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What is Clinical Psychology?

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What is Clinical Psychology? FIFTH EDITION

Edited by

Susan Llewelyn Professor of Clinical Psychology, Harris Manchester College, University of Oxford, Oxford, UK

David Murphy Joint Course Director—Oxford University Doctoral Clinical Psychology Programme, Oxford Institute of Clinical Psychology Training, Isis Education Centre, Warneford Hospital, Oxford, UK

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Preface to the fifth edition

‘What is Clinical Psychology?’ is a question that we continue to be asked by a range of people including patients who are referred to see us, undergraduates and postgraduates considering a career in this field, col- leagues in other health or social care professions, and interested family or friends. The aim of this book is to provide a broad but well-informed outline of the activities that clinical psychologists perform, and also to give a ‘feel’ of what it is like to practice as a clinical psychologist in dif- ferent fields.

Clinical psychology is one of the fastest growing health professions in the United Kingdom and in many countries elsewhere in the world. The first psychological clinic was only established a little over a hundred years ago in the USA and the profession of clinical psychology has only been formally recognized in the UK for some 60 years. Nevertheless, the size of the profession in this country has more than quadrupled since the publication of the first edition of this book in 1987. Moreover, the pro- fession has extended into a wide range of new settings and client groups. This edition contains new chapters on working with trauma, and clini- cal psychology and diversity. In addition, given that the last edition was written more than 7 years ago, we took the decision to approach new authors to completely rewrite the majority of the existing chapters, while the remaining chapters have been significantly updated by the previous authors. We therefore believe that the content of this book represents a comprehensive and contemporary account of the profession today. Although many examples are drawn from UK practice, most of the approaches and theories are shared internationally, and we have been conscious throughout the book to bear international readers in mind by providing explanation of UK context where appropriate.

In the 27 years since the first edition of this book was published, there have been numerous other books published in the field of applied psy- chology. These books fall into two broad categories: first, those that

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PrEFaCE TO THE FIFTH EDITIONvi

offer a detailed account of theory and practice of a particular special- ist area of practice, presenting problem or therapeutic modality, and second, those that have a broader remit and attempt to cover a field of applied psychology, such as mental health or health psychology, normally for the purpose of teaching. The specific aim of this book is somewhat different in that we aim to provide a living account of the day-to-day activities of clinical psychologists across a wide range of dif- ferent areas. In doing so, we have tried to convey not just what a clinical psychologist does but importantly why they do so, by linking in the underlying psychological models and theories that are applied in their work. We also aim to look ahead to identify emerging trends and driv- ers of clinical psychology practice in each area of specialist practice in the years ahead. This is undoubtedly an ambitious task and could only ever realistically be achieved by calling on the collective knowledge and experience of a number of authors, each of whom is a leader in their particular field.

This book does not need to be read from beginning to end, although most readers will find it helpful to start with Chapters 1 and 2 before proceeding further, since these provide the context for contemporary clinical psychology practice and describe the essential competencies that provide the foundation for practice with the different populations and presenting problems described subsequently. At the end of each chapter there is a list of key references and suggested further reading on the material covered. These have been chosen to be accessible to non- specialist readers.

This is the fifth edition of this text, and we are indebted to the editors of previous editions, Professor John Hall and Dr John Marziller, who have handed responsibility for this next edition to us. We hope that this book will be as helpful as the previous editions have been in presenting the profession clearly and informatively to our readership. Across all five editions of this book the editors have been fortunate to be able to call upon clinical psychologists who are at the cutting edge of their specialist fields to contribute their own particular, up-to-date perspectives, which we believe is a unique strength of the book. Clinical psychology con- tinues to be a rewarding and challenging career, which is still evolving.

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PrEFaCE TO THE FIFTH EDITION vii

There are now opportunities to work in new areas and to use innovative approaches that were not conceived of, or only aspired to, at the time of the first edition. We hope that in this book we have conveyed at least a sense of our excitement and enthusiasm for the profession as it contin- ues to develop.

We are grateful to all of the authors in the book for their willingness to contribute and for their dedication. We would like to thank Martin Baum and Charlotte Green of Oxford University Press for their support and encouragement through the process.

Oxford SL July 2013 DJM

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Contents

Contributors xi

1 Introduction: what is clinical psychology? 1 David Murphy and Susan Llewelyn

2 Competencies and models in clinical psychology 17 Susan Llewelyn and David Murphy

3 Working in primary health care 37 John Cape and Yvonne Millar

4 Working with children and young people 53 Duncan Law

5 Working with severe mental health problems 69 John Hanna and Alison Brabban

6 Working with older people 85 Cath Burley

7 Working with eating disorders 103 Hannah Turner

8 Working with people with intellectual disabilities 119 Steve Carnaby

9 Working in forensic mental health settings 137 Jeremy Tudway and Matthew Lister

10 Working with addictions 153 Frank Ryan

11 Working with trauma 169 Nick Grey and Sue Clohessy

12 Working with people who have physical health problems 187 Elenor McLaren and David Murphy

13 Working in clinical neuropsychology 205 Katherine Carpenter and Andy Tyerman

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x CONTENTS

14 Clinical psychology in teams and leadership 223 Susan Llewelyn

15 Working with cultural diversity 237 Kamel Chahal

16 The future of clinical psychology 253 David Murphy and Susan Llewelyn

Appendix 1 Becoming registered as a clinical psychologist in the UK 269

Index 273

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Contributors

Alison Brabban Clinical Lead, Early Intervention in Psychosis, Tees, Esk and Wear Valleys NHS Trust, Honorary Senior Lecturer, Durham University, St Aidans House, 2a St Aidans Walk, Bishop Auckland, County Durham DL14 6SA [email protected]

Cath Burley The Chair—Faculty of Psychology of Older People, Division of Clinical Psychology, British Psychological Society, 48 St Andrews House, Princess Road East, Leicester LE1 7DR [email protected]

John Cape Head of Psychological Therapies, Camden and Islington NHS Foundation Trust, St Pancras Hospital, 4 St Pancras Way, London NW1 0PE [email protected]

Steve Carnaby Consultant Clinical Psychologist, Autism Anglia and Affinity Trust, and Honorary Senior Lecturer, Tizard Centre, University of

Kent, Unit 3 Old Pharmacy Yard, Church Street, Dereham, Norfolk NR19 1DJ [email protected]

Katherine Carpenter Consultant Clinical Neuropsychologist/Trust Head Psychologist, Russell Cairns Unit, Level 3 West Wing, John Radcliffe Hospital, Oxford OX3 9DU [email protected]

Kamel Chahal Chartered Clinical Psychologist, South Lambeth Recovery and Support Team, South London and Maudsley NHS Foundation Trust, 380 Streatham High Road, Streatham, Lambeth, London SW16 6HP [email protected] [email protected]

Sue Clohessy Consultant Clinical Psychologist, Oxford Institute of Clinical Psychology Training and Oxford Health NHS Foundation Trust, Isis Education Centre, Warneford Hospital, Oxford OX3 7JX [email protected]

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CONTrIBUTOrSxii

Nick Grey Consultant Clinical Psychologist, Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust, 99 Denmark Hill, London SE5 8AZ [email protected]

John Hanna Consultant Clinical Psychologist/ Lead Psychologist for Acute Division, Camden and Islington NHS Foundation Trust, Acute Inpatient Clinical Psychology Service, Highgate Mental Health Centre, Dartmouth Park Hill, London N19 5NX [email protected]

Duncan Law Professional Lead for Psychological Service (CAMHS), Hertfordshire Partnership University NHS Foundation Trust, Hoddesdon Health Clinic, EN11 8BE Clinical Lead for CYP-IAPT, The Anna Freud Centre, 12 Maresfield Gardens, London NW3 5SU [email protected]

Matthew Lister Consultant Clinical Psychologist, Forensic CAMHS/Forensic Adult Services, Oxford Health Foundation NHS Trust,

Marlborough House Medium Secure Unit, Milton Keynes Hospital Campus, Standing Way, Eaglestone, Milton Keynes MK6 5NG [email protected]. uk

