) control: to sample fairly the range of possible occurrences wherever possible, as opposed to the passive acceptance of opportunistic data (control being the best way to control or counterbalance of risk of empirical biases); and e) falsification: this is a gradual process which requires repeated experiments by multiple researchers who must be able to replicate results in order to corroborate them. As a body of knowledge grows and a particular hypothesis or theory repeatedly brings predictable results, confidence in the hypothesis or theory increases.
This framework has provided the basis of the scientific revolution that underpins much of 21st-century life. The reason why this method is necessary when investigating humans is because we all have firmly held beliefs about functioning that are mistaken. Meehl (1993) emphasises that this tendency is not limited to practising clinicians, since academic researchers are just as prone to such errors as everyone else. O’Donohue et al. (2007) further emphasise that confounding this is the fact that most people are una- ware of their own cognitive biases. They describe the three most important ways in which human cognition is subject to error: confirmation bias, illusory correlation and hindsight bias. Confirmation bias refers to the tendency to selectively seek out and recall information consistent with one’s hypotheses and to neglect information incon- sistent with them. Illusory correlations are likely to arise when individuals hold power- ful a priori expectations regarding the co-variation between certain events or stimuli, thereby leading to our propensity to detect meaningful patterns in random data. The final bias is described by O’Donohue et al. as hindsight bias whereby individuals tend to over-estimate the likelihood that they would have predicted an outcome once they had become aware of it, known as the ‘I knew it all along’ effect.
The scientific method effectively challenges such erroneous belief formations and instead proposes beliefs more likely to be true. O’Donohue et al. suggest that ran- domised double-blind control trials are partial control against confirmation bias because they minimise the probability that investigators will influence participants. Systematic correlational designs minimise illusory correlation because they ensure the accurate computation of co-variation among variables, while carefully controlled lon- gitudinal designs militate against hindsight bias because they collect data at multiple
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time points. They conclude that science is an essential safeguard against error, albeit not a foolproof one, and that scientific method can be creatively utilised to subject theories to scrutiny, and to ensure that replacements do not contain falsehoods.
Popper (1962) characterises the growth of scientific knowledge as the repeated over- throw of scientific theories and their replacement by better and more satisfactory ones. Popper, using the concept of truth likeness, recognises that the final truth is never obtained and that the better scientists attempt to maximise constructive criticism, feedback and the identification of errors. Progress is made by being proved wrong. McFall (1991) suggests that scientific clinical psychology is the only legitimate and acceptable form, arguing that no one would tolerate unscientific clinical psychology. He believes that clinical psychology’s ‘split personality’, as manifested in the Boulder model, has allowed the notion of equity between science and practice, although he also believes in the primacy of science over practice.
This issue still divides the discipline today. Scientists argue that controlled research will be the final arbiter of truth in clinical psychology whereas many practitioners believe that their own clinical experience should be privileged. Some practitioners dis- miss the relevance of research findings on psychotherapy and assessment for their eve- ryday practice, maintaining that these findings should be disregarded when they conflict with clinical intuition or clinical experience. This divide has been exacerbated further by scientists sometimes adopting condescending attitudes towards clinicians and the validity of their experience.
The Nature of Clinical Psychology in Practice
In addition to suggesting that the cardinal principles of science should provide the only legitimate form of clinical psychology, McFall (1991) also proposed two important corollaries. The first suggests that psychological services should not be administered to the public until:
1. the exact nature of the service is described clearly; 2. the claimed benefits of the service are stated explicitly; 3. the claimed benefits are validated scientifically; 4. possible negative side effects that might out weigh any benefits are ruled out
empirically.
The second corollary suggests that the primary and overriding objective of doctoral train- ing programmes in clinical psychology must be to produce the most competent clinical scientists possible. Consequently he argues that the Boulder model, with its stated goal of training scientist-practitioners, is confusing and misleading, proposing instead that all students should be trained to think and function as a scientist in every aspect and setting of their professional lives, rather than completing particular clinical requirements.
