A Short Introduction to Clinical Psychology

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Katherine Cheshire & David Pilgrim

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  • Short Introductions to the Therapy Professions Series Editor: Colin Feltham

    Books in this series examine the different professions which provide help for people experiencing emotional or psychological problems. Written by leading practitioners and trainers in each field, the books are a source of up-to-date information about

    • the nature of the work
    • training, continuing professional development and career pathways
    • the structure and development of the profession
    • client populations and consumer views
    • research and debates surrounding the profession.

    Short Introductions to the Therapy Professions are ideal for anyone thinking about a career in one of the therapy professions or in the early stages of training. The books will also be of interest to mental health professionals needing to understand allied professions and also to patients, clients and relatives of service users.

    Books in the series:

    A Short Introduction to Clinical Psychology

    Katherine Cheshire and David Pilgrim

    A Short Introduction to Psychoanalysis

    Jane Milton, Caroline Polmear and Julia Fabricius

    A Short Introduction to Psychiatry

    Linda Gask

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    Preface

    This book aims to provide an account of British clinical psychology that is both descriptive and critical. We have sought to give the reader an understanding of the profession's history, nature and function, while avoiding the self-serving public relations view that characterises much professional rhetoric. In order to facilitate our examination of these issues, we adopt a sociological framework that allows us to locate clinical psychology within the network that post-structuralists refer to as the psy complex: psychiatry, psychiatric social work, mental health nursing, counselling, psychotherapy and psychology. We argue that the contested knowledge base of British clinical psychology and its history (particularly its evolution within the National Health Service) are responsible for many of the profession's distinguishing features. At the same time, clinical psychology shares a number of characteristics with other members of the psy complex.

    In the first two chapters of the book we provide the background to our subsequent exploration of contemporary British clinical psychology. In chapter 1 we examine the social and historical context from which the profession emerged. chapter 2 focuses on the knowledge base of the profession: its relationship with the academic discipline of psychology and its reliance on the scientist-practitioner model.

    chapters 3,4 and 5 describe how prospective members gain entry to the profession and give an account of the work that we do, followed by a discussion of likely developments in our role. chapter 3 begins with a view of clinical psychology training from the trainees' perspective, followed by an outline of current training arrangements and recent proposals to expand training provisions in order to meet the growing demand for our services. chapter 4 contains a collection of accounts written by us and some of our colleagues, describing the current role of clinical psychologists with a range of client groups. In chapter 5 we look more broadly at some of the emerging trends in clinical psychology and suggest some of the ways in which our role might evolve in the near future.

    The last third of the book, Chapters 6 and 7, continues the critical appraisal of the profession that we began in chapter 1. chapter 6 extends the discussion of professional expertise, begun in chapter 2, and examines how clinical psychology's credibility and marketability have developed on the basis of its claim to specific expertise within the psy complex. Finally, in chapter 7, we assess both the internal and external relationships that define our profession. We start by discussing the divisions and co-dependencies within the profession, and then examine how clinical psychology continues to negotiate its boundaries with the NHS, central government, other professionals and service users. The book concludes with a brief consideration of some continuing debates in British clinical psychology that we expect to shape the attitudes and work of its members as we progress through its sixth decade. We suggest that the most radical shift in orientation may come from the growing influence of the Positive Psychology movement that champions the active promotion of psychological well-being in contrast with the exclusive focus on pathology, disorder and distress, which has traditionally characterised our work. If this shift occurs it may, at least in the short term, increase the gap between clinical psychology and other professions in the psy complex.

    We hope that our readers find this book both informative and stimulating. Clinical psychology is still a very young profession but it is no longer in its infancy and we offer this contribution to debates about its nature and function in the belief that critical self-awareness is a sign of maturity within both individuals and organisations.

    Acknowledgements

    We would like to thank colleagues from the Fife Area Clinical Psychology Department, Stratheden Hospital, Cupar, Fife for their contributions to the following sections of chapter 4:

    • Dr Steven Hughes: Children and young people
    • Dr Frances Baty: Older adults
    • Mr Bob Walley: People with intellectual disabilities
    • Ms Kate McGarva: Clinical psychology in physical health care
    • Mr Andy Peters: Adults with substance misuse problems
    • Dr Alan Harper: Clinical neuropsychology
  • Glossary of Therapeutic Approaches

    This glossary provides very brief accounts of therapeutic approaches used by British clinical psychologists. One key reference is provided with each entry, for optional further reading. Cross-references are shown in bold type. The glossary only alludes to the therapeutic aspect of the role of clinical psychologists. It does not contain entries related to their other professional activities discussed in the book, such as assessment, consultancy and research.

