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A CONSUMER'S GUIDE TO CLINICAL PSYCHOLOGISTS

Clinical psychology is the branch of psychology interested in the diagnosis and treatment of mental disorders.

Psychologists cannot prescribe medications, but they may provide individual or group therapy to people with 'mental illness'.

Some clinical psychologists follow the writings of important theorists such as Jung or Freud. Others have more eclectic practices. They might use psychotherapeutic models, a variety of different 'talking methods' that include unravelling the past, or methods that concentrate more on the present and the future.

At the present time, various forms of behaviour therapy are preferred, cognitive behaviour therapy being one of the most common. See below for more on this.

Clinical psychologists are just one group among many groups of practicing psychologists. They may also work in the fields of research, human development, sports, industry, media and law, for example.


Styles of practice

Everyone who trains as a psychologist completes an undergraduate course that has been dubbed by some of us 'Rats & Stats', in reference to its positivist interest in research. Positivism is a science methodology that assumes that knowledge comes from evidence, which in turn comes from large-scale, statistical research; at its best, randomised, control trials. Psychologists pride themselves on the science of their trade.

Clinical Psychology is the branch of psychology that is interested in psychopathology; that is, the study of the causes and development of psychiatric/psychological disorders.

Even though clinical psychologists don't use medical drugs, they usually ascribe to a very medical model of practice. Sometimes they deny this; however, like psychiatrists, the clinical aspect of their training prepares them for identifying, classifying and 'treating' psychopathology.

Clinical psychologists don't practice with pills and potions. They cannot prescribe psychiatric medicines. Instead, they specialise in various forms of talking therapies and/or behavioural therapy. Some of us need to know the theoretical underpinnings of the therapy we are being offered and it's OK to ask.

Many clinicians will reply that their practice is eclectic (not following any one system or method but selecting and using what are considered the best elements of all systems) and empirical (based on practical experience from working with others and constantly evolving rather than scientifically proven). You need to dig deeper than that to really understand their approach.

Psychodynamic psychotherapy

Psychodynamic psychotherapy is a form of in-depth psychotherapy which has a primary focus on revealing unconscious beliefs and experiences that we are struggling with.

Similar to psychoanalysis but less formal, less intensive and shorter, it is strongly based on the therapeutic relationship.

Some of us are wary of any therapy that centres on these artificial relationships, which are really artifacts of the uneven power balance between therapist and client. Others have no problems with them and flourish under these circumstances.

Psychodynamic psychotherapy puts much weight on what has happened in the past influencing what is happening to us now. For a fuller description see here.

Humanistic therapy

Humanistic therapy applies a more holistic approach to understanding people based on the social context of their lives. It is most concerned with what is happening now rather than what happened in the past.

The humanistic approach has been criticised for being insufficiently political - still continuing to "help the person" rather than locating problems in the fabric of society.

Some of the humanistic approaches include gestalt therapy, holistic health, encounter groups, sensitivity training, family therapies, self-help, and co-counselling. For a fuller description see here.

Cognitive behaviour therapy (CBT)

CBT is an umbrella term covering several different approaches that are based on the theory that how we think (cognition), how we feel (emotion), and how we act (behaviour) are related and interact together in complex ways.

In this perspective, it is assumed that some of the ways we interpret the world lead to emotions that, in turn, contribute to 'behaviours' that we find hard to live with, or that others find hard to live with, or coping mechanisms that no longer work.

Some of us get a huge amount out of CBT approaches because they are practical, focused on our issues today and we can easily see what is working and what is not. Others feel patronised because we can 'see through' the therapy and feel manipulated.

Unlike other forms of therapy, CBT lends itself to 'easy evaluation' which provides an 'evidence base' (Hey! This really works!) that endears it to 'the scientists' lurking in some clinical psychologists' heads, not to mention bureaucrats. As people with real life experience we are not always so sure. It's easy to say that 'we're better' when we're not really (and we often do).

Systems or family therapy

Systems or family therapy emphasises that family relationships are important for psychological health. The central focus is on interpersonal dynamics, especially in terms of how change in one person will affect the entire family dynamic.

Some people diagnosed with 'mental illness' have got things out of family therapy, partly because it gives them a formal opportunity to be heard. Others can find family therapy excruciating. Perhaps this is due to the inexperience, attitude or lack of skills of the therapist but too often it involves the person with a mental illness diagnosis being expected to hold all the pathology for the whole family.

Other therapeutic approaches and perspectives

Others approaches include: existential psychotherapy; postmodern psychology; transpersonal psychology; multicultural approaches; feminist approaches; and positive psychology.


Case management

In Victoria clinical psychologists work as 'case managers'. As discussed in the chapter on case managers, other case managers come from the fields of psychiatric nursing, social work and occupational therapy.

Some clinicians resent the case management role because they are unable to utilise the clinical skills they so prize. Clinical psychologists have been loudest in voicing their frustrations with this. Sometimes this frustration plays itself out in their relationships with the people they 'case manage'.

Recently there has been a quiet turn on the wheel of evolutionary policy in Victoria, as behavioural techniques have crept back into popularity. Even more recently psychotherapy is returning for the first time since the First National Mental Health Strategy in 1993.

That strategy put economic pressure on the states and territories to privilege 'serious mental illness' and provide intensive case managment to 'the most serious' patients (a term challenged by many consumers). At that time psychotherapists either left the system and moved to private practice. A whole generation of psychotherapists were lost to the public mental health system. Others unhappily agreed to become case managers.


The therapeutic relationship

As with psychiatrists, there can be an enormous chasm between the power of the clinical psychologist and 'their' clients. The relationship can be strange and lop-sided.

Clinical psychologists have a good theoretical grasp on concepts to do with interpersonal interactions but are less well informed about issues to do with social control and interpersonal power. The relationship tends to take place on the therapist's terms; in her rooms, at a time that is convenient to her, with her privy to the theory and practice that we are often ignorant about, with notes being taken that we don't get to see, the clock located for only one set of eyes, and so on.

The real risk of clinical relationships is that one person will hold all the pathology and the other person (the therapist) will be granted, by her status, all the mental health. We all know deep down that this is impossible.

For these reasons it is a good idea to find out as much as you can about your psychologist's perspectives, approaches, and ways of working. We are entitled to do whatever we can to make this relationship work for us without having such attempts pathologised (though if you don't want to know, that's OK too).

The reply we get from a clinical psychologist about their style of practice will depend on many factors. These include whether the clinician sees it as in our interest to know, and whether she is a good communicator. Even if you get no clear answer, the style of response will tell you a lot about the psychologist.

Clinical psychologists must be registered (see the help sheet on Accreditation & Registration). They should have their certificate of registration signed and dated and displayed in their room but you can check their registration anyway at http://www.psychologyboard.gov.au/. Remember that registration in itself does not guarantee a practice that is ethical by the standards of consumers or clients.

If you have a complaint about a psychologist it should be directed to the Psychology Board of Australia or the Australian Psychological Society. Don't forget, however, that the APS's primary role is to represent practitioners. It does have an important and honoured role of maintaining the standard of psychological practice but it is not a neutral arbiter.

Government rebates

If you are eligible you can receive up to 16 counselling or psychological sessions per year, or 50 sessions a year if your GP can make a good case that your needs are great (in reality, few qualify for this).

Rebates for these services are available to patients with a 'mental disorder' who have been referred by a GP or psychiatrist. See the help sheet titled How money (or lack of it) affects a consumer's choices for more on this.