Susan Llewelyn Professor of Clinical Psychology, Harris Manchester College, University of Oxford, Mansfield Road, Oxford OX1 3TD

Oxford Health NHS Foundation Trust, Chancellor Court, 4000 John Smith Drive, Oxford Business Park South, Oxford OX4 2GX [email protected]

Elenor McLaren Principal Clinical Psychologist, The Pain Management Centre, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS FT, Queen Square, London WC1N 3BG [email protected] [email protected]

Yvonne Millar Consultant Clinical Psychologist, Community CAMHS, Northern Health Centre, 580 Holloway Road, Islington, London N7 6LB [email protected]

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CONTrIBUTOrS xiii

David Murphy Joint Course Director—Oxford University Doctoral Clinical Psychology Programme, Oxford Institute of Clinical Psychology Training, Isis Education Centre, Warneford Hospital, Oxford OX3 7JX [email protected]

Frank Ryan Consultant Clinical Psychologist, Substance Misuse and Forensic Division, Camden and Islington NHS Foundation Trust, 108 Hampstead Road, London NW1 2LS [email protected]

Jeremy Tudway Consultant Clinical and Forensic Psychologist, Clinical Director, Phoenix Psychology Group, 73–75 Priory Road, Kenilworth CV8 1LQ [email protected]

Hannah Turner Consultant Clinical Psychologist, Specialist Eating Disorders Service, Southern Health NHS Foundation Trust, April House, 9 Bath Road, Bitterne, Southampton SO19 5ES [email protected]

Andy Tyerman Consultant Clinical Neuropsychologist/Head of Service, Community Head Injury Service, Buckinghamshire Healthcare NHS Trust, The Camborne Centre, Jansel Square, Aylesbury HP21 7ET [email protected]

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Chapter 1

Introduction: what is clinical psychology?

David Murphy and Susan Llewelyn

1.1 What is clinical psychology?

Helen’s day begins with a visit to a large secondary school where she is meeting teachers to discuss Jodie, a 14-year-old girl who is currently sus- pended from school after violently assaulting another pupil. Last week Helen met with Jodie and carried out a clinical interview and psycho- metric assessment, and she hopes that the formulation she has developed about Jodie’s specific learning difficulties and deficits in social perception will help the school in developing an effective approach both to manage her behaviour and to improve Jodie’s engagement with school work.

Chris is sitting in a consulting room in the outpatients department of a local hospital with Rajiv, a successful 34-year-old advertising executive who has obsessive compulsive disorder. Rajiv avoided touching the door handle when he entered the office but Chris is explaining a behavioural approach that will eventually require Rajiv to touch the outside of doors, including the toilet door in the hospital, and then resist the urge to wash his hands. Chris is also collecting data on the outcome of the intervention, which will be used in a current research project to investigate key compo- nents of the treatment.

Jana is sitting at Colin’s bedside in a hospital spinal injuries unit; Colin was involved in a car accident 6 weeks ago which left him paralysed from the neck down. Jana has been asked to see him as the unit staff are very concerned about his mood and low motivation to participate in rehabili- tation. Colin has refused to allow his fiancée to visit him as he believes he is ‘no longer the man she wanted to marry’ and ‘doesn’t want her pity’.

Alice is carrying out a training session at a nursing home to help the staff develop the skills to effectively manage challenging behaviour in

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?2

people with dementia whilst continuing to maintain respect and dignity. A member of staff at the home has recently been reprimanded for shout- ing at an 80-year-old man who had thrown yoghurt at her during meal time. Alice is also building a database on effective systemic interventions for use when disseminating psychological skills to care staff.

Although they are working in very different environments and with quite different populations, Helen, Chris, Jana, and Alice have one thing in common, they are all clinical psychologists. Indeed, these four clini- cal psychologists are fairly representative of the profession in the UK. Prior to training as a clinical psychologist almost all have undertaken an undergraduate degree in psychology which confers eligibility for Grad- uate basis for Chartered Membership (GBC) with the British Psycholgi- cal Society (BPS), or a joint degree with a sufficient coverage of the core areas in Psychology to be awarded GBC. However, Chris undertook a first degree in law and subsequently undertook a conversion diploma course to obtain GBC, whereas Jana completed her undergraduate psy- chology course in another European country before coming to the UK, where she worked first as a health care assistant on an inpatient men- tal health unit and later as an assistant psychologist before starting her postgraduate clinical psychology training.

At present in the UK all clinical psychology training programmes are 3-year full-time doctoral courses (D.ClinPsych). They generally consist of an average of 3 days a week of clinical training on placement and 2 days a week of formal teaching at the university (see Appendix 1 for further details of training procedures). All programmes include under- taking a piece of research which forms the basis for a dissertation and also a shorter service evaluation project. Many other countries have now established similar training curricula and courses, at either doctoral or master’s level. Successful completion of the doctoral programme in the UK gives eligibility to apply to the Health and Social Care Professionals Council (HCPC) for registration as a clinical psychologist. This registra- tion is required by law in order to practice as a clinical psychologist, and indeed ‘Clinical Psychologist’ is one of the seven practitioner psycholo- gist titles that are protected by UK law, and, as such, non-registered indi- viduals inappropriately using the titles are liable to criminal prosecution.

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1.2 THE EMErgENCE OF PSyCHOLOgy aS a DISTINCT DISCIPLINE 3

The primary aim of this text is to provide an insight into the nature of the profession of clinical psychology and what it is like to be a clinical psychologist. As the preceding four short descriptions illustrate, clini- cal psychology is an enormously diverse profession. This introductory chapter will include a general overview of how the profession of clinical psychology has developed since its beginnings in the early 20th century and the current state of the profession in the 21st century, and will then scope out how psychologists work in practice, particularly in the UK’s NHS. There will also be an overview of the ethical and value base of the profession, and an examination of the possible impact on practition- ers themselves. Subsequent chapters each focus on a different setting in which clinical psychologists work, which we hope will help to provide a vivid but informed picture of what this work involves.

1.2 The emergence of psychology as a distinct discipline

Psychology as an undergraduate subject is now among the most popular subjects studied in universities in the UK and elsewhere. There are cur- rently approximately 70,000 full- or part-time students studying psy- chology at undergraduate level in UK universities. However, despite its popularity, psychology is still a relatively young subject. In textbooks it is quite rare to find references to any work before the 20th century.

The first person to refer to themselves as a ‘psychologist’ was the Ger- man physicist and physiologist Wilhelm Wundt who had been a student of the physicist Hermann von Helmholtz. Wundt established the world’s first experimental psychology laboratory at the University of Lepzig in 1879.

In the UK, experimental psychology evolved as a distinct discipline in the very early years of the 20th century, initially at University College London (UCL) where James Sully established a psychological labora- tory in 1889, about 10 years after Wundt, and then at the University of Cambridge where a psychological laboratory was established in 1912 by Charles Spearman who had trained as a physician but who then devel- oped an interest in psychology. Spearman later served as a consultant psychologist to the British Army in France during the First World War and went on to write the first scientific paper describing the condition known as ‘shell shock’.

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?4

In 1928, a separate Department of Psychology was created within London University, and Spearman was made Professor of Psychology, going on to develop the concept of general intelligence for which he is best remembered.

The first meeting of what was to become the BPS took place at UCL in 1901, and the Society was formally established in 1906. Although the Society was formed only from teachers of psychology, of the ten founder members present at the first meeting five had trained as medical practi- tioners. Only one was female, Sophie Bryant, the headmistress of North London Collegiate, an independent girls school.

1.3 Psychology in practice

Psychology was applied in practice very shortly after its establishment as a distinct academic discipline at the end of the 19th century, although psychology practice occurred only on a very small scale until the latter half of the 20th century. Whereas today the dominant areas of psycho- logical practice are probably within adult mental health and psychologi- cal therapy, in fact the early application of psychology in practice was mainly driven by the emergence of psychometrics and also the preventa- tive principles of the mental hygiene movement in the USA, and focused predominantly on children rather than adults.

