There has never been a better time to train as a clinical psychologist for three reasons. First, there is an increasing response to the recognition of the unmet need in mental health which is resulting in an increase in the number of clinical psychology jobs. Second, clinical psychology is enjoying a privileged position in mental health care because of its ability to provide an evidence-base for the services it offers (Newnham & Page, Reference Newnham and Page2010). Thus, despite the expense incurred by the provision of psychological services, we can show that their effectiveness assures savings that offset those costs. Third, the pandemic associated with COVID-19 has put the spotlight on evidence-based decision-making in health-care. It has been possible to model the impact of various public health interventions and some nations and states have used this to guide decision-making to good effect. Some areas have made decisions based on criteria other than the health evidence and the impact on health at the state and national level has been evident. In addition to the impacts of the disease itself, the pandemic has drawn attention to many existing unmet needs in the area of mental health (Marques et al., Reference Marques, Bartuska, Cohen and Youn2020) and ongoing, technology-driven changes have been accelerated in therapy delivery modalities and legal and reimbursement codes for therapy at a distance. The pandemic has also pointed to the need for a flexible and responsive attitude to the data. For example, some of the early dire predictions of the impact of COVID-19 on suicide have not been supported (Pirkis et al., Reference Pirkis, John and Shin2021), and reminded many that we neglected older data showing that national crises can be protective against suicide, arguably due to improved social cohesion (Botchway & Fazel, Reference Botchway and Fazel2021) ). This is the exciting challenge facing the graduates of today’s programmes: how will you shape clinical psychology?
Considering the first of these points, governments across the world are acknowledging the need to deal effectively with mental health. Within the United Kingdom, the response has been the development of an Improving Access to the Psychological Therapies (IAPT) (NHS, 2021) programme. This initiative aims to deliver interventions for people with depression and anxiety disorders that have been approved by the National Institute of Health and Clinical Excellence (NICE). In the United States, the Affordable Care Act (ACA) aims to improve equitable access to an improved quality of mental health care. In Australia, the Better Outcomes in Mental Health Care (Department of Health, 2021) programme improves community access to quality primary mental health care by providing access to allied psychological services which enables general medical practitioners to refer consumers to allied health professionals who deliver focused psychological strategies. Thus, the desire being expressed internationally (and tailored to the specific contexts of each nation) is to increase access to mental health services. This desire is leading to an increasing demand for mental health professionals who are able to provide the treatments required.
Second, there is a common theme across the international initiatives to increase the quantity of mental health care; namely a focus on quality. Funding agencies want to ensure that they receive value for money. Consequently, funding is often limited to treatments that have a strong evidence base. Private and public funders are looking to allocate scarce health care resources to areas where there is an assurance that treatment is effective and efficient (McHugh & Barlow, Reference McHugh and Barlow2010). The profession of clinical psychology has enjoyed a privileged position as a result of these pressures because it has a long history of accountability (Lilienfeld, Ammirati & David, Reference Lilienfeld2012). Its professionals are trained in the critical skills required to evaluate evidence and research methods to generate data on both existing and new treatments (Pachana et al., Reference Pachana, Sofronoff, Scott and Helmes2011). The status afforded to clinical psychologists, by virtue of their long history in demonstrating the accountability of their treatments, has meant that the profession as a whole benefits from the research base documenting the efficacy, effectiveness and efficiency of psychological treatments (Barlow, Reference Barlow2010; McHugh & Barlow, Reference McHugh and Barlow2010).
We are at a juncture when clinical psychology will carve out a path that will affect the profession as it goes forward (Barkham, Hardy & Mellor-Clark, Reference Barkham, Hardy and Mellor-Clark2010; Castelnuovo et al., Reference Castelnuovo, De Giorgio, Manzoni, Treadway and Mohiyeddini2020; Gruber et al., Reference Gruber, Prinstein and Clark2020). The decision facing the profession is: will science-informed practice inform the future practice of clinical psychology? The perception that psychology is scientific is not universal (Lilienfeld, Reference Lilienfeld2012). Thus, will science continue to inform the future practice of clinical psychology (see Lilienfeld & Basterfield, Reference Lilienfeld and Basterfield2020; Safran et al., Reference Safran, Abreu, Ogilvie and DeMaria2011; Stewart, Chambless & Baron, Reference Stewart, Stirman and Chambless2012)? To contextualize this decision, we will now discuss a revision of the psychiatric classification system.