    Because therapeutic approaches are not practised only by clinical psychologists, it is important to note that the entries describe activities carried out at times by other professions. For some of these professionals (e.g. psychiatrists, mental health nurses, social workers and occupational therapists) psychological therapies exist on the margins of their practice, and thus they generally deploy them less than clinical psychologists. However, for other professionals (e.g. medical psychotherapists, nurse therapists, counselling psychologists and counsellors) psychological therapy has a more dominant role than it does for some clinical psychologists.

    The glossary does not provide an exhaustive list of therapeutic approaches (there are hundreds of them). It is limited to the ones which, in the view of the authors, are most likely to be practised currently by British clinical psychologists. All entries apart from the first one are in alphabetical order.

    • PSYCHOTHERAPY is a generic term to describe any systematic approach to helping using a form of conversation (also called ‘psychological therapy’). Each of the various models described in this glossary then characterises a particular type. Psychotherapy can be used in groups and with families – it is not only about individual casework. The term ‘counselling’ is more often used in non-health settings but, in practice, the two terms are effectively interchangeable as descriptions of a form of psychological practice or enabling conversation. However, some psychotherapists depict ‘counselling’ as a less sophisticated or complex process and some counsellors reject the term ‘psychotherapy’ because of its medical connotations. Another term, which is sometimes used generically, is ‘talking treatment’. Broadly speaking, the psychotherapies exist on a continuum. This ranges from a fluid exploration of the client's biography (such as person-centred therapy and existential therapy), in which the therapist responds to what the client brings, moment to moment, to more structured and technique-driven approaches (such as behaviour therapy and cognitive-behavioural therapy). Hence, some psychotherapies are largely exploratory, non-directive and emphasise insight and meaning, whereas others are more structured, prescriptive and emphasise behaviour change. Several therapeutic approaches can be situated in between (such as personal construct therapy). Moreover, even action-orientated therapies like cognitive behaviour therapy entail the client revising the meaning of their actions. All models share some other common features, such as an emphasis on a positive working relationship between client and therapist, the importance of good listening and empathy skills on the part of the therapist and, most obviously, the role of talk in engendering personal change. [Feltham, C. (ed.) (1997) Which Psychotherapy? Leading Exponents Explain their Differences. London: Sage]
    • BEHAVIOUR MODIFICATION AND BEHAVIOUR THERAPY. Behaviour therapy emerged in the 1950s with an emphasis on the role of Pavlovian conditioning in generating and maintaining neurotic symptoms. Behaviour modification was based more on operant or Skinnerian conditioning. However, in the clinical literature the two terms are sometimes used interchangeably. Strictly speaking, behaviour modification is used to describe a variety of interventions that aim to decrease the frequency of dysfunctional or maladaptive behaviour, using negative reinforcement or (less commonly) punishment, and shape up more adaptive behaviour using positive reinforcement. Definitions of behaviour therapy vary and include any behavioural techniques that reduce psychological distress. Joseph Wolpe and Hans Eysenck at first emphasised techniques that would reduce anxiety-based symptoms, using knowledge from Pavlovian psychology and learning theory. During the 1970s, behaviour therapists began to work more with inner events (thoughts and feelings) as well as action. Once this occurred, the term was increasingly superseded, first by that of ‘cognitive-behaviour therapy’ and latterly by that of cognitive-behavioural therapy. With this change of technical emphasis came a shift towards the treatment of depression and personality problems, not just anxiety states. [Margraf, J. (1998) Behavioral approaches. In A.S. Bellack and M.Hersen (eds) Comprehensive Clinical Psychology Volume 6. Oxford: Pergamon]
    • COGNITIVE-ANALYTIC THERAPY (CAT), a form of eclectic psychotherapy, was developed by Anthony Ryle in the 1980s and integrated ideas from personal construct therapy and psychoanalysis. The therapist and client build up a shared formulation of the latter's life and jointly examine the dysfunctional patterns which repeat over time. CAT emphasises both intrapsychic and interpersonal processes. [A. Ryle (ed.) (1995) Cognitive-Analytic Therapy: Developments in Theory and Practice. Chichester: Wiley]
    • COGNITIVE-BEHAVIOURAL THERAPY (CBT) is the most commonly used term to describe the extension of behaviour therapy to include interventions targeting thoughts and feelings, as well as behaviours. Sometimes the term ‘cognitive behaviour therapy’ is used instead. CBT places the emphasis on clients resolving their presenting problems by developing better coping strategies in their lives and modifying the ways in which their beliefs generate and maintain dysfunctional behaviour. The approach is collaborative and clients are encouraged to engage in behavioural experiments between sessions to test out fears and predictions. This emphasis on ‘homework’ can be found in other models such as solution-focused brief therapy but it is absent from interpretive therapies (psychodynamic psychotherapy) and exploratory therapies (e.g. person-centred therapy). CBT is probably the commonest form of intervention used by clinical psychologists in mental health settings. [Hawton, K., Salkovskis, P.M., Kirk, J. and Clarke, D.M. (1989) Cognitive Behaviour Therapy for Psychiatric Problems. Oxford: Oxford Medical Publications]
    • COGNITIVE THERAPY is a generic term covering a range of therapies that focus on the client's thoughts, feelings and beliefs. Sometimes (somewhat confusingly) it is used as a synonym for cognitive-behavioural therapy in the everyday discourse of clinicians. However, more accurately, other prominent cognitive therapies are subsumed by the term, including cognitive-analytic therapy, rational emotive behaviour therapy and personal construct therapy. [Blackburn, I-M. (1998) Cognitive therapy. In A.S. Bellack and M. Hersen (eds) Comprehensive Clinical Psychology Volume 6. Oxford: Pergamon]
    • DIALECTICAL BEHAVIOUR THERAPY (DBT) is a particular application of cognitive behavioural therapy that was developed by Marsha Linehan in the 1980s to assist people with a diagnosis of borderline personality disorder – individuals who often have a history of childhood abuse/neglect. This adaptation of CBT places an additional emphasis on the interpersonal processes involved in helping patients change. The attention to the therapeutic relationship and interpersonal processes in DBT is similar to the emphasis within interpersonal psychotherapy. [Linehan, M.M.(1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press]