These issues are currently being debated. Touyz (1995), for example, raises concerns about clinical psychology abandoning the scientist-practitioner approach and suggests
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38 Paul Kennedy, Susan Llewelyn and Helen Beinart
that a clinical psychologist without a scientific background would become a counsellor indistinguishable from a social worker, counsellor or nurse consultant. Professional competencies could eventually become devoid of a scientific basis and would become focused on reified professional guild issues. Beutler et al. (1995), however, point out that in virtually every discipline in which the usual access to knowledge is through the scientific method, scientists lament that practitioners are inadequately trained, are insensitive to the value of scientific findings and fail to read the right journals. Conversely, practitioners are dismayed because scientists are consumed by irrelevant questions and fail to appreciate the knowledge that arises from practice.
Kennedy and Llewelyn (2001), with the backdrop of rapid growth of clinical psy- chology training in the late 20th century and the apparent variability in the acceptance of the principles of Boulder, reviewed the current approach to clinical psychology training in the UK, using a Delphi methodology to explore the likely future compo- nents of clinical training courses, key professional strategic developments and the model that underpins training. They compared and contrasted these questions in a group of clinical psychology trainers, clinical psychology trainees and practitioner clinical psychologists. Their research confirmed the centrality of the evidence-based scientist-practitioner model, but also suggested the need to include a high degree of responsiveness to the cultural and institutional context of practice. They concluded that the scientist-practitioner model primarily reflected an attitude to practice rather than a commitment to participation in the academic community requiring the submis- sion of research papers to refereed journals. Results also showed that trainers were strongly committed to the model, although practitioners were significantly more likely to emphasise socio-cultural, social care and diversity issues. Kennedy and Llewelyn (2001) suggested that there may be a need to reformulate the scientist-practitioner model to incorporate the more complex understanding of the practice of science, as well as to integrate a more social perspective.
This last point raises the question of the profession’s responsiveness to social need. In the USA, the Vail Conference of 1973 (reported by Korman, 1974) de-emphasised the scientist-practitioner model in favour of a practitioner-oriented approach, propos- ing that doctoral dissertations should be relevant to the delivery of social welfare. Extensive focus on the production of empirical work was considered unnecessary, since trainees principally needed to develop an awareness of research and to acquire the abil- ity to evaluate its implications for practice. So while the development of professional training in clinical psychology as distinct from academic training validated the claim for professional status, are we at risk of simply wanting the best of both worlds? There is no doubt that from a professional perspective we have benefited from the status of doctoral programmes and have promoted our research competencies as unique selling points when compared to other healthcare professionals. So perhaps we have acted at least partially in self-interest. Another related issue is that of the social construction of the discipline. Lane and Corrie (2006), for example, have argued that our professional practice happens in specific social contexts, and that our self-identity is based on rela- tional discourses, whereby we create our identities out of the conversations we have within our practice. The implication of this is that our scientific practice is not pure or
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The Conceptual Base 39
objective, but is socially embedded within the contextual relations we happen to have. Further, these are normally organised to act at least as much in our own interests as in the interests of the recipients of our services.
The Nature of our Discipline
The debates reported above raise the question of how all these different imperatives and issues are to be understood and integrated satisfactorily. There is no doubt that from a professional perspective we have benefited from the status of doctoral pro- grammes and have effectively promoted our research competencies as unique selling points when compared to other healthcare professionals. Yet if we are to pursue the ideal suggested by McFall (1991), that we should hold our theories and practice up to the utmost scientific scrutiny, then we probably need to broaden the base of our inquiry. In support of this point, the British Psychological Society’s report on the future of psychological science (1991) has recognised both the impact on minority professionals of the dominant academic rhetoric and the impact on marginal groups of the imposi- tion of primarily white, male and colonial theories of deviant behaviour. From this perspective, Lane and Corrie (2006) suggest that we should actively confront the prior- ity given to certain forms of knowledge over others. Indeed, as an illustration of the way in which permitted narratives determine what is legitimate and true, we have shown above how the Boulder report was heavily influenced by the social economic objectives of post-war North America, being convened by a grouping of stakeholders that included the Federal Government, the Veterans Administration Hospitals, the American Psychological Association and the Universities, in order to endorse a model that would result in rapid expansion of professional services. Another example is the acceptance in the USA by psychologists of the use of the medically constructed Diagnostic and Statistical Manual (DSM) in diagnosing and describing human problems, which is fully embedded within the funding system, such that clinical psychologists must code according to the manual if they are to deliver funded services to clients.