Allen Frances chaired the committee responsible for the fourth revision of the American Psychiatric Association’s diagnostic system; the Diagnostic and Statistical Manual of the Mental Disorders (DSM-IV). After the publication of the fifth revision (i.e., the DSM-5) he wrote a book, Saving Normal (Reference Frances2014), in which he cogently critiqued the new taxonomy and the malign forces which he believed to be responsible for the errors. As a psychiatrist writing from retirement, he was excluded from any decision-making, but there is another level on which the book can be read. Much of his invective is directed at the multinational pharmaceutical companies who, in his opinion, control the agenda and directly and indirectly influence the formation of diagnostic categories and the uses to which they are put. However, what is clear is that Frances has seen (perhaps too late) the predicament that psychiatry has found itself in. In recent years, the number of prescriptions for medications used to treat mental health conditions has increased to meet the rising demand. Since the number of psychiatrists has remained relatively static, general practitioners have taken over the role of key provider of psychopharmacology. Psychiatrists have been relegated to the position of small players in a big market and their voice, once pre-eminent, has become one among many. For example, the head of the Royal Australian and New Zealand College of Psychiatrists echoed the same sentiment in an interview (ABC, 2014) where he noted that some groups in the community were increasingly more likely to seek advice from their GP rather than a psychiatrist. Thus, psychiatry is realizing that its pre-eminent position in mental health care has been eroded. As society has realized that the burden of mental health care is far larger than psychiatry can ever manage, it has sat by while other professions have stepped up to the task.
This cautionary tale provides clinical psychology with a window of opportunity. In the coming years the profession of clinical psychology will be settling itself down into the new mental health care environment. Clearly there are not enough clinical psychologists to meet the mental health care needs of the twenty-first century; clearly, there will never be enough (Kazdin, Reference Kazdin2011). The appropriately stringent and lengthy training of the profession will always be a limiting factor. Therefore, the exciting challenge for clinical psychologists is how to adapt themselves to this new environment. If the profession continues in the way it has been operating, it risks losing its pre-eminent role, just as psychiatry has. The remainder of the book will outline one possible future, where we will argue that clinical psychology must be a science-informed practice. By continuing to develop, evaluate and offer evidence-based treatments; by delivering treatments in a monitored error-correcting clinical practice (Lillienfeld & Basterfield, Reference Lilienfeld and Basterfield2020; Scott & Lewis, Reference Scott and Lewis2015); by training other mental health professionals in evidence-based treatments; and by fostering skills that complement (rather than duplicate) those of our colleagues in other professions, clinical psychologists will bring to the mental health team an expertise that will ensure them a continuing strong future (Barlow, Reference Barlow2010; Ward et al., Reference Ward, Zagoloff, Rieck and Robiner2018; Youngstrom et al., Reference Youngstrom, Van Meter and Frazier2017).
These are both exciting and challenging times and the profession of clinical psychology has a bright future ahead. We are confident because psychologists know that the best predictor of future behavior is past behavior. If we consider the history of clinical psychology, we can see that a science-informed approach to practice has served the profession well. Last century, Hans Eysenck (Reference Eysenck1952) threw down the gauntlet to clinical psychologists when he reviewed the 24 available studies and concluded provocatively that individuals in psychotherapy were no more likely to improve than those who did not receive treatment. Although the conclusion itself was questionable given the extant data (Lambert, Reference Lambert1976), the field responded assertively and effectively to these criticisms (e.g., Meltzoff & Kornreich, Reference Meltzoff and Kornreich1970). Perhaps the most effective response came from Smith, Glass, and Miller (Reference Smith, Glass and Miller1980). Using meta-analytic statistical techniques to review 475 studies, they provided quantitative support for the conclusion that psychotherapy was superior to both no-treatment and placebo control conditions (see also Andrews & Harvey, Reference Andrews and Harvey1981; Prioleau, Murdock & Brody, Reference Prioleau, Murdock and Brody1983). More recently, reviewers in the USA, the UK and Australia have sought to take the next step and identify criteria for empirically supported treatments, thereby providing listings of treatments that are “effective” for particular disorders (e.g., Andrews et al., Reference Andrews, Crino, Hunt, Lampe, Page, Lopez-Ibor, Lieh-Mak, Visotsky and Maj1999; Chambless & Hollon, Reference Chambless and Hollon1998; Nathan & Gorman, Reference