Clinical Psychology Interventions
Interventions in clinical psychology are behavioral or verbal actions taken by a professional with the intention of altering the emotions, thoughts. or actions of a client in the direction of greater health or adaptiveness. We often think of interventions as synonymous with psychotherapy, and of this psychotherapy as taking place in the office of the professional. On both counts, this is only an approximation of the truth. Interventions occur in private offices, but they also occur in public outpatient settings as well as in a wide range of inpatient settings, and can also take place in facilities within the community at large. These interventions include psychotherapy, perhaps as the most prominent example, but also include many other actions by trained professionals. It should also be noted that there are important interventions currently outside the scope of clinical psychology, such as the use of psychotropic drugs to alter emotions, thoughts, and actions. Finally, interventions can be used by psychologists in fields other than clinical psychology, and by professionals in disciplines other than psychology. This page will be restricted to the activities of clinical psychologists, with all the caveats implied above, and with full recognition of the great breadth of interventions that are available to the professional community.
Perhaps the best way of organizing the approaches to intervention is derived from public health, and consists of distinguishing among various levels of prevention (Caplan, 1964). The most basic level, primary prevention, refers to efforts to reduce the incidence of psychosocial problems, and thus is geared toward preventing the occurrence of the target problem. In a medical setting, vaccination would be a good example of a primary prevention effort. Next is secondary prevention, an attempt to reduce the duration of difficulties that already have occurred, directed toward the early identification and treatment of an existing problem so as to minimize its potential for damage to the client. Medically, screening that allows early detection of illness, such as X-rays to detect tuberculosis, would qualify as secondary prevention. Finally, there is tertiary prevention, or the treatment of an already existing disorder so as to reduce the severity of its impact. Seeking the services of a physician after developing the symptoms of a disorder is the usual tertiary prevention effort we see in the medical community.
Clearly, the use of the term prevention is different in this technical sense than it is in common parlance, as tertiary prevention is much more commonly associated with treatment than with prevention. Additionally, there are many approaches to secondary prevention. The approaches that identify problems in their earliest stages are consistent with our usual thoughts about prevention; however, approaches that address existing acute problems in their early stages might also be thought of as treatment rather than as prevention oriented. Regardless of these difficulties, we will use these distinctions as an organizing framework, and will not attend further to whether activities are truly preventative or more nearly therapeutic.
Although it is not the topic of this page, mention must be made of the role of evidence in psychological interventions. Many interventions are based on clinical experience rather than on a solid scientific footing, much as is the case in medicine. However, the importance of using whatever evidence exists, and of contributing to the body of knowledge that does exist, cannot be gainsaid. It is encouraging to note that a growing number of psychological interventions are rooted in a substantial knowledge base (Roth & Fonagy, 1996), and this should influence practice in future years. In evaluating existing evidence, it also is critical to recognize the distinction between efficacy and effectiveness. Briefly, efficacy refers to evidence gathered in a research environment, allowing for all of the controls that are necessary to generate sound findings. Effectiveness refers to evidence gathered in a clinical setting, with all of the naturalistic variables at play that serve to reduce the ability to implement the best of experimental designs, but that do encourage generalizability to the setting in which the intervention is to be used. The two sources of evidence are not in competition with one another, but should complement each other in developing a clear sense of which findings have a sound scientific foundation, and to whom they apply.
Primary Prevention
Primary prevention efforts can be directed toward the community as a whole. or toward specific groups of individuals within the community. Thus, the focus can be on the environment or on the individual. Although it may seem as though psychologists would be most interested in the individual, there are several examples of psychologically based, environmentally oriented prevention programs. For example, an attempt to establish job training programs, or a remedial education program, within a disadvantaged community is an example of a service that is intended to have an impact on an entire community that may be viewed as at risk, and should serve to ameliorate some of the sources of risk. A more focused approach that is similar to this is when specific groups are identified on the basis of their developmental status, and programs are developed to be helpful to them. Examples of such programs include well baby clinics, premarital counseling programs, and retirement counseling efforts. In these cases, there are no specific identified patients, and there are no symptoms that have been developed yet, but individuals at those stages, of life are viewed as being at risk for the development of symptoms, and attempts to help them can prevent the difficulty before it occurs. Other, less developmentally based programs focus on conditions that often lead to difficulty, but do so before the difficulty begins. Programs for children of alcoholics or for people who have been victimized by a natural disaster can anticipate the stress of these circumstances and provide assistance before the stress begins to take its toll. Finally, primary prevention programs not only can serve to reduce the: incidence of emotional problems, they also can be designed so as to enhance functioning in otherwise well-functioning individuals.