The development of psychology practice came about as a result of the work of a number of pioneering individuals originating from a wide range of academic backgrounds, who all became influenced through various means by the emerging discipline of experimental psychology, and then developed innovative ways of applying psychological princi- ples to people’s lives.

One of the first of such individuals was Alfred Binet who graduated from Law school in France in 1878 and, after studying natural sciences at the Sorbonne, developed an interest in psychology and educated himself through reading early textbooks at the National Library in Paris.

A chance meeting on a Paris railway platform in 1891 with Dr Henri Beaunis, then Director of the Experimental Psychology Laboratory at the Sorbonne, led to Binet being appointed associate director of the Lab- oratory. Towards the end of the 19th century, the French Government

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1.3 PSyCHOLOgy IN PraCTICE 5

introduced a law requiring all children from the ages of 6 to 14 to receive state education. In 1901 Binet was asked by the Department of Education to develop a standard test to identify children who would require addi- tional educational support. Binet took on the challenge and the result was the world’s first IQ test, the Binet-Simon Scale. This test was soon adapted by American psychologists Lewis Terman and Robert Yerkes who constructed measures that were administered on a very large scale to prospective recruits to the US Army, thereby firmly establishing the applied use of psychometrics.

The application of the psychometric method in the UK owes much to the work of Cyril Burt who graduated in Philosophy from Oxford in 1906. Although a formal degree course in Psychology was not estab- lished at Oxford until after the Second World War, Burt developed an interest in the newly emerging field of Psychometrics fostered by Wil- liam McDougall who had been appointed as a reader in Mental Philoso- phy (psychology was generally regarded as a branch of philosophy at the time).

After graduation, Burt worked with McDougall on a national survey measuring mental and physical attributes of the general population (together with Charles Spearman). In the summer of 1908, Burt visited the University of Würzburg, Germany, where he first met the psycholo- gist Oswald Külpe who had been an assistant to Wundt at Lepzig and further influenced Burt’s interest in psychometrics.

In 1913, Burt took the part-time position of a school psychologist for the London County Council (LCC), with the responsibility of identify- ing ‘feeble-minded’ children, in accordance with the Mental Deficiency Act of 1913. The fact that some of his later work was discredited should not obscure the significance of his earlier contribution.

The first use of the term ‘clinical psychology’ is widely credited to Lightner Witmer in the USA, who founded the world’s first psychologi- cal clinic in 1896 at the University of Pennsylvania. Witmer, whose first degree had been in economics followed by graduate studies in political science, had become interested in remediation of educational difficulties whilst working as a school teacher and where he had assisted a 14-year- old boy overcome specific language difficulties. He subsequently joined

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?6

the experimental psychology laboratory at Pennsylvania as an assistant to James Cattell, another former student of Wilhelm Wundt, and indeed Witmer himself also spent a year as a student of Wundt in Lepzig.

Subsequently Clifford Beers founded the mental hygiene movement in America as a result of witnessing and himself experiencing maltreat- ment while hospitalized because of depression and paranoia. Starting in the 1920s, mental hygienists promoted a therapeutic perspective toward the everyday problems of children with the aim of prevention and early intervention. The US National Committee was also instrumental in the establishment of Child Guidance clinics.

In the UK the children’s department at the Tavistock Hospital was founded in 1926 and was staffed by doctors, social workers, and also psychologists whose role was ‘the carrying out of psychological tests and the ascertainment of intelligence quotients’.

Shortly afterwards the Notre Dame Centre in Glasgow opened in 1931 and was the first Child Guidance Clinic to be directed by a psy- chologist, Sister Marie Hilda, and is still operating today. Child guid- ance clinics provided services for children with a range of problems, from bed- wetting and stammering to delinquent behaviour. In addition to conducting psychometric tests, psychologists used play therapy to understand the nature of the children’s difficulties.

Despite these early steps towards applying psychology in practice, the discipline of psychology in the UK remained very small until after the Second World War: the number of members of the BPS stood at only 811 in 1941.

The focus of academic psychology was understandably drawn towards military issues during this period, particularly selection and support for the forces. However, in the aftermath of the war the National Health Ser- vice (NHS) was created and this presented an opportunity for psycholo- gists to formally establish a new profession: clinical psychology.

1.4 Clinical psychology in the National Health Service

It was only after the war that UK psychologists began working in the field of adult mental health. An informal ‘Committee of Professional Psychologists (Mental Health)’ formed within the BPS, and held its first

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1.4 CLINICaL PSyCHOLOgy IN THE NaTIONaL HEaLTH SErvICE 7

meeting in 1943. The inclusion of ‘mental health’ created an explicit link with the establishment of the National Association for Mental Health (NAMH), assembled from a merger of the three main national volun- tary mental health organizations of the time: the Central Association for Mental Welfare, the National Council for Mental Hygiene, and the Child Guidance Council (interestingly in 1972 the NAMH was renamed MIND and remains a major mental health charity today).

The BPS Committee was initially made up of a fairly small group of educational psychologists, mainly women, and was chaired by Lucy Fildes. Fildes was another pioneer in the application of psychology for children’s difficulties: she had initially worked as a researcher at Cam- bridge under C.S. Myers and later Frederic Bartlett, and subsequently went on to become the head of psychology at the London Child Guid- ance Clinic. Much of the administration of the committee was under- taken by May Davidson. Davidson grew up in South Africa and studied psychology at UCL. She went on to be appointed as Educational Psychol- ogist for the City of Oxford in 1946 and later to the Warneford Hospital where she began working with adults and then to develop pioneering clinical psychology services. She was subsequently appointed as the First Consultant Adviser on Clinical Psychology to the Department of Health and Social Security 1973–1980, for the first time explicitly marking the involvement of psychologists in national policy making.

In an article written when she was President of the BPS, Davidson eloquently captured the tension that has always existed between the scientific foundations of psychology as an academic discipline and the application of psychology in practice. ‘A psychologist educated in the Brit- ish academic tradition normally internalizes a demand for certainty and acquires the expectation that human behaviour will be fully explained. The student who then obtains training in applied psychology enters a state of conflict brought about by the ambiguities and uncertainties of practical work, and colleagues and clients who do not share the value system that requires scientific explanations of human behaviour’ (Davidson, 1977). This is a theme that will be returned to elsewhere in this book.

The first ever trainees in clinical psychology in the UK started at the Maudsley Hospital in 1946 and the course was formalized in 1949 into

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?8

a 13-month postgraduate diploma course awarded by the University of London. From the outset the course was led by Monte Shapiro who had come to the UK after completing an undergraduate degree in South Afri- ca. Clinical work amongst psychologists at the Maudsley Hospital was initially confined solely to psychometric testing. Indeed, the then head of the Psychology Department, Hans Eysenck, initially argued against psychologists taking on any therapeutic role, claiming that therapy was ‘essentially alien’ to a scientific discipline like psychology. There was cer- tainly no pressure for psychologists to take on therapeutic roles, since psychotherapy remained the exclusive preserve of medically qualified psychiatrists who showed no indication that they wished to relinquish their monopoly.

Nevertheless, Shapiro developed a person-centred clinical approach based on a hypothesis-testing single case experimental methodology. Initially, this approach was restricted to assisting in establishing a diag- nosis, but the conditioning principles identified by Pavlov and others presented an opportunity to apply the approach to intervention.

Subsequently, Eysenck also began to modify his views after visiting the University of Pennsylvania in 1949, where clinical psychology was developing a much more directly therapeutic role (perhaps unsurpris- ingly since it had been the base for Witmer’s first clinic some 50 years previously). Indeed, in 1958 Eysenck delivered a lecture at the Royal Medico-Psychological Association (which later became the Royal Col- lege of Psychiatry) in which he described the emerging field of behaviour therapy and argued that psychiatrists should focus on disease processes, whilst psychologists should modify learned responses. Subsequently, the application of learning principles to treatment of phobias and other anxiety disorders was developed by H. Gwynne Jones and Vic Meyer, two clinical psychologists working at the Maudsley Hospital in London.

