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Clinical psychologists may work in a variety of settings, but the challenges of working in private practice can be beyond the experience of a trainee. Thus the chapter outlines the conduct in a private practice. It describes the important role of promotion and community education to engage with key stakeholders. The chapter highlights the added value of an evidence-based approach to practice and quality improvement, as they improve accountability and allow the demonstration of effectiveness. The chapter discusses the impact of the need to monitor costs and to adopt a business mentality. It concludes by describing two models for maintaining research engagement while in private practice.
The chapter describes how the clinical psychologist can work in rural and remote settings. The specific rewards and challenges are outlined. The chapter reviews the effectiveness of therapy at a distance and developments in the delivery of clinical psychology services. Consideration is given to the relevant legislation and regulations, and provides a practical guide to providing therapy at a distance. These steps involve a consideration of privacy and security, risk management, telehealth, and adapting therapeutic skills to the digital and distance context. The chapter concludes with the unique elements of mental health services in rural communities and the impact on professional boundaries of life in small communities.
The science-informed approach to clinical practice is founded upon ongoing quality improvement and involves key skills that allow clinical psychologists to confidently provide services in a competitive health care market. Thus, programme evaluation is a core clinical psychology competency but needs to be provided via a co-design framework. The chapter outlines how co-designed programme evaluation addresses patients’ needs in five steps: (i) asking the right questions, (ii) developing an evaluation plan, (iii) collecting and analysing data to produce usable findings, (iv) translating the findings into recommendations for action, and (v) advocating and promoting change. The chapter illustrates how empirically-based programme evaluation supports accountable clinical practice, both at the level of the individual patient and at the aggregate level of the service provider or agency.
After assessing a client a treatment plan is required. The chapter outlines the practical steps in proceeding from a case formulation to a treatment plan. Since many techniques are modified for application in many different clinical problems and psychological disorders, we will concentrate on providing a description of particular procedures that are broadly applicable. The chapter provides practical illustrations of treatment planning with outlines of behaviour therapy, dialectical behaviour therapy, cognitive therapy, and interpersonal psychotherapy. It includes specific examples of clinical cases and explains how these approaches can be subsumed under a transdiagnostic framework of treatment planning. Consideration of transdiagnostic interventions involves targeting negative affect, intolerance of uncertainty, anxiety sensitivity, avoidance and safety behaviours, emotion regulation, and metacognitve therapy.
The chapter outlines low intensity psychological Interventions (LIPIs). These are treatments that have low usage of a specialist’s therapist time (e.g., 5–8 sessions), or uses the time in a manner that reaches a large number of people. Low intensity does not refer to the client’s experience. Even though the contact with the specialist is less, the client’s involvement in terms of time, effort and emotional investment can be intense. The chapter outlines in a practical manner stepped-care, how to offer choice to service users, and shared decision-making. Given that LIPIs can be challenging to master, the chapter provides an illustrative example of adapting case formulation and treatment planning to this mode of delivery.
The chapter outlines an evidence-based approach for clinical psychologists to select and provide group treatments. The process begins with selecting the appropriate treatment programme and then selecting the appropriate patients for the group. The chapter will identify principles for selection and assessment as well as how the use of interpersonal interaction as a therapeutic tool in the here-and-now context of a group can be an inherent advantage of group interventions. In addition, it outlines practical steps for implementation of a group that includes pre-group orientation, enlisting patients as informed allies, providing guidelines about how best to participate, clarifying the format and duration, setting ground rules, anticipating problems and instilling optimism among members. The chapter concludes with a consideration of how monitoring of process and outcomes can enhance outcomes.
Case management skills are critical to the effective, efficient and ethical delivery of clinical psychological services. The chapter will outline how case management involves the combination of practice-based evidence with management and documentation tasks. We outline the key management and documentation tasks associated with specific phases of the treatment process, framing them in a context of generating practice-based evidence. We illustrate good record keeping, maintainance of confidentiality, treatment planning, treatment implementation (including suicide risk assessment) and treatment termination.
Clinical psychology is at an exciting point in time. We describe the current state of clinical psychology, framing it in terms of a trajectory from the foundation of the scientist-practitioner model to present developments. The chapter outlines how the how core competencies of clinical psychology practice are framed by the question, “How would a scientist-practitioner think and act?” We present a model of science-informed practice of clinical psychology and 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. The model illustrates how the client is viewed through a lens of evidence-based literature and clinical experience, and how a clinical psychologist collaborates with a client in assessment, case formulation, treatment planning, process-informed treatment delivery, treatment measurement and monitoring, to permit evaluation and accountability. It concludes with a consideration of the perspectives of the key stakeholders, namely the client, the therapist and the broader society, and how these perspectives shape interest in the monitoring of effectiveness, efficacy and understanding of the mechanisms and processes responsible for mental health problems.