Nathan and Gorman2015; Roth & Fonagy, Reference Roth and Fonagy2004; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). In parallel, other reviewers have collated evidence regarding the effective components of psychotherapy relationships (e.g., Norcross & Lambert, Reference Norcross and Lambert2019; Norcross & Wampold, Reference Norcross and Wampold2019; Orlinsky, Grawe & Parks, Reference Orlinsky, Grawe, Parks, Bergin and Garfield1994; Orlinsky, Rønnestad & Willutzki, Reference Orlinsky, Rønnestad, Willutzki and Lambert2004). Together, these two lines of research provide a strong response to Eysenck’s criticism. While people continue to debate the relative merits and contributions of the psychotherapy relationship and the specifics of particular therapies (e.g., Asnaani & Foa, Reference Asnaani and Foa2014; Laska, Gurman & Wampold, Reference Laska, Gurman and Wampold2014; Norcross & Lambert, Reference Norcross and Lambert2019; Norcross & Wampold, Reference Norcross and Wampold2011; Wampold, Reference Wampold2001), the conclusion that psychotherapy is better than no treatment, and better than a supportive caring relationship alone, is strongly supported.
Thus, Eysenck’s provocative comments spurred a spirited and methodical response that allowed clinical psychology to clearly defend itself against general criticisms of ineffectiveness. In addition, the profession is able to identify, with increasing precision, the relational and specific therapeutic factors that mediate clinically meaningful change. Why was clinical psychology able to respond so effectively?
The purpose of the clinical psychologist, as a contributor to science, is to discover the relation between cause and effect in applying the various pedagogical remedies to a child who is suffering from general or special retardation … For the methods of clinical psychology are necessarily invoked wherever the status of an individual mind is determined by observation and experiment, and pedagogical treatment applied to effect a change.
Although there has been much written about the scientist-practitioner model, the broad principles are that clinical psychologists, as scientist-practitioners, should be consumers of research findings, evaluators of their own interventions and programmes, and producers of new research who report these findings to the professional and scientific communities (Hayes et al., Reference Hayes, Barlow and Nelson-Gray1999). The commitment to an ideal of combining research and practice has infused the profession of clinical psychology to such a degree (e.g., Borkovec, Reference Borkovec2004; Martin, Reference Martin1989; McFall, Reference McFall1991) that the response to Eysenck’s scepticism (see also Peterson, Reference Peterson1968, Reference Peterson1976a, Reference Peterson1976b, Reference Peterson2004) was not an appeal to the authority of a psychotherapeutic guru, nor a rejection of its legitimacy followed by attempts to ignore it; rather, the profession produced and collated empirical data to refute the claim (Butler et al., Reference Butler, Chapman, Forman and Beck2006).
Despite the success of the scientist-practitioner model in shaping clinical psychology as a discipline committed to empiricism and accountability, advocates of the model have not been blind to its failure to achieve the ideal (Hayes et al., Reference Hayes, Barlow and Nelson-Gray1999; Nathan, Reference Nathan2000). Shakow et al. (Reference Shakow, Hilgard, Kelly, Luckey, Sanford and Shaffer1947) of training individuals who could not only be scientists and practitioners, but could blend both roles in a seamless persona. They sought to achieve this goal by giving an equal weighting to research and practice in training programmes. However, ensuring the mere presence of these two equally weighted components did not by default produce an integrated scientific practice and did not win the hearts and minds of many graduates. In the words of Garfield, “unfortunately, (psychologists in training) are not given an integrated model with which to identify, but are confronted instead by two apparently conflicting models – the scientific research model and the clinical practitioner model” (Garfield, Reference Garfield1966, p. 357; Peterson, Reference Peterson1991). More recently, there have been renewed efforts to provide a concrete instantiation of scientific practice (Borkovec, Reference Borkovec2004; Borkovec et al., Reference Borkovec, Echemendia, Ragusea and Ruiz2001; Scott & Lewis, Reference Scott and Lewis2015). Hayes and colleagues (Reference Hayes, Barlow and Nelson-Gray1999) attributed the apparent lack of better science-practice integration to two factors: First, the “almost universally acknowledged inadequacies of traditional research methodology to address issues important to practice”, and second, the “lack of a clear link between empiricism and professional success in the practice context” (p. 15). Our goal in the remainder of the book is not to address the first of these concerns (see Hayes et al., Reference Hayes, Barlow and Nelson-Gray1999; Neufeldt & Nelson, Reference Neufeldt and Nelson1998; Seligman, Reference Seligman1996a), but to speak to the second. Our goal is to articulate ways that a scientific clinical psychology can be practiced.