There are now, however, significant calls for us to draw upon a wider range of evidence and theory to inform current practice. For example, in the USA there has been some recent debate and challenge to the use of the DSM, and the possible abuses of it in practice. Lane and Corrie (2006) claim that by failing to legitimise clients’ stories (or rather by requiring clients to conform to our way of telling them) we have come to favour technical solutions which do not challenge those in authority. They argue that the lay public is expert in other ways to which we have often failed to give sufficient credence. In this way, we are failing to recognise how we contribute to the problem rather than the solution.
As our world of knowledge and practice expands, perhaps we also need to redefine, re-explore and reappraise the type of bridge we require between these various perspec- tives. To do this, it is important to consider the nature of the problem. For instance, Beutler et al. (1995) challenge the belief held by many researchers that clinicians are not interested in research. In a survey of 365 scientists and practitioners, they found that
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40 Paul Kennedy, Susan Llewelyn and Helen Beinart
clinicians report finding research writings to be useful and that they regularly incorporate results into their daily work. Conversely, however, academics often fail to acknowledge the value of clinical practice, and report reading clinical accounts less often than scien- tific writings are read by clinicians. Moreover, academic researchers often suggest unre- alistic ways in which clinicians may correspond with them in order to establish collaboration, i.e. by writing research articles (Beutler et al., 1995). These findings sug- gest that to bridge the gap between scientists and practitioners, communication needs to be increased in both directions, but perhaps particularly by exposing researchers to clinical issues in practice.
Interestingly, Beutler et al. (1995) report that both psychological scientists and psychological practitioners believe that they alone are concerned with ‘reality’. To resolve this discrepancy, they suggest: the building of links between scientific research groups; and that scientists should initiate and maintain relationships with practition- ers. They also suggest that practitioners should reconsider the role of science; and research should be relevant to clinicians, developing vehicles for translating science to practice. There is therefore a growing recognition of the need for greater integration, and more recent attention may provide a stronger foundation and clearer strategies for resolving this divide. We also propose that both perspectives need to incorporate service user views (see Chapter 29) to comprehensively address this divide.
Hofmann and Weinberger (2007), who come from opposing ‘camps’, believe that differences between scientist and practice are indeed complementary and not incom- patible. Westen (2007) proposes three forces that have strained relationships between clinician and researchers in the USA. The first is managed care, which has reduced resources for mental health. The second is described as a ‘capitalisation of academia’ which creates incentives for Universities to select faculty with strong grant records. In the UK the RAE exercise has contributed to similar strains. Westen (2007) identifies the evidence-based practice (EBP) movement in medicine as the third force. He believes that this is largely due to EBP being operationalised in psychology as the utilisation of brief manualised therapies, tested in randomised clinical trials. Westen indicates that the convergence of these forces has resulted in many researchers not only devaluing clinicians and clinical practice but also attempting to prescribe and proscribe how clinicians should practise. He adds that most practitioners would like to be partners with researchers in a bi-directional exchange of ideas to learn what could be most helpful to service users.
To resolve this, Westen and Morrison (2001) suggest a strategy that could be viewed as a bridge, proposing that scientists should observe the therapeutic strategies used by experienced clinicians, in a wide range of patients with broadly defined symptom patterns, who may or may not have substantial comorbidities, in order to examine the relationship between specific intervention strategies and outcome. This is conceived as a way of utilising scientific methods to evaluate clinical outcomes, and the associated efficacy of a constellation of treatment strategies. This would also enable these empiri- cally derived treatments to be subject to community scrutiny and to identify what works in practice. For example, Morrison et al. (2003) carried out a naturalistic study of suc- cessful treatments in clinical practice. Participants were 242 experienced doctoral-level
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The Conceptual Base 41
clinicians (from a wide range of orientations) who reported on their last successfully treated patients for significant depression, panic or anxiety. Most patients were treated for longer than the 8–16 sessions characteristic of efficacy trials and most presented with significant comorbidity. The authors concluded that such effectiveness studies could bridge the gap between research and practice by examining ecologically valid samples and using such data to generate prototypic treatments. As another example, Thompson-Brenner and Westen (2005) examined 145 completed treatments of people with bulimic symptoms. The mean length of cognitive behavioural therapy was 69 sessions and even longer for eclectic and psychodynamic therapies. Over 40 per cent of this sample would have been excluded from randomised controlled trials using four common exclusion criteria. These patients showed higher pre-treatment severity and required longer treatment to achieve positive outcomes relative to patients who did not meet the exclusion criteria. Thompson-Brenner and Weston concluded that such research confirms the validity of genuinely collaborative endeavours, with clinicians doing what they do best by treating patients, and researchers doing what they do best, i.e. testing hypotheses, especially those generated by senior clinicians.
