Creating Public Health Policy

In recent years, clinical psychology has made significant contributions to mental health policy through its increasing focus on the notion of evidence-based practice and an empirical approach to clinical decision-making. These developments have not been without challenges, however. Most notable are issues with the acceptability of treatment design among practitioners and the difficulty of implementing and sustaining high-quality practices in real-world contexts. Two specific barriers central to these challenges are discussed, namely, the highly specialized architecture of most research-based mental health treatments and the unavailability of a dedicated supervisory and training infrastructure. Solutions are proposed that suggest the need to rethink both the way treatments are packaged and the way they are supported in real-world practice.

A History of Clinical Psychology

To be memorable, a history such as this might best be organized under a small number of headings. Accordingly, this chapter is structured around the work of seven pioneers who arguably had the greatest influence on the development of the field. Lightner Witmer is generally considered to have founded clinical psychology in 1896 (McReynolds, 1987, 1997; Routh, 1996; Watson, 1956). Hippocrates was the ancient Greek founder of medicine, always a close professional cousin of clinical psychology and a scientific model for psychology in general. Theodule Ribot led the development of psychology as an academic discipline in 19th-century France, as one primarily focused on clinical issues. Alfred Binet, also in France, devised the first practical “intelligence” test in 1905; administering such tests was among the most common activities of early clinical psychologists. Leta Hollingworth was an early practitioner who played a large role in the development of organized clinical psychology beginning in 1917 (Routh, 1994). Sigmund Freud founded psychoanalysis, the first influential form of psychotherapy practiced by clinical psychologists, among others. Finally, Hans Eysenck was among the earliest to conceptualize behavior therapy and to promote the use of what have come to be known as evidence-based methods of intervention in clinical psychology.

The Future of Clinical Psychology

In this chapter, we speculate on near to immediate future trends in clinical psychology and make ten predictions in the broad areas of training, diagnosis and assessment, and treatment. These include: (1) an increased focus on competencies in training; (2) the implications of evidence-based practice as a new major focus of training; (3) changes in the accreditation of training programs; (4) a move to dimensional conceptions of diagnosis; (5) clinical outcomes assessment as an integral part of practice, as well as a more individual focus in clinical research; (6) the increasing recognition and dissemination of psychological treatments; (7) the end of single-diagnosis psychological treatment manuals; (8) the development of drugs that specifically enhance the mechanisms of action of psychological treatments; (9) an expanded role for technology in service delivery; and (10) a clearer delineation of the terms “psychological treatments,” referring to interventions directed at psychopathology and pathophysiology in the context of our health-care delivery system, and, “psychotherapy,” increasingly based on data from positive psychology, but directed at enhancing personal adjustment and growth.

A Prolegomenon to Clinical Psychology

In 1969, David Shakow, generally acknowledged as the founding father of modern-day clinical psychology, recounted his 40-year odyssey in the field. He focused on advances in training, diagnosis and assessment, and treatment, and projected trends in these areas in the years to come. The author recounts his own 40-year odyssey, beginning in 1969, and reflects on the remarkable growth of clinical psychology, progress that has occurred in the areas of training, diagnosis and assessment, and treatment, and the extent to which Shakow’s vision has been realized.

Evidence-based Practice in Clinical Psychology

The Institute of Medicine identifies evidence-based practice (EBP) as a core competence for all 21st century health professionals (Greiner & Knebel, 2003). Psychology is a relative newcomer to the evidence-based movement, having just adopted EBP as policy in 2005 (www2.apa.org/practice/ebpstatement.pdf). Evidence-based practice is both a conceptual model and a process for basing clinical decision-making on the integration of research, client characteristics, and resource considerations. We describe the evolution of models of EBP across the health disciplines and discuss how the concepts and methods of EBP apply in clinical psychology. Psychologists’ roles in relation to EBP are as creators, synthesizers, and consumers of evidence. We consider implications of EBP’s adoption for clinical psychology training, and describe learning resources that support clinical psychologists in mastering EBP.

The Nature and Treatment of Bipolar Disorder and the Bipolar Spectrum

In this chapter, we review the nature and treatment of bipolar disorder. We first present a perspective on the disorder, based on the dominant bipolar I and II classifications, and review the current state of medication and empirically supported psychosocial interventions (e.g., cognitive-behavioral therapy, family-focused therapy, interpersonal and social rhythm therapy, and group treatment), including factors that lead to poor treatment response. Given the increased attention to how bipolar I and II may lie at one end of a continuum of patterns of mood instability, we subsequently address spectrum conceptualizations of bipolar disorder. The proposed spectrum models are presented and then considered in relation to revised prevalence rates and treatment implications.

Interventions with Culturally Diverse Populations

This chapter addresses the need for cultural competence in the delivery of clinical psychological services. It advocates for cultural integrity in the adaptation of mainstream psychological practice. The role of cultural mirrors in the psychotherapeutic process is examined, namely, how worldviews, the therapeutic relationship, and communication affect therapy. The centrality of a sociocentric worldview in the delivery of psychological interventions for culturally diverse individuals is emphasized. The chapter discusses the role of cross-cultural therapeutic relationships, including racial identity developmental theories and ethnoracial bias, in addition to communication styles and their impact on clinical practice. The author advocates for the incorporation of ethnic specific therapies into psychological practice, and concludes with a discussion of ethnocultural psychological practice, an approach developed to integrate culture and ethnicity into the delivery of interventions with culturally diverse individuals.

Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) describes two eating disorder diagnoses, anorexia nervosa (AN) and bulimia nervosa (BN). Provisional criteria are also provided in DSM-IV for binge eating disorder (BED), which is an example of an eating disorder not otherwise specified. This chapter presents a summary and synthesis of research related to the clinical features and treatment of AN, BN, and BED, including studies of prevalence, common comorbidities, and treatment efficacy. Both psychological and pharmacological treatments are reviewed, including cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, and the use of antidepressant medications. Recommendations are made for future research across the eating disorders.

Disorders of Development

Disorders of development include a range of disorders first evidenced in childhood. Although most disorders have their origins in childhood, a few fully express themselves before early adulthood. This chapter describes the nature, assessment, and treatment of the more common disorders that are revealed in a clinically significant way during a child’s developing years. The disorders of development affect a range of functioning from single skills deficits to more pervasive problems that negatively impact a child’s ability to function. Included is coverage of several disorders usually diagnosed first in infancy, childhood, or adolescence, including the neurodevelopmental disorders (e.g., attention-deficit/ hyperactivity disorder, autism spectrum disorder, communication disorders, intellectual disability, and specific learning disorder) and the disruptive, impulse control, and conduct disorders (e.g., oppositional defiant disorder, conduct disorder). Recommendations for future research on the potential for advancing knowledge regarding spectrums within some of these disorders as well as recommendations for treatment are outlined.

Diagnoses, Dimensions, and DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) is often said to have provided a significant paradigm shift in how psychopathology is diagnosed. The authors of DSM-5 have the empirical support and the opportunity to lead the field of psychiatry to a comparably bold new future in diagnosis and classification. The purpose of this chapter is to address the validity of the categorical and dimensional models for the classification and diagnosis of psychopathology. Considered in particular will be research concerning substance use disorders, mood disorders, and personality disorders. Limitations and concerns with respect to a dimensional classification of psychopathology are also considered. The chapter concludes with a recommendation for a conversion to a more quantitative, dimensional classification of psychopathology.