The Aim of This Book
Our aim is to assist the student of clinical psychology to contemplate a scientific practice and to develop a mental model of what a scientist-practitioner actually does to blend state-of-the-science expertise with quality patient care. Our goal is not to describe a model of clinical practice (e.g., Asay et al., Reference Asay, Lambert, Gregerson and Goates2002; Borkovec, Reference Borkovec2004; Edwards, Reference Edwards1987), nor to outline a broad conceptual framework for a scientist-practitioner (see Beutler & Clarkin, Reference Beutler and Clarkin1990; Beutler & Harwood, Reference Beutler and Harwood2000; Beutler, Moliero & Talebi, Reference Beutler, Moliero and Talebi2002; Fishman, Reference Fishman1999; Hershenberg, Drabick & Vivian, Reference Hershenberg, Drabick and Vivian2012; Hoshmand & Polkinghorne, Reference Hoshmand and Polkinghorne1992; McHugh & Barlow, Reference McHugh and Barlow2010; Nezu & Nezu, Reference Nezu and Nezu1989; Schön, Reference Schön1983; Spencer, Detrich & Slocum, Reference Spencer, Detrich and Slocum2012; Stricker, Reference Stricker2002; Stricker & Trierweiler, Reference Stricker and Trierweiler1995; Trierweiler & Stricker, Reference Trierweiler and Stricker1998; Yates, Reference Yates1995), or even to portray a scientifically grounded professional psychology (Peterson, Reference Peterson1968, Reference Peterson1997), since each of these has been effectively presented elsewhere. Our aim is to consider each of the core competencies that a trainee clinical psychologist will acquire with the following question in mind: “how would a scientist-practitioner think and act?” The value of the scientist-practitioner model as a sound basis for the professional identity and training of clinical psychologists lies in its emphasis on generalizable core competencies, rather than specific applications of these core competencies to each and every client problem or service setting (Shapiro, Reference Shapiro2002). Accordingly, we will first describe our conceptual model of the core elements of science-informed practice. Then, in the remainder of the book, we will illustrate how this model allows individual practitioners to provide value for money in a competitive health care market indelibly shaped by the forces of accountability and cost-containment (see also Detweiler-Bedell et al., Reference Woody, Detweiler-Bedell, Teachman and O’Hearn2003; Fishman, Reference Fishman2000; Kraus et al., Reference Kraus, Castonguay, Boswell, Nordberg and Hayes2011).
The starting place for any action in clinical psychology practice is the client and his or her problems. Therefore, the discussion of a science-informed model needs to begin with the client. In addition, the meeting of client and therapist involves a relationship, so that at its heart the interaction is relational. The beginning of the relationship involves the presentation of the client’s problems to the clinical psychologist. As shown in Figure 1.1, this information is conveyed to the clinician (depicted by the thin downward arrows) and some of it passes through the “lens” of the clinical psychologist. This lens comprises the theoretical and empirical literature as well as clinical (and non-clinical) experience and training. It serves to focus on the information about the client. Continuing with the lens metaphor, not all the information passes through the lens (indicating by some arrows missing the lens) because clinicians will be limited by the level of current psychological knowledge, their theoretical orientation and the extent of their experience. The client might also not disclose important information that would otherwise influence clinical decision-making. For example, the client might not initially see the relevance of particular information or may not be aware of it in the initial phases of treatment. Information may also be intentionally withheld because of shame, at least until trust has been developed in the psychologist. The clinician needs to be alert to relevant new information that emerges during therapy so that it can be integrated into the treatment plan.