Although the Maudsley course was the first formal clinical psychol- ogy training course, other related courses developed at around the same time from very different traditions. An adult-focused training course developed from the existing child-focused course at the Tavistock Clin- ic, which had been founded in 1920 and was strongly influenced by the psychodynamic models developed by Sigmund Freud.

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1.5 SUBSEqUENT PrOFESSIONaL DEvELOPMENTS 9

A different approach to clinical psychology was also developing con- temporaneously at the Crighton Royal Hospital in Scotland where the psychologist John Raven had been invited to set up a department of psy- chological research in 1943. This programme was heavily influenced by humanistic psychology, an approach that rejected much of what it saw as the reductionism of experimental psychology, valuing instead intuitive forms of knowledge and the importance of personal relationships and self-understanding.

From the very beginnings of clinical psychology in the UK, and indeed in the USA, a number of approaches have therefore influ- enced the nature of the profession, although the behavioural and later cognitive-behavioural model emerging from the Maudsley was more dominant in the UK, whereas the psychodynamic model remained the dominant influence in the USA. This may help to explain why the cogni- tive approaches of Aaron Beck (an American psychiatrist) and Albert Ellis (an American psychologist) became much more quickly and read- ily adopted into mainstream clinical psychology training in the UK than in their homeland.

1.5 Subsequent professional developments

Based in the UK, a working group of the BPS Committee of Profes- sional Psychologists (Mental Health) (CPP-MH) was formed in 1950 of psychologists working with adults, which then led directly to a highly significant event on 7 February 1952, when the first Whitley circular (PTA 10) was published by the Department of Health, and which offi- cially recognized the existence of clinical psychologists within the NHS. It specified the minimum qualifications required for employment as an honours degree in Psychology, and a grading structure—entry level (£380 per year), basic grade (£520 per year), senior (£810), and top grade (£1,300).

In September 1957, the Department of Health officially approved named training courses, three of which were ‘general’ courses (Institute of Psychiatry, Tavistock Clinic, and the Crichton Royal) in that they provided training with children and adults, whereas four courses were in Educational Psychology and provided training with children only.

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?10

The additional ‘probationer’ route to enter the profession, essentially a supervised apprenticeship with no formal assessment, remained avail- able throughout the 1970s.

Despite the emergence of clinical psychology as a distinct entity soon after the birth of the NHS in 1946, a separate Division of Clinical Psy- chology was not established within the BPS for another 20 years, until 1966. However, the two annual UK professional achievement awards currently presented by the BPS Division of Clinical Psychology are still named after the pioneers May Davidson and Monte Shapiro.

The clinical psychology profession continued to develop at a fairly slow but steady rate through the1970s and 1980s, although through the 1990s and the first half of the next decade there was a very substantial and sustained increase in the number of training places (see Figure 1.1), and thus the profession. Progressively all the training courses evolved into university-based master’s courses, and eventually into 3-year doctorates.

Fig. 1.1 Clinical psychology training places in the UK. Data reproduced from Clinical Psychology Training Clearing House (<http://www.leeds.ac.uk/chpccp/>).

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1.6 CUrrENT CONTExT OF CLINICaL PSyCHOLOgy PraCTICE 11

1.6 Current context of clinical psychology practice

Although the number of clinical psychologists working within the NHS has increased dramatically since 1998, the numbers are still relatively small in comparison to the number of people in the general population who experience psychological difficulties. For instance, based on large- scale prevalence studies, it is estimated that there are over 6,000,000 individuals currently experiencing depression or anxiety disorders in England alone. This equates to less than one practising clinical psychol- ogist for 600 people with common mental health problems, not count- ing any other type of presenting problems. The New Ways of Working in Applied Psychology report produced jointly between the Department of Health and the BPS in 2008 highlighted the need for a mix of skills within the psychological workforce, and the need to utilize flexible approaches to service delivery (see also Lavender, 2009).

Then in 2008, the Department of Health in England launched a major programme of new investment in psychological therapies provision (Increasing Access to Psychological Services or IAPT) which consisted of an additional £900 million of funding allocated over 6 years. A key objec- tive of the programme was to produce 6,000 additional psychological therapists including clinical psychologists and other mental health pro- fessionals, trained to deliver formal evidence-based psychological thera- pies. Another aim was training psychological wellbeing practitioners, via a 1-year training programme, to deliver low-intensity psychological inter- ventions such as guided self-help and group-based psycho-educational programmes under supervision, within a ‘stepped-care approach’. This stepped-care model was recommended by the National Institute for Health and Clinical Excellence (NICE) and had two essential principles: 1 The intervention provided must have the best chance of delivering

positive outcomes whilst simultaneously placing the least possible burden on the patient.

2 There must be a system of scheduled review to detect and act on non- improvement to enable ‘stepping up’ to more intensive treatments; ‘stepping down’ where a less intensive treatment becomes appropri- ate; and ‘stepping out’ when an alternative treatment or no treatment become appropriate.

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?12

While the IAPT programme is limited to England, similar stepped- care programmes to expand access to evidence-based psychological therapies have been developed in other nations within the UK. In par- ticular the NHS in Scotland has developed a very comprehensive frame- work across a range of client groups for matching the appropriate level of intervention to specific psychological difficulties (NHS Education for Scotland, 2011).

1.7 Current interface between science and practice

The scientific foundations of clinical psychology have developed very significantly since the early application of psychometrics and classical conditioning. The impressive development of the profession has resulted from a dynamic interaction between psychological research and clinical practice.

Recent examples of such innovation have included work in the field of post-traumatic stress disorder by Emily Holmes, a clinical psycholo- gist, who has undertaken research based on cognitive neuroscience (Holmes et al., 2009). She has developed a novel treatment for the pre- vention of post-traumatic stress symptoms, building on research that has demonstrated that the brain has selective resources with limited capacity, and that new memories consolidate in the brain over a period of about 6 hours. Holmes reasoned that it might be possible to develop a ‘cognitive vaccine’ which would selectively compete for resources required to generate mental images and thereby to disrupt the con- solidation of flashback memories in the immediate aftermath of a trau- matic event. Holmes and colleagues showed in an experiment with normal volunteers that undertaking a visual spatial task, based on the computer game Tetris, for just 30 minutes after watching a film show- ing traumatic events led to significantly fewer flashbacks being experi- enced in the following week. Thus an intervention that was developed directly from predictions from psychological theory may in the future be shown to prevent the occurrence of psychological disorders in prac- tice, and become incorporated into clinical protocols designed to help people who have experienced traumatic events (see also Chapter 11). Similarly, other observations and insights from clinical practice may

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1.8 INTEgraTION WITHIN aND CONTrIBUTION TO MaINSTrEaM HEaLTH CarE 13

be used by clinical psychologists to modify existing theories about the causes, maintenance, and effective treatment of psychological disor- ders. For instance, psychologists such as David Fowler, Phillipa Garety, and Elizabeth Kuipers have conducted influential research questioning existing psychiatric diagnostic approaches to schizophrenia, instead developing therapeutic interventions for people experiencing psy- chosis by modification of distressing symptoms, or by helping people to change their understandings of these symptoms (see Fowler et al. (1995) and also Chapter 5).

1.8 Integration within and contribution to mainstream health care

As this brief historical outline of the profession has shown, clinical psy- chology is a relative newcomer to health care, creatively finding its place alongside the giants of medicine and nursing, together with many other well-established but smaller professions such as occupational therapy, speech and language therapy,and physiotherapy. Clinical psychology also claims its own unique contribution as an applied science, draw- ing on the science of psychology (see Chapter 2 for more discussion of this issue). In some cases, psychologists have taken on and developed tasks previously carried out by other groups (testing children or psy- chotherapy, for example), while in other instances they have become service innovators (for example devising many original behavioural treatments and neuropsychological assessements). In most cases clinical psychologists have worked with others in multi-disciplinary teams, and have contributed to team work by adding their essential psychological perspective to the care of patients. Although their early work was often linked with mental health difficulties, currently psychologists work in a wide range of health care settings, including paediatrics, palliative care, spinal injury, burns, and diabetes units, for example, demonstrat- ing the growing integration of the profession with mainstream services. Broader developments in health care mean that psychological issues are nowadays given far more recognition than they were hitherto, opening numerous avenues for psychologists to make contributions to the wel- fare of people in distress or pain. Fifty years ago it would have been quite

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?14

rare to meet a clinical psychologist anywhere at all: now psychologists play an accepted role in most modern health care services and settings.

