Emerging trends in clinical psychology

E-mail: giovanniandrea.fava@unibo.it
Department of Psychology, University of Bologna

A recent paper by a leading American clinical psychologist, James Overholser1, discusses some critical areas of development of the discipline. A fundamental characteristic of clinical psychology is its deep roots into clinical practice, unlike other fields of psychology. The major advances in psychological assessment and treatment that have been introduced by clinical psychologists in the past decades have found their inspiration from their activities in the front-lines delivery of clinical services. Overholser is very concerned by the increasing number of clinical psychologists in the US who do not provide such services and are thus not familiar with many important clinical issues to be developed in research projects 1. Such problem, however, also applies to psychiatry and other clinical specialties2. The weight and potential growth of clinical psychology lie in its capacity to maintain a strong clinical focus in research and to progress in emerging lines of research that have been developed.
The first line is concerned with psychological assessment. Clinical psychologists in the seventies found a role as experts in psychological testing (particularly the IQ, or MMPI and the Rorschach in doubtful diagnostic case) at a time when there was very little emphasis on psychiatric diagnosis. In those years, however, a clinical psychologist, Jean Endicott, and a psychiatrist, Robert Spitzer, developed the Research Diagnostic Criteria that paved the ground for the advent of DSM-III and subsequent refinements. This renewed emphasis on symptomatic assessment apparently decreased the role of clinical psychologists, because of the shared ground with psychiatry. It seemed that not much could be added to the practical implications of a DSM diagnosis. The validity and reliability of MMPI and projective testing faded, and neuropsychologists took over cognitive assessment. However, in due course, the substantial limitations and clinical inadequacies of this approach emerged 2. Exclusive reliance on diagnostic criteria has impoverished the clinical process and does not reflect the complex thinking that underlies decisions in psychiatric practice2. Paul Emmelkamp and other clinical psychologists3 have introduced the concept of macro-analysis (a relationship between co-occurring syndromes and problems is established on the basis of where treatment should commence in the first place). It is supplemented by micro-analysis, a detailed analysis of specific symptoms, which can be accomplished by the use of questionnaires and rating scales2,3. This approach supplants the obsolete notion of psychometric battery to be administered to everyone, which is still fashionable, for instance, in neuropsychology.
A second line of research is concerned with psychobiologic exploration of clinical states. Current diagnostic definitions of psychiatric disorders based on symptoms collection encompass very heterogeneous populations and are thus likely to yield spurious results when exploring biological correlates of mental disturbances. The customary clinical taxonomy in psychiatry, which emphasizes reliability at the cost of clinical validity, does not include effects of comorbid subclinical conditions, timing of phenomena, rate of progression of illness, responses to previous treatments, and other distinctions that demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same psychiatric diagnosis 2. Clinical psychology may provide the missing link between clinical states and biomarkers, building pathophysiological bridges from clinical manifestations to their neurobiologic counterparts4. Clinical pharmacopsychology is an area of clinical psychology which is concerned with the psychological effects of medications (including behavioral toxicity and iatrogenic comorbidity) and the interaction of drugs with specific and non-specific treatment ingredients5.
A third line of research is concerned with psychotherapy. In the past two decades, unprecedented refinements of the technical components of psychotherapy have occurred, with clinical results from randomized controlled trials that are in striking contrast with the disillusionments that have characterized psychotropic drug development and use5. Clinical psychology is the leading force underlying psychotherapy research and practice, including its organization in clinical services within the National Health Systems in the UK and German countries.
These emerging trends of clinical psychology provide important opportunities for development and may be an antidote to oversimplified models that derive from biological reductionism, neglect individual responses to treatment and clash with clinical reality.
1. Overholser JC. Protesting the decline while predicting the demise of clinical psychology: can we avoid a total collapse? J Contemp Psychother 2014; 44: 273-81.
2. Fava GA, Rafanelli C, Tomba E. The clinical process in psychiatry: a clinimetric approach. J Clin Psychiatry 2012; 73: 177-84.
3. Emmelkamp PMG, Bouman TK, Scholing A. Anxiety Disorders. Chichester: Wiley, 1992.
4. Fava GA, Guidi J, Grandi S, Hasler G. The missing link between clinical states and biomarkers in mental disorders. Psychother Psychosom 2014; 83: 136-41.
5. Fava GA, Staccini L, Delle Chiaie R, Belaise C, Tomba E. Farmacopsicologia clinica. Riv Psichiatr 2014; 49: 251-4.