As with all metaphors, the notion of a lens filtering client data is limited in that it does not capture the dynamic nature of the interaction between client and clinician. The client is not analogous to a light source passively emitting illumination, but a client actively engages in an interactive dialog with the clinician so that the information elicited is influenced by the clinician’s responses, and the material the client proffers in turn influences how the clinician chooses to proceed. Thus, the interaction between client and clinician is a rich and dynamic dialogue, but while it has the potential to be a free-ranging and unconstrained discussion, the process has an “error correcting” mechanism, whereby the clinician focuses on the information and channels it into diagnosis and a case formulation. The case formulation, described later, provides direction to the decisions that a clinical psychologist, together with the client, makes about treatment (indicated by the dotted arrows), which are then implemented and their outcomes measured, monitored and evaluated. These processes involve feedback loops, so that information garnered at each stage feeds back to support or reject earlier hypotheses and decisions in a cycle of error correction.
Finally, there are processes associated with the public accountability of clinical practice. The results of treatment are fed forward by the clinical psychologist to modify the theoretical and empirical bases of practice. In addition, the results will be fed back to inform the person’s clinical experience that will guide future clinical practice. Dissemination of evaluations of clinical practice outcomes serves not only to demonstrate that the practice is accountable, but also ensures the sustainability of clinical psychology. In the same way that logging forests without replanting new trees is unsustainable because it starves the timber industry of its raw material, if clinical psychology fails to replenish its resources (effective assessment and treatment), then it will be unsustainable. Other professions will step forward with potentially more efficient and effective alternatives to those that are presently available. To stretch the logging metaphor further, trees will grow stronger over time if weaker branches are removed so that finite resources and energy can be redirected towards strengthening the trunk. Likewise, psychologists’ iterative use of evidence-based practice and practice-based evidence provides new knowledge about less effective or efficient approaches that need to be cleaved off so that therapeutic time and effort can be redirected into approaches that have demonstrated the strongest and most rapid effects. Thus, we would agree with Miller (Reference Miller1969) that, “the secrets of our trade need not be reserved for highly trained specialists. Psychological facts should be passed out freely to all who need and can use them in a practical and usable form so that what we know can be applied by ordinary people” (pp. 1070–1071). We can “give psychology away” in the sure knowledge that we are capable of generating new knowledge at least as fast as we can disseminate existing knowledge.
Operating alongside the skills associated with each of the elements of linking client data to case formulation to inform treatment planning and implementation is the process dimension, upon which all therapeutic content is superimposed. The “superimposed” nature of therapeutic content on therapeutic process is reflected in Figure 1.1, where process is shaded behind assessment, treatment planning and measurement, treatment implementation and monitoring, and evaluation and accountability.
Process refers to the interactions between therapists and clients. Clients come to therapy with a range of experiences, relational patterns and beliefs that will play out during therapy sessions. For example, clients with a history of maltreatment or abuse may expect further maltreatment from others, including the therapist. Strategies clients use in an attempt to prevent these feared outcomes will differ (e.g., overly compliant and eager to please, defensive, or sarcastic interaction styles), but they aim to serve a common protective function. Freud (1912, cited in Parth et al., Reference Parth, Datz, Seidman and Löffler-Stastka2017) initially coined the term transference to capture the idea that clients may transfer or re-enact patterns of relating to others learned in the context of developmental relationships into the therapeutic relationship. The term countertransference reflects all of the responses therapists have to their clients. For example, a client who is meek and overly apologetic (“client stuff”) may initially elicit nurturance and support followed by frustration and rejection from others, and the therapist may also experience these feelings as therapy progresses. On the other hand, therapist-induced countertransference occurs when the client triggers the therapist’s own problematic beliefs or relational patterns (“therapist’s stuff”). For example, a therapist might feel resentful or dismissive of a client who reminds them of a parent with whom the therapist has a problematic relationship.