There are many examples of primary prevention programs, but one exemplar must suffice at this point. The best known of all the primary prevention programs, in all likelihood, is Project Head Start (Zigler & Valentine. 1979). Head Start was a massive and politically charged federal program that was developed in order to increase the ability of disadvantaged children to express social competence. It is a classic example of primary prevention, in that attention was focused on preschool children who were at risk for social difficulties in order to forestall those difficulties with a preemptive psychological and educational intervention. The project has been subjected to a great deal of evaluation research became of its political implications, and probably has been overly praised by its defenders and overly criticized by its detractors. Nonetheless, the results appear to indicate that children in the program, as compared to those who were not, showed clear benefits. They also demonstrated gains on preschool achievement tests (not the focus of the project), but these dissipated over time (and may have been maintained if there had been adequate follow-up. either at home or in the schools). It is not necessary to pursue the political agendas that have greeted evaluations of Project Head Start to note that it was an effort directed at children at risk and, at least on some levels, the children benefited, thereby demonstrating the potential advantage of a primary prevention intervention.
Secondary Prevention
Secondary prevention efforts have a clearly defined target, unlike primary prevention, which is directed toward populations rather than people, because signs of difficulty already are present when secondary prevention becomes appropriate. These signs may be in the early stages of a disorder, or they might be more extreme and occur in the acute phase of the disorder. In either case, the goal of secondary prevention is to assure that the disorder is arrested at an early stage so that the long-term consequences for the client are minimized.
Secondary prevention programs that target early stages of potentially damaging disorders are similar to the high-risk interventions of primary prevention, but incipient signs of difficulty already are present. The establishment of hot lines to provide access to services for people who feel in need, such as suicide hotlines, is a good example of such an effort. Attempts to provide counseling and other services for preadolescents with some behavioral problems in school also can be classified as secondary prevention. These efforts do have the danger of overprediction, as many identified high-risk people will not develop the feared condition. However, in a serious matter such as suicide, providing services for many people who would not need them is a small price to pay for offering such services to the very few who would go on to make an attempt on their life.
The exemplar we will describe for secondary prevention is the Primary Mental Health Project (PMHP; Cowen et al.. 1996). Primary refers to the grade of the children being studied and not to the level of prevention. as this is a secondary prevention project directed at high-risk children. The PMHP originated more than 40 years ago and has both undergone continuous evolution and spawned multiple attempts to duplicate its success in other school districts. Of particular note, not only has the project provided service to many needy children, it also has been subject to critical research scrutiny, so that the apparent success can be well documented.
The heart of the program is a massive screening effort with 6-year-old children in school. Children who displayed either actual signs of maladjustment or a high probability that it would develop were identified by the placement of a red tag on their school folders. These children, left to their own devices, developed in a more dysfunctional manner than their non-red-tagged peers. The introduction of a comprehensive mental health program in the school led to a significant improvement in all of the children in the school, including those who otherwise seemed destined for multiple problems. This ability to intervene at an early stage and reduce the severity of subsequent pathology is an excellent example of secondary prevention.
Tertiary Prevention
Tertiary prevention only can be considered prevention under the nomenclature that we have adopted. It ordinarily would be viewed as treatment, and as the stereotypic view of what psychological intervention consists of. When we think of clinical psychological intervention, we usually think of individual psychotherapy delivered by a clinical psychologist to a single client in a private office setting. This is tertiary prevention, but it is not all of tertiary prevention activities. Tertiary prevention, or psychotherapy, can take place in many settings with many modalities and many orientations. Many are described at greater length separately, so we will simply review the large number of possibilities that fall under this rubric.