One question that arises as a consequence of this relatively recent pro- fessional arrival is, what constitutes psychologists’ special contribution, or ‘unique selling point’, amongst all other health care providers? The issue of professional identity is hotly debated, but most psychologists would point to their particular ability to provide detailed, theoretical- ly derived assessments or formulations, and complex evidence-based treatments for a range of patients, together with a scientific approach to clinical problems, drawing on advanced clinical research skills. So, for instance, Helen, Chris, Jana, and Alice (introduced earlier in this chapter) all apply unique clinical formulations to their patients’ dif- ficulties and develop personalized treatment plans, but they also seek to use their skills to further develop the evidence base for use by other clinical professionals in future. Of course there are also a range of other branches of applied psychology, such as educational, organizational, and counselling, and all share many similarities: the core feature of clini- cal psychology, however, is its focus on working clinically within the health care context and its use of a range of therapeutic models, together with a research or evidence-based orientation to clinical problems or phenomena.

1.9 Ethics and values of the profession

The key professional values of clinical psychologists are contained in the BPS Code of Ethics and Conduct (2009), comprising the need to meet standards of respect, competence, responsibility, and integrity. This means that psychologists ‘value the dignity and worth of all persons, with sensitivity to the dynamics of perceived authority or influence over clients, and with particular regard to people’s rights, including those of privacy and determination’ (p. 10). In practice this means taking scrupu- lous care to respect confidentiality and always to obtain informed con- sent for interventions, and to work to advance client autonomy wherever possible. Psychologists need to be mindful of boundaries which protect both them and their clients, and to be aware of the impact of their own beliefs and values on their work. They have to avoid being drawn into

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1.10 THE IMPaCT OF BECOMINg a CLINICaL PSyCHOLOgIST 15

‘sides’ and to maintain objectivity when possible. Having regular super- vision is essential here, with the recognition that professional learning is a life-long requirement. Psychologists must not take on work that is outside their own sphere of competence, and should aim to work col- laboratively with others, including staff, carers, and families.

1.10 The impact of becoming a clinical psychologist

Working with psychological issues can be a demanding experience, especially for trainees when they embark on the career and as they move from placement to placement, learning new skills with a range of clients in novel contexts, and managing the anxiety of seemingly repeatedly being moved back to square one for every new clinical experience, while at the same time being assessed by stringent university procedures and requirements. Trainees are expected to take on a variety of new chal- lenges and responsibilities, including encountering human distress in a variety of forms, which means that they may have to confront issues such as mortality, abuse, or trauma, which do not normally form part of most people’s daily working lives. In addition, some trainees find it hard to maintain as much contact as they might like with family or friends liv- ing elsewhere, and time is limited for socializing. Nevertheless, trainees do progressively attain many transferable skills and gain in confidence as they master the core competencies, as well as developing their own par- ticular set of interests in specialist clinical areas. Training programmes have evolved a variety of approaches to encourage the development of personal and professional competencies, for example some courses fund confidential personal learning sessions for trainees, whilst others pro- vide small groups run by an external facilitator, so that trainees can learn about themselves within a confidential small group setting. The good news is that, despite the heavy demands, very few trainees fail to com- plete their clinical training, and the vast majority, once qualified, con- tinue to work as clinical psychologists for the rest of their working lives.

Over a career, clinical psychologists can expect to gain competence and skills in a range of ways of approaching and reducing human dis- tress. This is a highly fulfilling career, deepening the psychologist’s understanding of what it means to be human and to confront and survive

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INTrODUCTION: WHaT IS CLINICaL PSyCHOLOgy?16

distress. Experienced psychologists often report developing greater respect for individual differences and increased tolerance towards oth- ers, as well as having many valued memories of client triumphs. The demands of work are often considerable, and while financial rewards and the physical environment are not always as good as many would (understandably) prefer, nonetheless most psychologists consider their work to be a privilege, as well as being a source of constant stimulation and value.

References

British Psychological Society (2009). Code of Ethics and Conduct. BPS, Leicester (<http://www.bps.org.uk/sites/default/files/documents/code_of_ethics_and_ conduct.pdf>).

Davidson, M. (1977). The scientific/applied debate in psychology. Bulletin of the British Psychological Society, 30, 273–278.

Fowler, D., Garety, P., and Kuipers, E. (1995). Cognitive Behaviour Therapy for Psychosis. Wiley, Chichester.

Holmes, E.A., James, E.L., Coode-Bate, T., and Deeprose, C. (2009). Can playing the computer game ‘Tetris’ reduce the build-up of flashbacks for trauma? A proposal from cognitive science. PLOS ONE, 4, 1–6.

Lavender, T. (2009). Reflections on the impact of new ways of working for applied psychologists. Journal of Mental Health Training, Education and Practice, 4, 23–28.

NHS Education Scotland (2011). The Psychological Therapies Matrix (<http://www. nes.scot.nhs.uk/education-and-training/by-discipline/psychology/matrix.aspx).

Further reading

British Psychology Society Division of Clinical Psychology (2010). The Core Purpose and Philosophy of the Profession (<http://www.bpsshop.org.uk/clinical-psychology- the-core-purpose-and-philosophy-of-the-profession-p1394.aspx).

British Psychological Society History of Psychology Centre (<http://hopc.bps.org.uk/>). Hall, J. (2007). The emergence of clinical psychology in Britain from 1943 to 1958

part I: core tasks and the professionalisation process. History and Philosophy of Psychology, 9 (1), 29–55.

Hall, J. (2007). The emergence of clinical psychology in Britain from 1943 to 1958 part II: practice and research traditions. History and Philosophy of Psychology, 9 (2), 1–33.

Improving Access to Psychological Therapies (IAPT) (<www.iapt.nhs.uk>).

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Chapter 2

Competencies and models in clinical psychology

Susan Llewelyn and David Murphy

2.1 Introduction

The professional activities of most contemporary clinical psycholo- gists are underpinned by the reflective scientist practitioner model, an approach that integrates evidence-based practice with awareness of the importance of context and an ethical and value base. In applying this model, psychologists generally employ an iterative cycle of psychologi- cal competencies (assessment, formulation, intervention, evaluation, communication/consultation, and, if appropriate, service development) using interventions that are all to a varying extent based on psychologi- cal theory and empirical evidence. These competencies are used in order to understand how to resolve a range of psychological difficulties, in a variety of clinical settings. Exactly how all of these competencies are employed varies according to the specific therapeutic model used, and as applicable to a specific clinical presentation. In addition, the work is always subject to the psychologist’s own scrutiny and questioning about the underlying values and purpose of the work, and in whose interests the work is being carried out.

2.2 Psychologists as reflective scientist practitioners

Although most clinical psychologists aim to integrate the two aspects of the reflective scientific practitioner model, these are quite distinct perspectives and there is potentially a tension between the two. The scientist practitioner model was first articulated as an outcome of the Boulder Conference, held in 1949, which determined the content of clinical psychology training in the USA, and was subsequently enor- mously influential elsewhere. The model assumes that we will find the

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COMPETENCIES aND MODELS IN CLINICaL PSyCHOLOgy18

most helpful possible way to help a patient or family if we consistently apply and refine theories and practices about what works best, support- ed by evidence. In contrast, the reflective practitioner model, building on the work of Donald Schön (e.g. Schön, 1983), accepts that there are always a variety of ways to intervene, that no one position can ever be ‘right’, and that what we mean by ‘what works best’ depends on whose perspective is being taken. Striking a balance between these perspec- tives provides a fascinating dimension to clinical work, and means that, although drawing on a common evidence base, no two psychologists will practice exactly alike.