    • EXISTENTIAL THERAPY shares similar assumptions with personal construct therapy and person-centred-therapy about human responsibility and agency. In this model, psychological disturbance is not understood in terms of past conditioning or historical causes. Instead, the emphasis is on the client facing life's challenges in a truthful or authentic way. Existential therapy makes no suppositions about symptoms, other than that they have particular relevance and meaning within a person's biography. The role of the existential therapist is to enable the client to face life authentically using a combination of empathic clarifications and honest challenges. [van Deurzen, E. (2000) Existential counselling and therapy. In C. Feltham and I. Horton (eds) Handbook of Counselling and Psychotherapy. London: Sage]
    • INTERPERSONAL PSYCHOTHERAPY (IPT) has evolved over the past thirty years from an approach originally developed by Gerald Klerman and Myrna Weissman in the context of a North American clinical trial evaluating treatment of depression. IPT also derives from the work of Harry Stack Sullivan and Adolf Meyer and assumes that the onset, response to treatment and outcome in depression are influenced by the interpersonal relations of the depressed individual with significant others. Clients are assisted in making links between their current low mood and specific interpersonal events that are maintaining their difficulties. Therapy thus takes an interpersonal rather than an intrapsychic focus and concentrates on assisting the depressed person to utilise available social support more effectively and, where appropriate, to develop their existing social network. IPT is a time-limited intervention with a collaborative and descriptive emphasis similar to that of cognitive-analytic therapy. It has now been developed for application to a wide range of psychological disorders. [Klerman, G.L., Weissman, M.M., Rounsaville, B.J. and Chevron, E.S. (1984) Interpersonal Psychotherapy of Depression. New York: Basic Books]
    • PERSON-CENTRED THERAPY derives from the work of Carl Rogers in the 1950s and is also called ‘client-centred counselling’. Rogers was committed to the idea that the resources for personal change were inherent in clients and that it was the role of the therapist, via the therapeutic relationship, to offer support and facilitation for this potential in human growth. For this reason, Rogers did not emphasise technique but the therapist's personal qualities – they should be genuine, warm and empathic. He considered these to be the necessary and sufficient conditions for psychological change. [Merry, T. (2000) Person centred counselling and therapy. In C. Feltham and I. Horton (eds) Handbook of Counselling and Psychotherapy. London: Sage]
    • PERSONAL CONSTRUCT THERAPY (PCT) is derived from the work of George Kelly in the 1950s, who emphasised the unique ways in which individuals construe their world. When a person's personal construct system becomes dysfunctional or distressing they are encouraged to work collaboratively with the PCT therapist, who flexibly combines empathy with challenge and experimentation to help the client re-construe their world to their advantage. Constructivist approaches have been developed further in psychotherapy especially by family therapists under the influence of postmodern social science. PCT was one important source of cognitive-analytic therapy, although its role in this has lessened. PCT remains a form of therapy in its own right. [Fransella, F. and Dalton, P. (1996) Personal construct therapy. In W. Dryden (ed.) Individual Therapy in Britain. London: Sage]
    • PSYCHOANALYSIS is a broad term which refers to the work of Sigmund Freud, and to that of his followers who adhered to his views or modified them whilst retaining the term. The emphasis in psychoanalysis is on the therapist making interpretations of the client's life and their flow of verbalisations within the therapeutic relationship. The model (whatever its variations) emphasises unconscious mental life and its role in generating neurotic or dysfunctional activity. The analyst interprets this unconscious material, making very sparse interventions during sessions, and does not advise or direct the client, although the client is encouraged to simply say whatever is on their mind (‘free association’). In its pure form psychoanalysis is very intensive (five times per week for many years). However, it is shortened and diluted within psycho-dynamic psychotherapy. [See the comparative section on ‘Psychodynamic approaches’ therapy in C. Feltham and I. Horton (eds) Handbook of Counselling and Psychotherapy. London: Sage]
    • PSYCHODYNAMIC PSYCHOTHERAPY is a term used to describe any form of psychotherapy derived from psychoanalysis or from the works of those who split away from Freud (such as Carl Jung and Alfred Adler) or later modified his views (such as Melanie Klein, Ronald Fairbairn, Donald Winnicott and John Bowlby). It is sometimes called ‘psychoanalytical psychotherapy’ or simply ‘dynamic psychotherapy’. Whatever the name used, the approach always emphasises unconscious mental life and the role of interpretation by the therapist in encouraging insight in the client. Whereas psychoanalysis is primarily concerned with understanding the unconscious, forms of dynamic psychotherapy, as well as being less intensive in frequency, focus more on personal change. [See the comparative section on ‘Psychodynamic approaches’ therapy in C. Feltham and I. Horton (eds) Handbook of Counselling and Psychotherapy. London: Sage]
    • RATIONAL EMOTIVE BEHAVIOUR THERAPY (REBT) was developed by Albert Ellis in the 1950s (and at that time was called ‘rational therapy’). Ellis changed the name to ‘rational emotive therapy (RET)’ in 1962 and altered it again in 1993 to ‘rational emotive behaviour therapy’, although in Britain the term RET is still often used. The focus of this approach is on challenging the client's irrational beliefs about themselves and the world. The goal of therapy is to enable the client to shift towards a clearer and less rigid way of thinking, which will bring with it reduced distress and greater fulfilment in life. This ‘thinking’ emphasis places RET firmly within the domain of cognitive therapy. [Dryden, W. (1996) Rational emotive behaviour therapy. In W. Dryden (ed.) Handbook of Individual Therapy. London: Sage]
    • SOLUTION-FOCUSED BRIEF THERAPY (SFBT) Whereas most models of therapy focus on uncovering, understanding and working with the client's problems, SFBT for the great part avoids ‘problem talk’. Instead it focuses on the client's preferred future and how far they have already moved towards achieving it. This entails drawing attention to what has already been achieved, what next steps could be taken and what exceptions there are to the problem in their life (i.e. when the problem is not there). The ‘brief’ aspect to the approach does not necessarily signify duration of time, but refers to the minimum number of sessions needed for the client to become autonomous of therapy. As in cognitive-behavioural therapy, there is an emphasis on inter-sessional experimentation by clients to try out new solutions. However, this is framed less as prescribed ‘homework’ and more as optional work for the client to consider. [Hawkes, D., Marsh, T. and Wigosh, R. (1998) Solution Focused Therapy: A Handbook for Healthcare Professionals. Oxford: Butterworth/Heinemann]