Reflective Practice
Many clinical psychology training programmes (Scott et al., 2004), especially in the UK, now highlight the importance of reflective practice as an important way of making sense of the interface between science and practice. Stedmon et al. (2003) propose that a reflective approach recognises the importance of giving equal amounts of attention to different sources of knowledge in clinical practice. Reflection requires an individual to take a critical and evaluative position in relation to their understanding of practice, often by going beyond models to explore their wider cultural and socio-political back- ground. Reflection begins with the individuals developing self-awareness about their own histories, and how their own personal experiences and values contribute to their professional development. This self-awareness is then extended to understanding the importance of diversity, the social and cultural context of work, working within an ethical framework and the need for continuing professional and personal development. The British Psychological Society (2004) recommends that reflective practice is incor- porated into personal development plans, which enable psychologists to identify needs and reflect upon learning and application to practice. Lane and Corrie (2006) also believe that reflective practice is an appropriate adjunct to counter the Western slant of most models and case conceptualisations. They argue that psychotherapy is primarily about overcoming problems located within an individual, whereas Eastern philoso- phies are more systemically oriented and contextually aware.
Lavender (2003), drawing on the ideas of Schön (1983), summarises the four main processes involved in reflective practice. The first concerns reflection in action whereby the individual reflects cognitively and emotionally about what is happening at a given point and what should happen in the future. This involves rapid analysis of the specifics of the context using immediately available theories and constructions. It parallels the
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42 Paul Kennedy, Susan Llewelyn and Helen Beinart
notion of meta-cognition or ‘supervisor within’. The second process is reflection on action. This occurs after an event and can happen by reviewing therapy tapes, writings, etc. or with supervision. The third process comprises reflection on the impact of self on others, whereby the individual seeks feedback from a variety of sources such as clients, peers and members of the team. The fourth process concerns reflection about the self which includes having an awareness of our background histories and contexts as well as our vulnerabilities and social experiences. A final process has been added by Smail (2006), amongst others, who points to the need both to be aware of, and to attempt to tackle, aspects of the sometimes invisible but dysfunctional context of our work, includ- ing the operation of discrimination, inequalities, covert interest groups, and power.
New Proposals
An attempt to resolve some of the conceptual ambiguities of the profession has been made by Snyder and Elliott (2005). They consider that although clinical psychology has prospered in the sixty years following Boulder, the Boulder model does not prepare graduates to meet the diverse demands of likely mental and physical health issues in the 21st century and that its emphasis on mental illness rather than mental health renders it outdated. Instead, they propose a four-quadrant matrix model, derived from the ideas of Wright (1991), in which there are two dimensions. The first is Valence, the degree to which any given diagnostic focus is either positive or negative, that is, on the person’s strengths or weaknesses. The second dimension is Source, which locates significant factors within the person or within the person’s environment. Snyder and Elliott argue that previous clinical training has emphasised the individual, with lesser attention being given to the interpersonal level, or larger institutional and societal com- munity contexts. The matrix model is also embedded within four levels, i.e. the indi- vidual, interpersonal, institutional and the societal-community levels. At the individual level, research, diagnosis and therapeutic activities are normally aimed towards an identified person and delivered by a single clinical psychologist, usually in a therapeutic context. The overall curriculum for educating at this level focuses on weaknesses. Snyder and Elliott, however, consider that positive dimensions are needed to validate personal strengths, hope, optimism and self-efficacy, as a counterpoint to the traditional widely used pathology-oriented DSM approach (American Psychiatric Association, 1994). The matrix model instead fosters a thorough search of the total person, recog- nising weaknesses and strengths.