In practice, the ‘scientist’ aspect of the model refers not only to the psychologist’s attempt to base his or her professional interventions on evidence, but also, and in fact more crucially, to his/her aim to approach each new client, patient, or family like a scientist might approach a research question. Thus a psychologist will select an intervention based on a theoretically derived hypothesis, and apply it in a particular case, which may then be accepted, changed, developed, or rejected depend- ing on the outcome. So, for example, when asked to help a boy with nocturnal enuresis (bed wetting) a psychologist will first talk with the family and develop a hypothesis about what is causing the problem (for instance, that the boy had never learned to associate the sensation of bladder fullness with the need to wake up and urinate). At this point the psychologist might suggest a programme of therapy (for example, using a bell and pad), implement this with the boy, and assess whether or not the treatment has had any impact. If it has, this at least partially confirms the psychologist’s hypothesis, and the therapy will continue until the problem is resolved. If it has not, the psychologist (using the scientific method) will seek to develop another hypothesis which may imply the need for a different type of intervention. For example, the child’s level of anxiety at school or in the home might be identified as impacting indi- rectly on his difficulty in developing bladder control, so the next stage of intervention may focus on anxiety management.

The reflective aspect of the model is an essential part of professional practice. Psychologists need to be aware of the limits of what they are offering, and how values and beliefs shape understanding of what should

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2.3 COMPETENCIES aND MODELS WITHIN CLINICaL PSyCHOLOgy 19

be provided; hence reflection is a crucial component of their work. For example, a focus simply on the child with enuresis might deflect atten- tion from a wider systemic problem in the family, or could obscure evi- dence that he is being expected to gain bladder control at an early age because of a shared cultural belief despite this being beyond his current ability. Having reflective capacity ensures that psychologists think care- fully about their work to ensure that they practice in an ethically aware and culturally sensitive way, and in a way that allows for modification and development of theory and practice to fit individual circumstances. Reflection essentially means questioning, and having sensitivity about professional and clinical issues, and awareness of the values and assump- tions that underpin all our actions.

Nonetheless, the profession of clinical psychology also affirms certain overarching values, based on the fundamental acknowledgement that all people have the same human worth and the right to be treated as unique individuals. Clinical psychologists therefore aim to treat all people with dignity and respect, and to work collaboratively in partnership, to reduce psychological distress, and to enhance and promote psychologi- cal wellbeing, while being sensitive to the social circumstances within which people live. Supervision is seen as a life-long process which aids thought and promotes good professional practice, and as such provides an invaluable aid to effective reflection.

As both scientist and reflective practitioners, psychologists also always attempt to link theory and practice, and to increase understanding of how best to intervene. They therefore evaluate the outcomes of interven- tions so that services offered to similar patients in future will improve (clinical audit), whilst knowledge about the conditions or therapy will also increase (clinical research). In addition to benefiting the individual client, these processes benefit both future clinical services and the devel- opment of psychological theory more generally.

2.3 Competencies and models within clinical psychology

During their training, clinical psychologists develop a set of core clinical competencies. The specific application of these competencies depends

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COMPETENCIES aND MODELS IN CLINICaL PSyCHOLOgy20

on the nature of the client group. For example, an assessment with a cli- ent who has sustained a mild brain injury is more likely to involve paper and pencil psychometric tests than would an assessment with a client with a severe learning disability. Furthermore, the nature of assessment undertaken also reflects the theoretical perspective adopted. For exam- ple, if a systemic perspective is taken, then the focus is likely to be on patterns of interaction between family members, whereas a cognitive- behavioural perspective will require greater focus on an individual’s negative cognitions. This chapter introduces these issues and thereby forms the foundation for all the other chapters, in which applications of a range of competencies and models to specific clinical presentations are explained.

2.4 The core competencies

Assessment involves gaining an understanding of a person or situation, as well as of change and stability, and may involve contrasting the indi- vidual’s performance or results with those of comparable others. Assess- ment is normally the first step in any psychologist’s work, and forms the basis of what follows, although assessing the progress and outcome of any subsequent intervention is also routine. In the UK, the Health and Care Profession Council’s Standards of Proficiency state that clinical psychologists should ‘be able to choose and use a broad range of psycho- logical assessment methods, appropriate to the client, environment and the type of intervention likely to be required’. The Clinical Psychology Benchmark Statements (Quality Assurance Agency, 2004) provide a concise statement of the practice and purpose of assessment: ◆ the development and use of psychometric tests (including an appre-

ciation of the importance of sound psychometric properties of test instruments, such as reliability and validity);

◆ the application of systematic observation and measurement of behaviour in both daily life contexts and other settings (for exam- ple, comparing interaction patterns between a child and her peers in a nursery, before and after an intervention designed to decrease expressed hostility towards other children);

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2.4 THE COrE COMPETENCIES 21

◆ devising self-monitoring strategies for individual service-users, such as recording of daily activities or thoughts;

◆ the use of formal and informal interviews with clients, carers, and other professionals.

Carrying out meaningful assessments requires psychologists to devel- op an effective alliance with clients, families, or carers, and to under- stand the context of the presenting difficulty. For example, a psychologist might administer a widely used depression inventory, and a standard- ized cognitive battery of other tests, when trying to understand the problems of an elderly man who is becoming increasingly withdrawn and non-communicative with his family. However, when doing so, the psychologist will also seek to gain an understanding of his history, and current family and personal circumstances. Psychologists may also devise and use one-off, individualized assessment procedures. Working with a child with a specific but uncommon fear of butterflies, for exam- ple, might require the development of an individualized scale around the fear-inducing characteristics of butterflies to assess the child’s pro- gress. As another example, a psychologist aiming to reduce self-harming in a learning-disabled man might carry out an observational assessment of the sheltered accommodation in which the man is living, using a spe- cific schedule to investigate the unique working patterns of the staff in that particular unit.

According to the model used, the psychologist will pay particular attention to the ways in which clients, carers, or families describe them- selves and their difficulties, and will consider if there are any patterns to their responses. For example, if employing a cognitive model, the psy- chologist may seek specific examples of how a young person interprets her social experiences, and may try to uncover some of her negative assumptions about herself in relation to peers. However, a psycholo- gist employing a psychodynamic approach would pay more attention to the client’s way of seeking to relate personally to the psychologist. If applying a systemic therapy approach, a psychologist would probably assess the client together with significant family members or peers, and observe the nature of the interaction that takes place. No matter which

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COMPETENCIES aND MODELS IN CLINICaL PSyCHOLOgy22

model is used, a risk assessment will also be conducted whenever there is any suggestion that harm is a possibility, or in contexts where the cli- ent or others may be vulnerable.

Although assessment invariably takes place at the start of an interven- tion, it is also an on-going process occurring throughout, as the psychol- ogist seeks to ensure that the intervention is having the desired effect. Generally an initial assessment will be conducted in a single session, although some therapeutic approaches also suggest that formal assess- ment should take place over several sessions so that enough information can be obtained to produce a reasonably comprehensive formulation. As new ideas or information emerge during the intervention, it is often necessary to reassess the difficulty. For example, someone who presents with depression might reveal after several sessions of therapy that they have experienced traumatic sexual abuse as a child, which will undoubt- edly need further exploration, and will probably suggest changes to the intervention offered.

The assessment phase normally also involves the psychologist inform- ing the client about the likely course and outcome of the intervention as well as gaining informed consent (or that of appropriate family mem- bers or carers).

Formulation is a specific psychological process which brings togeth- er and integrates information gained during assessment, with relevant psychological theory and data, in order to provide an individually derived working model of the causal factors leading to and maintain- ing the problem. This model can then be used to plan an individualized approach for intervening. As such it is the cornerstone of professional practice, and has sometimes been seen as the key distinguishing feature of clinical psychology.