Let us first address some of the modalities of psychotherapy that exist. Many clients are seen individually, but other possibilities also exist. Small groups, such as couples, can be seen. Typically, these couples are heterosexual married couples who seek help with a dysfunctional relationship. However, dysfunctional relationships can exist in other groupings, so that we also have couples therapy for unmarried couples, for homosexual couples, for adult parent and child, and for unrelated couples such as business partners. The group can become larger if the entire family is seen, and family therapy, too, can be offered to families of many types. In even larger groups, therapy can be used to help unrelated people gathered together, or these people may be related by a common concern, such as alcoholism. The groups often have professional leadership, but many 12-step programs are leaderless, or are led by nonpsychologists. In another variation, some groups have more than one leader. In some cases, the intention of the group is not to correct psychopathology but rather to enhance functioning and promote growth, but such groups would not be considered tertiary prevention activities (groups also can be used for primary and secondary prevention).
The venue in which intervention is offered can be a private office, but it is not limited to that setting. Much intervention occurs in public facilities, such as community mental health centers. The most seriously impaired of clients frequently are treated, at least initially, in an inpatient hospital setting, from which they may go on to a partial care setting such as a day hospital, and then may be returned to the community for individual treatment. Much intervention of value is delivered within a school setting. Within hospitals, treatment can be offered as a liaison to medical services, such as psychotherapy intended to reduce the anxiety of a patient with a serious medical illness, or in anticipation of a stressful procedure such as surgery. The settings in which psychotherapy is offered, and the combinations of clients who may be seen, are limited only by the imagination of the clinical psychologist. However, with all these variants possible, it remains critical for research programs to document the success (or failure) of each effort.
Estimates of the number of orientations to psychotherapy vary from a very small number to well over 400. The larger estimates confer the title of orientation on every variation of technique that exists, and probably are using the term orientation improperly. Two very common, and much smaller, estimates of the number of orientations are two and three. The two orientations consist of action and reflection, with some approaches geared toward active attempts to change behavior and thought, and other approaches focused primarily on increasing self-reflection and self-knowledge. It is likely that active changes in the client will lead to some changes in self-regarding attitudes, and that greater insight will lead to some behavioral change, so that the division between the two is not as clean as it may seem. Often the three orientations are seen as psychodynamic, behavioral, and humanistic. Psychodynamic approaches are the oldest, and clearly it in the reflection category. They place a premium on self-understanding, with the implicit (or sometimes explicit) assumption that increased self-understanding will produce salutary changes in the client. Behavioral approaches are geared toward action, with a clear attempt to mobilize the resources of the client in the direction of change, whether or not there is any understanding of the etiology of the problem or the ramifications of the change. Humanistic approaches also aim toward increased self-understanding, often in the direction of personal growth, but use treatment techniques that often are much more active than are likely to be employed by the psychodynamic clinician.
These very broad categories each describe what may be seen as a pure-form orientation. However, more and more, clinicians are following hybrid approaches that attempt to combine the best of the various approaches, either as guided by an attempt to select whatever works best (eclecticism) or in a manner that is guided by theory (psychotherapy integration). Because of the importance of the psychotherapy integration movement (Stricker & Gold, 1993), we will describe it in much greater detail as an important contemporary development in tertiary prevention.
Psychotherapy Integration
Psychotherapy integration includes various attempts to look beyond the confines of single-school, pure-form approaches in order to see what can be learned from other perspectives. It is characterized by an openness to various ways of integrating diverse theories and techniques. The term psychotherapy integration has been applied to a common-factors approach to understanding psychotherapy, to assimilative integration (a combination of treatments drawn from different approaches but guided by a unitary theoretical understanding), and to theoretical integration (an attempt to understand the patient by developing a superordinate theoretical framework that draws from a variety of different frameworks).