Although the concepts of transference and countertransference initially derived from psychoanalytic theory, the idea that clients’ (and therapists’) relational styles contribute to therapeutic outcomes is pan-theoretical and is supported by empirical evidence (Cartwright, Reference Cartwright2011; Gelso, Reference Gelso2014; Parth et al., Reference Parth, Datz, Seidman and Löffler-Stastka2017). Cognitive therapists can easily accommodate these concepts within cognitive theory by referring to constructs such as core beliefs and schemas (Cartwright, Reference Cartwright2011). Therapists will benefit from an ability to identify and formulate the process dimension, but in some instances they may choose to circumvent process issues during therapy. For example, in very brief therapies there may not be time for significant process issues to emerge between the therapist and client, or the therapy may be focused on teaching specific skills and addressing broader relational styles may not be a priority or necessary. In these instances, therapists may simply use their awareness of process issues to formulate their own reactions to the client and to use this knowledge to guide the way in which they relate to the client to optimize engagement so that process issues (e.g., ruptures) are less likely to interfere with therapy outcomes (Cartwright, Reference Cartwright2011; Gelso, Reference Gelso2014; Parth et al., Reference Parth, Datz, Seidman and Löffler-Stastka2017) . Therapists who are unable to identify, formulate and respond effectively to clients’ interpersonal styles are at risk of replicating and reinforcing these problematic patterns. Effectively responding to unhelpful relational styles can reduce the risk of ruptures in the therapeutic alliance, non-adherence to treatment and client dropout. This book will draw readers’ attention to potential process issues that may emerge at each stage of therapy, and how these can be understood and managed by trainee clinicians, to optimize effectiveness.
Stakeholders in the Practice of Clinical Psychology
In the previous section we outlined how the foundations of science-informed practice rest on the clinical psychologist assuming three interrelated roles. Clinical psychologists are consumers of research, in that they draw on the existing theoretical and empirical literature, they are evaluators of their own practice, and they are producers of new practice-based research and knowledge. However, the style of research and type of research product varies according to the stakeholder. Three classes of stakeholders can be identified (see Figure 1.2). The first stakeholder is the client (included in this category are the client’s family, friends and supporters). The second class of stakeholder is the clinician, including the professional’s immediate employment context (e.g., clinic, hospital, government department). The final class of stakeholder includes the broader society comprising individual members of society, government agencies, professional groups, academics and the private sector. The type of research that each group will be interested in is displayed schematically in Figure 1.2
Clients have a legitimate interest in efficacy studies. Efficacy studies demonstrate in randomized controlled designs the superiority of a clinical procedure or set of procedures, presented in a replicable manner (e.g., using a treatment manual) over a control condition. The research has clearly defined inclusion and exclusion criteria, with an adequate sample size, and participants are evaluated by assessors blind to the experimental condition. Collating information across a group of efficacy studies permits the identification of evidence-based or “empirically supported treatments” (e.g., Andrews et al., Reference Andrews, Crino, Hunt, Lampe, Page, Lopez-Ibor, Lieh-Mak, Visotsky and Maj1999; Chambless & Hollon, Reference Chambless and Hollon1998; Nathan & Gorman, Reference Nathan and Gorman2015; Roth & Fonagy, Reference Roth and Fonagy2004; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). Clients may find this information useful in deciding which treatment has a good probability of success for carefully selected groups of individuals with problems like their own.
Clients will have an even greater interest in the effectiveness of a given treatment and ongoing monitoring of their own condition. That is, effectiveness research evaluates treatments as they are usually practiced. In contrast to the treatment described in efficacy studies, clients who present for treatment may have multiple problems, may not meet all diagnostic criteria and will choose (rather than being randomly assigned) to receive a particular treatment whose duration is aimed to match their needs. The clinician may modify treatment based on a client’s response. Within this class of research one can include studies that examine the generalizability of efficacious treatments to “real-world” settings (e.g., Peterson & Halstead, Reference Peterson and Halstead1998), consumer surveys (e.g., Seligman Reference Seligman1995, Reference Seligman1996a, Reference Seligman1996b), as well as information on the outcomes of a specific clinic or clinician. Effectiveness can also be used broadly to refer to the measurement of change (e.g., pre- and post-treatment) within the client in question, the ongoing and idiographic monitoring of the client’s problems (see Dyer, Hooke & Page, Reference Dyer, Hooke and Page2014; Hawkins et al., Reference Hawkins, Lambert, Vermeersch, Slade and Tuttle2004; Howard et al., Reference Howard, Moras, Brill, Martinovich and Lutz1996; Lyons et al., Reference Lyons, Howard, O’Mahoney and Lish1996; Newnham, Hooke & Page, Reference Newnham, Hooke and Page2010a; Sperry et al., Reference Sperry, Brill, Howard and Grissom1996 for examples) and issues concerning service delivery. Arguably, as the data become more personal, they become more relevant to the particular client and those who may be involved in the client’s care. Thus, in the left-hand box in Figure 1.2, proportionally more space is allocated to monitoring and effectiveness (light gray), than efficacy research (gray) to reflect the interests of an individual client.