Different theoretical approaches will of course focus on different pos- sible causal and maintaining factors, and will draw upon different types of supporting evidence. But whatever the model used, formulation is central to any intervention. This ability to ‘access, review, critically eval- uate, analyse and synthesise data and knowledge from a psychological perspective is one that is distinct to psychologists’ (Clinical Psychology Benchmark Statements (Quality Assurance Agency, 2004)). Formulation

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2.4 THE COrE COMPETENCIES 23

is also probably the most creative aspect of a clinical psychologist’s work. It is normally carried out in collaboration with the client, and aims to make sense, for both client and psychologist, of the presenting difficulty.

Formulation is a process distinct from that of diagnosis, which is a pro- cedure particularly associated with a medical model. However, psychol- ogists may use diagnostic frameworks in addition to formulation, and in many ways the two processes can be seen as complementary to one another. Arriving at a diagnosis essentially involves using one of the two internationally recognized classification frameworks for mental health difficulties: the International Classification of Disease (ICD) published by the World Health Organization, or the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association. This is done in order to locate an individual’s presentation within a category or group of similar presentations. Making a diagnosis allows a clinician to draw on existing evidence about prognosis and likely effective interventions, and to facilitate communication between clinicians and with third parties, as well as to make threshold decisions about whether intervention is appro- priate. Diagnosis is essentially a ‘top-down’ process involving matching an individual’s presentation to a pre-existing category, whereas psycho- logical formulation is a ‘bottom-up’ process which involves creating a unique, tailored model based on the information presented by the client. Clinical psychologists can, and do, use both approaches in their work; however, in using a diagnostic framework psychologists are required to be mindful of the limited reliability and validity of many discrete diag- nostic categories within mental health, and the potential negative effects of the use of diagnostic labels in terms of stigmatizing a client and/or inappropriately locating a problem within one particular individual within a system (British Psychological Society, 2012).

When developing a formulation, attention is paid to background, pre- disposing factors which provide the setting, or sensitizing context, for the problem to develop, any precipitating factors which triggered the current concern, the presenting problem itself, and the perpetuating fac- tors that maintain it. Protective factors will also be noted. By contrast, systemic approaches particularly focus on identifying the client’s unique narrative, seeking out personal or culturally specific understandings.

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Other issues frequently included in psychological formulations are accounts of how physiological, behavioural, cognitive, and affective reactions all interact in maintaining distress. Some approaches to treat- ment (for example, the cognitive) provide a diagrammatic representa- tion of the problem which is shared with the client. This diagram will illustrate the links between previous experience, the formation of dys- functional assumptions or behaviours, how they were triggered by criti- cal incidents, how this led to distressing thoughts or imagery, and how this may then have led to the mental health problem. This is linked to behaviours (such as avoidance or checking of bodily sensations); physi- cal reactions (such as increased arousal); cognitions (such as rumination or focusing on body changes); and affect (such as anxiety or depression). Some therapeutic approaches (for example, cognitive-analytic therapy (CAT)) involve providing a written reformulation of the client’s difficul- ties, which is a short, sympathetically written prose account of when and why the client’s problems arose, and how the client’s symptoms may be a dysfunctional but understandable attempt to resolve problems that unfortunately trap the client into perpetuating the problem. Psychody- namic formulations will not normally be shared with clients, but will likewise represent the psychologist’s provisional understanding of the conflicts experienced by clients, normally in terms of unresolved or unexpressed wishes or fears, with symptoms conceptualized as symbolic manifestations of conflict.

The next core competence, intervention, involves using a psychological model or approach to facilitate some desired change. Intervention will normally be based on the formulation (which may alter in the light of developments or new information gained during the subsequent inter- vention), although some approaches (for example, solution-focused therapy) do not consider formulation a prerequisite for intervention. However, for most psychologists, formulation provides an effective springboard for action. For instance, the formulation of the withdrawn elderly man already described might suggest that he has become depressed as a result of growing isolation, as well as his belief that as an older person he no longer has any value; hence a cognitive-behaviour therapy (CBT) approach to modifying his self-defeating beliefs might

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2.4 THE COrE COMPETENCIES 25

be implemented to help him. If a psychodynamic model was considered more appropriate, the intervention chosen might be life review, allowing the man to gain a better understanding of his relationships and values, whereas a systemic model might suggest working with those around him to develop a more supportive and stimulating environment. Alter- natively, further assessment might have revealed some cognitive impair- ment related to an underlying dementia, in which case the intervention might alter to a discussion with him and his relatives about the likely prognosis and outcome of his condition, as well as a referral for other possible treatments or services. Any of these interventions are tests of the provisional hypotheses contained in the formulation, and are always subject to modification in the light of experience and new information.

Interventions do not just involve individual clients, but could also involve the provision of training and support for others, such as staff, relatives, and carers. An important role for a clinical psychologist is often the dissemination of psychological knowledge through teaching, supervision, and consultation. For example, a psychologist may have been asked to contribute to the therapy of an adolescent with anorexia, but after assessment and formulation, the psychologist may decide that the most appropriate form of intervention is to offer supervision to a dietician who has already made a good relationship with the cli- ent, and who is eager to implement a psychologically based treatment programme herself. Likewise, much work with children may be most effectively carried out by parents or teachers, although with help and directive guidance from the psychologist.

Duration, model, and mode of intervention vary, according to the presenting problem and the nature of the intervention provided. Many clients are seen on a one-to-one basis, whereas others, particularly chil- dren or people with learning disabilities, may be seen together with their families or carers. Interventions may be brief, although may be extended for people with psychotic symptoms, or with a range of complex prob- lems, or for those with major social and economic difficulties. Infre- quent although regular contact with those with learning disability and some types of physical disability, such as spinal cord injury, may last several years. Another crucial component of intervention is recognizing

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when not to intervene, or when further intervention will not be helpful. Awareness of this is an important aspect of reflective competence.

Evaluation is a central and integral part of the clinical psychologist’s work, which takes place both during and after intervention. Both the effectiveness of any specific intervention and any on-going needs may be evaluated. Clinical outcomes are normally assessed by using stand- ardized measures of symptomology, while patient experience and quali- tative aspects may be assessed using satisfaction questionnaires, or by interviewing participants. Where the psychologist has administered psychometric measures or some individually derived measure prior to treatment, these will normally be repeated on termination, together with qualitative reports of improvement. In addition to evaluation of single interventions, whole treatment programmes or services may be evaluated. Comprehensive service evaluation can encompass several dimensions including a variety of therapeutic outcomes (as measured by standardized measures), as well as functions such as treatment fidel- ity, uptake of the programme by different social demographic groups, drop-out rates, and accessibility.

A related and also highly important activity is that of research into the nature of the psychological problem, or the effectiveness of interven- tions. Research includes investigation of psychological processes and outcomes (basic research), the development and evaluation of specific psychological interventions (primary research), and the consolidation and evaluation of primary research (secondary research). When car- rying out research, clinical psychologists may also go beyond evalua- tion or audit of the effectiveness of specific interventions or services, to an investigation of the operation of underlying psychological issues or processes, thereby contributing to theoretical development and to new intervention models.

This aspect of psychologists’ work is critical for the development of knowledge, although obtaining time and funding may be difficult, especially in publicly funded services. The establishment of clinical guidelines and evidence-based treatment manuals has been a highly sig- nificant outcome of research carried out by clinical psychologists (and also of course by others). The rapid growth of the profession, referred

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2.4 THE COrE COMPETENCIES 27

to in Chapter 1, may in part be due to its success in being able to dem- onstrate its clinical effectiveness, through well-publicized research and outcome studies. The development of qualitative approaches has fur- ther enriched the research output provided by psychologists, especially where it contributes greater understanding of service user perspectives. Nevertheless, the assumption that clinical work can ever be entirely based on evidence has also been disputed: a clear instance of the tension between the reflective and scientist-practitioner aspects of the profes- sional role already discussed.