Clinical psychology trainees embarking on a professional career are faced with the prospect of work that, daily, has ethical questions and challenges to respond to people from varied cultures and social groups. The chapter describes how to provide a culturally-sensitive clinical psychology practice. It evaluates the current evidence-base antecedences guiding practice. The chapter suggests how Structured Problem Solving can be applied to help acquire greater skills in engaging with people from different cultures and groups (e.g., the elderly). The same Structured Problem Solving approach is then applied to ethical decision-making and illustrated with a discussion on confidentiality and dual relationships. The chapter outlines how these approaches may help the clinical psychologist respect the humanity of their clients in all facets of their engagement.
Supervision is a critical opportunity for a clinical psychology trainee to receive feedback to develop their skills. The chapter begins by describing ways to make the most of this opportunity. Practical steps are outlined that include, goal setting for supervision sessions, planning agendas, ways to learn from sessions recordings, and accounting for supervisory outcomes and activities, and how to challenge yourself to advance beyond the familiar. The chapter also critiques recent developments in “reflective practitioner” approaches to supervision and outlines practical steps to remain evidence-based by using data-driven reflective practice. The chapter concludes with a discussion about how to begin to learn supervisory skills as the clinical psychology trainee anticipates one day moving into a supervisory role.
Case formulation links the client and his or her problems with the treatment. It captures both the strengths and the weaknesses in a complete summary of the client. The chapter introduces case formulation by first describing a behavioural case formulation and how a functional analysis can be conducted. The illustration of a behavioural formulation is then developed into a model that goes beyond identifying the antecedents and consequences of behaviours, and includes reference to the potential of mediation by thoughts and beliefs. Thus, a broader cognitive-behavioural model of case formulation distinguishes steps: (i) presenting problems, (ii) predisposing factors, (iii) precipitating variables, (iv) perpetuating cognitions and consequences, (v) provisional conceptualization, (vi) prescribed interventions and (vii) potential problems and client strengths. The chapter then provides two clinical examples of case formulation, beginning with a cognitive-behavioural case formulation then an example from the perspective of interpersonal psychotherapy. The chapter concludes with a discussion of transdiagnostic approaches to assessment and case formulation.
Clinical psychologists, even those who work in solo practices, are part of a larger health care delivery system. The chapter frames the evidence-based practice of a clinical psychologist in the broader context by outlining the evolving parameters of service delivery and how the field is aiming to provide integrated, patient-centred care that is committed to accountability. It is apparent that clinical psychology’s commitment to accountable practice adds value to integrated care and psychologists bring specific skills to the health care system. The chapter outlines the specific skills that clinical psychologists need to provide effective interventions expeditiously, be good team players, understand their medical colleagues, articulate their distinctiveness, be accountable for outcomes and to attend to ethical issues.
Clinical psychological practice is founded upon the therapeutic relationship. A science-informed practice then requires that the elements used to build that relationship have an evidence base. Thus, the chapter reviews the empirical foundations of the therapeutic relationship and what steps can be taken to build a therapeutic alliance that correlates positively with beneficial treatment outcomes. The chapter outlines in practical steps how strong therapeutic relationships can be built by evidence-based practices that strengthen the alliance in an empathic manner. It illustrates key skills of building empathy through encouraging, re-stating, and paraphrasing communications in a manner that conveys to the patient an understanding of the content and the emotion behind what is communicated. The chapter concludes with a discussion of problems that can arise in the therapeutic relationship and practical steps to manage alliance ruptures.
The evidence-based practice of clinical psychology may begin with a review of efficacy studies, but it cannot end there. It needs to translate these data to the patient who presents for treatment. The chapter begins with a discussion of the principles whereby a clinical psychologist can seek to match evidence-based treatments to a client’s clinical presentation. The chapter additionally reviews future developments in personalized medicine and methods that have the potential to improve the matching of treatments to presenting problems. The chapter also considers how session-to-session progress can be monitored to identify when a patient’s progress deviates (either positively or negatively) from an expected course. The concept of clinical significance is described, and practical illustrations are provided of how this can be used to monitor progress and ways of responding to clients who are on and off track are outlined. The discussion of why Routine Outcomes Monitoring systems work is demonstrated by illustrating implementation in routine clinical conversations.
The chapter describes how to manage ruptures in the therapeutic alliance. It opens by outlining a conceptual model to understand the ruptures and proceeds to consider the ways that ruptures may manifest at different points in psychotherapy. One way to respond to some ruptures in alliance in via enhancing motivation and therefore the technique of Motivational Interviewing is described in detail; outlining the steps of expressing empathy, developing discrepancies (between actual and desired outcomes), avoiding argumentation, rolling with resistance and supporting self-efficacy. The chapter reviews ways to manage the assignment and review of homework exercises so that they are a productive element in clinical psychology practice. The chapter concludes with a close examination of psychotherapeutic process; defining what “process” is, and how to work with transference and countertransference.