Next, they suggest that the interpersonal level has been given too little attention. Humans live within a social context, and almost everything that is done across the lifespan is based on interpersonal issues. They argue that greater focus should be placed on these issues. Third, the institutional level involves research, consultation, adminis- tration and liaison roles, conducted in schools, hospitals and employment settings. Psychological expertise at this level should promote coordinated provision of psycho- logical research and practitioner services across institutions. Snyder and Elliott believe we still operate out of 20th-century models when we ignore the behavioural and social
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The Conceptual Base 43
mechanisms which are known to have profound impact on the physical health and psychological well-being of persons with chronic conditions (Israel et al., 1998).
The final level can be described as societal-community, and addresses the major issues and challenges facing all delivery systems, including those providing mental and physical health care. Future trainers need to know how to conduct research in large settings using archival data, how to allocate resources and how to influence the forma- tion of healthcare policies. While current clinical psychology services focus on delivery to a single client, Snyder and Elliott argue that we would have more impact with a top-down approach. Future clinical psychologists should be much more involved in commissioning, accrediting and validating service provision. Finally, they argue that there is no intrinsic loss of kudos or effectiveness in promoting less costly forms of psychological treatment possibly delivered by less intensively trained staff, as long as such individuals are appropriately monitored, supervised and evaluated. This is an argument which is currently finding much favour in the UK, which is introducing the widespread delivery of evidence-based psychological therapies by relatively junior therapists under the supervision of trained clinical psychologists. In conjunction with the New Ways of Working initiative, this project (Improving Access to Psychological Therapies, see also Chapter 29) aims to significantly increase the influence of psy- chology in healthcare contexts (British Psychological Society, 2007).
Finally, Stricker (2007) presents the Local Clinical Scientist (LCS) model as another potential bridge between science and practice. The LCS model operates from the assumption that science is not defined by activities or generalisations, but by attitudes. Activities vary, generalisations decay, but attitudes cut across disciplines and findings. All scientists should aim to be keen observers, characterised by disciplined inquiry, critical thinking, imagination, rigour, scepticism, and openness to change in the face of evidence. The LCS carries these attitudes into the practice setting, raising hypotheses in the consulting room and seeking confirmatory or disconfirmatory evidence in the immediate response to the patient. This scientific attitude towards clinical phenomena is crucial since it is the systematic study of clinical work that reduces distortions and refines effective clinical decision making. The model recognises the salience of idio- graphic aspects of practice, but also accommodates knowledge of data and the balance of evidence. Stricker (2002) calls for more research to be based on naturalistic phenom- ena which are more likely to be of value to the clinician and be incorporated within daily practice.
A Way Forward
Many advocates of practice-focused research now consider that the gap between the scientist and practitioner aspects of the profession could be bridged by bringing more science into the practice. Reflective practice also plays a significant part in articulating this junction. The methodological pluralism that is necessary to achieve this would create an alliance that is likely to be increasingly effective in managing psychological problems, if only because it calls on a much broader understanding of clinical phenomena.
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44 Paul Kennedy, Susan Llewelyn and Helen Beinart
The bi-directional integrated approach also necessitates a more active patient participant and a more flexible therapist or experimenter. Patients or clients would therefore no longer be passive participants who are studied and manipulated by researchers to pro- duce findings which have limited generalisability. Snyder and Elliott (2005) believe that it should not be beyond the scholarship of the 21st century to manage the ‘disconnect’ between academic research and applied clinical areas. They further suggest that our research expertise should be used to triage persons who require the services of high-cost doctoral-level providers, as compared to those who may fare well with low-cost providers. Research should examine existing clinical practice, which could be uplifted by newer applied research methodologies and more sophisticated forms of clinical data analysis. Such joint scholarship may help move away from the simplistic, reductionist perspective of linear causality, and may help to build a model to promote clinical psychology in the 21st century, just as constructively as the Boulder model did for the 20th.
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