Common factors refer to aspects of psychotherapy that are present in most, if not all, approaches to treatment. Most practicing psychotherapists appear to be aware of this common core and. as a result, we can expect that more experienced therapists will make greater use of the common factors. Although there is no fixed, established list of common factors, consensus suggests that such a list would include the development of a therapeutic alliance, exposure of the patient to prior difficulties followed by a new corrective emotional experience, expectations by the therapist and by the patient for positive change, beneficial therapist qualities such as attention, empathy, and positive regard, and the provision to the patient of a rationale for problems. For those therapists who are impressed by the mutative role of the common factors, the critical question is how much any specific technique or theoretical understanding adds to the benefit provided by these common factors. It is for this reason that the inclusion of a control group that provides the common factors is critical in any definitive psychotherapy research program.
Assimilative integration is an approach in which a solid grounding in one theoretical position is accompanied by a willingness to incorporate techniques from other therapeutic approaches. It probably is the single most practiced approach to psychotherapy integration, although many practitioners may not have the terminology to refer to it as such. Whatever the theoretical preference of the therapist may be, it is not unusual to incorporate techniques from other approaches, and this constitutes an attempt to assimilate these other approaches into the one defined by the dominant preference. This also leads to a challenge to the dominant theory, as the therapist must then think about why this effective approach is not suggested by the preferred theory, and what the success means in terms of possible needed revisions to the theory.
Theoretical integration is the most difficult level at which to achieve integration, for it requires bringing together concepts from disparate approaches, some of which may differ in their fundamental worldview. Thus, for example, the possible integration of psychoanalysis and behavior therapy (Wachtel, 1977) requires an integration of an approach that sees people as unwitting victims of their history with another that views people as actively capable of altering their fate and making it work out well in the end. It also requires finding an appropriate balance between the reflection favored by one and the action preferred by the other. It is much easier to assimilate the techniques of either approach into the theory of the other than it is to develop a true integrative theory that combines such disparate assumptions and roots.
An eclectic approach, in contrast to psychotherapy integration, is one in which the therapist chooses interventions because they work, without the need for a theoretical basis for, or understanding of, or necessary concern with, the reason for using the technique other than the one of efficacy. Psychotherapy integration differs from eclecticism in that it attends to the relationship between theory and technique. However, several practitioners of eclecticism feel that they do employ theory, and this distinction may be one that is more reliant on terminology then on genuine difference.
The general point to be made is that there is a clear value to the role of theory in the combination of therapeutic techniques, whether or not the process is called psychotherapy integration. This is true whether the theory is the level at which integration occurs, the framework that governs the choice of a breadth of technical interventions, or the organizing principle for understanding the common factors that are present in all psychotherapy.
Future Directions in Clinical Psychology
Research in psychopathology, including its assessment and treatment, has greatly accelerated during the past 100 years. Much more research in this field has been published during the twentieth century than in all previous centuries (Routh, 1998). Research funding is available from various private foundations, from the National Institutes of Health in the United States, the Medical Research Council in the United Kingdom, and other such governmental organizations. Thus, clinical psychology, psychiatry, and other disciplines involved in research in this domain are in a relatively healthy state.
In the domain of the delivery of professional services in mental health, however, powerful trends are under way to cut costs, improve efficiency, and transform the field into a more businesslike operation. In the United States, these efforts go on under the heading of managed care. Since a large share of health costs is taken up by the salaries and fees paid to relatively expensive professionals, including psychiatrists and clinical psychologists, their incomes are now under threat. Psychotherapy can be delivered by social workers and others with master’s degrees or even more modest levels of training. Similarly, prescriptions for psychotropic medications can, in many cases, be written by primary-care physicians without the need for psychiatric referral. Thus, there is some possibility that what happened to the primary-care specialty of neurology at the beginning of the twentieth century could happen to clinical psychology and psychiatry now. They might come to exist as fields primarily consisting of researchers, teachers, and high-level consultants and not be so much involved in everyday mental health care. Whatever the outcome, it is clear that the situation will be much changed even within the next decade.
See also:
- Clinical Psychology History
- Clinical Psychology Theories
- Clinical Psychology Assessment
- Clinical Psychology Bibliography