Moving to the far right-hand side of Figure 1.2, the interests of society are depicted. In contrast to the individual client, society will have a general interest in knowledge about the effectiveness of treatments but will have no particular interest in monitoring the progress in treatment of a particular individual. Thus, the relevance of monitoring and effectiveness studies (light gray) is less for society in general than the individual, indicated by the smaller proportion of the right hand rectangle devoted to it. Society will have a greater interest in knowing the results of efficacy studies, so that governments and investors can make rational planning and funding decisions and services can be efficiently and effectively managed. Additionally, society takes an interest in a research agenda that may have little interest to individual clients, namely the research on the mechanisms and processes of disorders and treatment (dark gray). Included within this category of research endeavor are investigations of descriptive psychopathology and the etiological mechanisms that initially cause or maintain a set of client problems as well as those mechanisms involved in client change (e.g., O’Donohue & Krasner, Reference O’Donohue and Krasner1995). The category also includes research into the process of psychotherapy (e.g., Norcross & Lambert, Reference Norcross and Lambert2019; Norcross & Wampold, Reference Norcross and Wampold2019); that is, research on the relationship variables critical to client improvement.
Standing between the clients on the one hand and society on the other, is the clinical psychologist. Clinical psychologists share the interests of both the client (in the monitoring and measurement of each client’s particular problems and the delivery of the most efficacious treatment) and society (in understanding the fundamental mechanisms involved in each problem a client may present with and knowing which treatments are efficacious for a particular problem, and the degree to which these treatments translate into practice). For example, for the present authors, when we manage our clinic’s smoking cessation (Stritzke, Chong & Ferguson, Reference Stritzke, Chong and Ferguson2009) and anxiety disorder programmes (Andrews et al., Reference Andrews, Creamer, Crino, Hunt, Lampe and Page2003; Page, Reference Page2002a) we not only want to know that the programs are empirically supported, that they are effective outside the centres where they were tested on carefully selected samples, but we need to be able to demonstrate that the outcomes of our clinicians running our programs are comparable to those in the published literature. Studies that compare effects from a psychologist’s clinical practice to past clinical trials can be used to confirm that outcomes are meeting international benchmarks (e.g., McEvoy et al., Reference McEvoy, Nathan, Rapee and Campbell2012, Reference McEvoy, Erceg-Hurn, Anderson, Campbell and Nathan2015a) Likewise, while a single case study may not be publishable unless it reveals particularly important information about a novel case presentation or application of an intervention, it provides an excellent way for individual practitioners to demonstrate to themselves and to a client the degree of improvement (Fishman, Reference Fishman2000).
Drawing together the themes discussed (and portrayed in Figures 1.1 and 1.2), the scientific practice of clinical psychology exists in a social network that ripples outward from the individual client, with a research agenda that becomes more generalizable. Thus, there is probably not one single science-informed model of clinical psychology, but an array of ways that science informs practice and vice versa. The knowledge generated by large-scale efficacy studies (e.g., Elkin et al., Reference Elkin, Shea and Watkins1989) exists alongside the knowledge generated by an individual clinician tracking the Subjective Units of Discomfort (SUD) of a phobic progressing through an exposure hierarchy. Both can appropriately be considered the products of a scientific practice of clinical psychology. Acknowledgement of diversity in the type of research product across different stakeholders is not to imply that there are no boundaries to a scientific clinical psychology, just that it is broader than is often characterized.