Communication/consultation and service delivery are areas of compe- tence that are central to many aspects of clinical psychologists’ work- ing lives. Most straightforwardly, this involves writing reports about work done with clients, their families, and professional staff (such as general practitioners or community mental health teams). Reports may be addressed to the referring person or, in more complicated cases, to a wider set of services. For example, a mother receiving therapy for depression may in addition have a child receiving help from a family service, who may also be working with the school. The family may be in receipt of input from the probation service and have support from social services in connection with a child protection concern. The mother may also be receiving occupational therapy and physiotherapy services for mobility problems. In situations such as these the clinical psycholo- gist is likely to be involved in on-going communication across health, social, and educational service boundaries, and any therapeutic input provided by the psychologist will comprise only a small element of the team’s response to the presenting difficulties. A key skill is therefore that of being able to express psychological ideas succinctly, and the ability to formulate and present psychological reports in ways that make sense to the wider care network as well as to clients themselves.

At a more complex level, psychologists may use their communication and organizational skills to facilitate the effective delivery of some aspect of a specific health care system, for example by facilitating a staff sup- port group or helping a service to implement a therapeutic programme for residents. It is therefore important that psychologists feel comfort- able when communicating with others, both directly (face-to-face) and

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indirectly via all forms of electronic communication. Equally important is the ability to teach and present information to other staff, as well as to disseminate research findings through discussion or publication. Psychological interventions are clearly not the prerogative only of psy- chologists: many other professional groups also have competence in the delivery of psychological care. Therefore clinical psychologists need to be good team players as well as effective individual therapists, and need to be able to demonstrate sensitively their unique contribution to the delivery of care. Most clinical psychologists are involved in supervising others, especially trainee clinical psychologists, so it is vital that they have the ability to explain what needs doing and why, to a variety of audiences, and to develop the ability to nurture and facilitate the devel- opment of skills of others.

Finally, leadership is increasingly recognized as a core competence: the Clinical Psychology Leadership Development Framework (British Psychological Society Division of Clinical Psychology, 2010) highlights the development and application of leadership competencies at all stages of a clinical psychologist’s career, beginning during post-graduate train- ing, and becoming more central as the psychologist gains experience and competence over the years of practice. These issues are considered throughout in this text, but particularly in Chapter 14.

2.5 Therapeutic models

This chapter now turns to an overview of the main therapeutic models used by clinical psychologists. The application of each model is differ- ent depending on the specific context, but the essential components are outlined here, with specific instances and applications being covered in subsequent chapters. At a broad level, clinical psychologists tend to use what is described as a biopsychosocial approach. This means that all aspects of a person are weighed up and considered, including the influence of biological factors (such as any physical disease processes, legal and illegal substance use, and prescribed medication); social fac- tors (such as employment status, ethnic origin, poverty, social class, and sexual preference); and the more obvious psychological factors. A wide range of specific models of psychological therapy exist, but, for the sake

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2.5 THEraPEUTIC MODELS 29

of clarity, in the rest of this chapter only the major models are outlined, which will be expanded further with clinical examples in other chapters.

Behavioural approaches

Historically the first major contribution to interventions made by clinical psychologists, and still widely in use today, is the behavioural approach. This focuses on modifying current behaviour, via the encouragement of new learning or modification of existing maladaptive patterns of behaviour. Using both operant and classical conditioning paradigms, the psychologist will attempt to understand and alter the cues that elic- it either dysfunctional or adaptive behaviour. Therapeutic techniques arising from behaviour theory include functional analysis, selective reinforcement, shaping, modelling, and extinction. Examples of appli- cations include using reward schemes to build up pro-social behaviour, the development of language in people with learning disabilities, and parent training programmes using selective reinforcement designed to improve children’s conduct. Aspects of behavioural approaches are also incorporated in many other psychological interventions, as, for exam- ple, in dementia care, or as part of rehabilitation programmes for people with neurological disorders. They may also form part of wider treatment approaches such as the use of behavioural activation for people present- ing with depression.

Cognitive-behaviour therapy and cognitive therapy

Developing from an awareness of the limitations of a purely behavioural approach, the most prominent therapeutic model applied by contempo- rary clinical psychologists across the lifespan is probably CBT, nowadays often developed to emphasize primarily the cognitive component, and known as cognitive therapy (CT). The predominance of this model is partly explained by the well-established evidence base for treatment, but also because of the ready applicability of specific cognitive models which provide a clear framework for intervention and evaluation (Roth and Fonagy, 2004). Although other professional groups also use CBT and CT, and clinical psychologists are required to have proficiency in more than one model of therapy, CBT/CT is the one model in the UK that is

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specified within the Standards of Proficiency for Practitioner Psycholo- gists (Health and Care Professions Council, 2009) as essential for prac- tice as a clinical psychologist.

The fundamental assumption of CBT and CT is that psychological distress is best understood and resolved by addressing the cognitions (thoughts, meanings, and beliefs) the person has about him/herself and his/her difficulties. An additional assumption (building on behavioural models) is that many psychological difficulties have developed via mala- daptive learning, and that solutions to these may also be understood and learned. A good therapeutic relationship is seen as an important foundation for treatment, but not as being therapeutic in and of itself. Essentially, therapy involves a careful assessment and specification of how problems arose, and how faulty cognitions as well as inappropri- ately learned behaviours may be maintaining the problem. This is fol- lowed by joint examination of the cognitions or inappropriately learned behaviours, and the development, through homework and experimen- tation, of alternative, more functional ways of thinking and behaving. A collaborative stance is central, with an emphasis on problem-solving in the present, rather than aiming for either profound personality changes in the client or an understanding of the past.

How this is achieved will vary depending on the developmental stage and difficulty presented by the client. Normally therapy commences by carefully noting the history of the client’s symptoms and beliefs, and assessing their current and earlier life circumstances. This leads to for- mulation, and re-casting symptoms in terms of the model, which is then shared with the client (known as socialization to the model). Next is a series of negotiated challenges to the client’s current ways of thinking and acting, through guided discussion (often via a process known as Socratic questioning) during which clients are invited to examine the rational basis and evidence for and against their beliefs, or by behavioural exper- imentation, a key aspect of which is generating predictions about a spe- cific situation and then testing this out (for example by approaching an avoided object or situation). Gradually the client is encouraged to revise any inappropriate strategies or beliefs and to develop new less restric- tive understandings and behaviours. Finally, provision is also made for

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2.5 THEraPEUTIC MODELS 31

maintaining therapeutic gains after the end of therapy, by anticipating future challenges and planning for ways of coping with them. Hence therapists may provide a ‘blueprint’ of therapeutic principles for the cli- ent to use after termination, as a way of preventing relapse. For children or young people, the parents may be closely involved in the therapy; likewise interventions may be carried out in collaboration with carers or staff when working with people who are living in residential units.

CT, in particular, has developed enormously since its early application to depression in the 1970s, and there are now a range of models and therapeutic approaches proposed for most mental health difficulties, in both adults and children. More attention has recently been paid to pro- cess issues and how the therapist–client relationship may affect outcome. Different aspects of a client’s experience, such as imagery, are also now being included in CT, for example when working with post- traumatic stress or eating disorders. Upsetting images, which are assumed to be stored and activated precognitively and therefore are less easily avail- able for rational examination, are addressed and modified, in addition to observable behaviours. For further detail of these developments, see Chapters 7 and 11.

One of the undoubted strengths of the cognitive approach has been the development of specific models of particular presentations. For exam- ple, social anxiety, according to the cognitive model, results from a strong desire to fit in and to convey a particular or favourable impression of one- self to others, combined with insecurity about one’s ability to do so. When faced by a social situation, the person believes that other people will notice their anxiety symptoms, such as sweating, shaking, speaking quickly, or blushing, and that they will make a fool of themselves, leading to rejec- tion and ostracism. Self-focusing, combined with a range of behaviours adopted to cope with the situation, leads to a vicious cycle in which the anxious person feels as if they are indeed the centre of negative attention, which leads to higher levels of anxiety and increased self-consciousness. This is made worse by the person conducting personal ‘post-mortems’ after the event about how they behaved in recent social situations. Thera- py involves shifting the attention focus from the self to the environment, and developing more realistic cognitions about self and others.

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