    Further Reading

    Bunn, G.C., Lovie, A.D. and Richards, G.D. (2001) Psychology in Britain. Leicester: BPS Books.
    Carr, A. (1999) The Handbook of Child and Adolescent Clinical Psychology: A Contextual Approach. London: Routledge. http://dx.doi.org/10.4324/9780203360828
    Emerson, E., Hatton, C., Bromley, J. and Caine, A. (eds) (1998) Clinical Psychology and People with Intellectual Disabilities. Chichester: Wiley.
    Jones, D. and Elcock, J. (2001) History and Theories of Psychology. London: Arnold.
    Leahey, T.H. (2001) A History of Modern Psychology.
    Third edition
    . Upper Saddle River, NJ: Prentice Hall.
    Marzillier, J. and Hall, J. (eds) (1999) What is Clinical Psychology?
    Third edition
    . Oxford: Oxford University Press.

    Appendix

    The British Psychological Society can be contacted at:

    St Andrews House

    48 Princess Road East

    Leicester LEI 7DR

    Tel 0116 254 9568

    Fax 0116 247 0787

    http://www.bps.org.uk Information requests: enquiry@bps.org.uk

    Further information on clinical psychology training and how to apply is available from:

    The Clearing House for Postgraduate Courses in Clinical Psychology

    15 Hyde Terrace

    Leeds LS2 9LT

    chpccp@leeds.ac.uk

    http://www.leeds.ac.uk/chpccp

    The Affiliates Group of the Division of Clinical Psychology of the British Psychological Society represents the interests of assistant and trainee clinical psychologists. Officers of the Committee of the Affiliates Group can be contacted through the BPS for information about assistant psychology posts or clinical psychology training. The Affiliates Group also produces a Handbook containing information on the training courses provided by current trainees. The Alternative Handbook can be obtained from the BPS.

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