It is worth noting that specification of the different stakeholders helps to clarify what information needs to be presented to which groups and by whom. Individual clients will be interested in feedback about how they have performed on psychological tests relative to appropriate normative samples and about the rate and extent of progress, both referenced against their pre-treatment scores and relevant norms (see Crawford et al., Reference Crawford, Cayley, Lovibond, Wilson and Hartley2011; Woody et al., Reference Woody, Detweiler-Bedell, Teachman and O’Hearn2003). Further, the results of therapy may be communicated to other stakeholders in ward rounds, clinic meetings, training workshops and other clinical settings (cf. Castonguay, Reference Castonguay2011; Haynes, Lemsky & Sexton-Radek, Reference Haynes, Lemsky, Sexton-Radek, McNamara and Appel1987; Mitchell, Reference Mitchell2011). In contrast to the local presentation of individual client data, professional societies and funding bodies will seek information about the most cost-effective ways to treat specific disorders of all clients who present for treatment. They will require reliable answers, based on studies comprising good internal and external validity that point to answers that can be generalized to particular populations. Thus, an important skill for clinical psychologists is not only to be able to produce evidence, but to know how to generate and present research outcomes relevant to the target stakeholder.
One example of the targeted presentation of research evidence is the way that clinical psychology is responding to the increasing industrialization of health care. Health care costs began to rise dramatically during the 1980s and it became clear that both the private and public sectors needed to be more assertive in the management of health funds. Employee Assistance Programmes (EAPs) were one of the first responses, offering corporations targeted services of early identification and minimal, time-limited interventions followed, if necessary, by appropriate referral. In the US, managed (health) care organizations evolved with the development of Health Maintenance Organizations (HMOs; where individuals or companies contract an organization to provide all health services), Preferred Provider Organizations (PPOs; who reimburse a panel of providers on a fee-for-service basis, typically with some form of co-payment), and Individual Practice Association (IPAs; in which providers organize themselves to contract directly with companies to provide health services). Although the particular structure of health care varies markedly across different countries, all Western nations face the same problems of increasing costs of health care (compounded by a growing aged population) and share the same need of third-party payers (i.e., insurance companies and governments who pay the health bills) to rein in health care costs. Increasing costs have focused attention more than ever upon efficient and effective health care and thus the need for clinical psychologists to be able to demonstrate that their assessment and treatment processes are not only effective, but they can be targeted, delivered in a timely manner and offered in a definable and reproducible manner. Thus, in the past the rationale for a scientific-informed practice was promoted within the discipline by professional organizations (e.g., the American Psychological Association, the British Psychological Society) and foresighted individuals (e.g., Thorne, Reference Thorne1947), but in recent times the rationale has become increasingly externally motivated, in the form of third-party payers who are demanding cost-effective health care. Whereas in the past the scientist-practitioner model could be seen as a luxury representing an ideal worthy of pursuit, in the present era of accountability it is a necessity ideally suited to demonstrate the value that can be returned for every health care dollar invested in clinical psychology services (Schoenwald et al., Reference Schoenwald, Hoagwood, Atkins, Evans and Ringeisen2010). Stepped-care approaches, where lower-intensity psychological interventions (e.g., brief focused interventions) are first delivered by generalist psychologists, with clients only referred to clinical psychologists if they do not recover, aim to maximize the number of people who can be assisted within finite workforce resources and without compromising outcomes. Lower-intensity interventions can also be helpful for reducing the burden on clients (e.g., travel time, time away from work). The aim is to match the level of care to clients’ needs – no more, no less. As consumers seek to purchase quality services at cheaper prices, there will be a market edge to those who are able to demonstrate that their products are both effective and economical.
In sum, science-informed clinical psychology does not have a single product to market, but it produces many different outputs relevant to diverse audiences (Castonguay, Reference Castonguay2011). Clients will be interested in their personal well-being, whereas society will be interested in the broader issues of descriptive psychopathology, etiological models of disorders, treatment processes and outcomes, as well as efficient and effective health care (Kazdin & Blase, Reference Kazdin and Blase2011). The individual clinical psychologist requires the skills to collect and present data relevant to particular stakeholders. Not all clinical psychologists are employed in the same capacity and the stakeholders each person deals with are different, and therefore it is better to conceptualize the implementation of a science-informed model of clinical practice as not being epitomized by a particular instantiation, but as a strategic commitment to a scientific approach at the core of clinical practice. Priority of strategy over procedure is essential, because the evidence base will always be incomplete. The core competencies of a scientist-practitioner are most needed when the evidence is equivocal or lacking (Newnham & Page, Reference Newnham and Page2010; Shapiro, Reference Shapiro2002). In the remaining chapters we outline ways that a person with a commitment to the application of science to clinical practice might approach the many tasks clinical psychologists engage in. The first of these activities will be the difficult task of developing a strong therapeutic relationship.