PSYCHOLOGY IN ACTION

AMERICAN PSYCHOLOGICAL ASSOCIATION. Graduate education In psychology. Washington, D. C.: APA, 19S9. AMERICAN PSYCHOLOGICAL ASSOCIATION. Report of the ad hoc committee on problems of practician agency evaluation. Washington, D. C.: APA, 1961. (Mimeo) EWALT, J. (Ed.) Action for mental health. (Final report of the Joint Commission on Mental Illness and Health.) New York: Basic Books, 1961. KELLY, E. L. (Ed.) Training in clinical psychology. (Conference on graduate education in clinical psychol-

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ogy at Boulder, Colorado, August 1950) New York: Prentice-Hall, 1959. RAIMY, V. C. (Ed.) Training in clinical psychology. New York: Prentice-Hall, 19SO. SCIIOMELD, W. Logistics in professional psychology. Paper read at Princeton Conference, June 1962. STROTIIER, C. R. (Ed.) Psychology and mental health. Washington, D. C.: American Psychological Association, 19S6. WOT.FLE, D. America's resources of specialized talent. New York: Harper, 1954.

GRADUATE TRAINING FOR COMMUNITY CLINICAL PSYCHOLOGY

MARSHALL R. JONES AND DAVID LEVINE University of Nebraska

UCH attention has been devoted in recent years to the major problems that our society is facing in the field of mental health. The final report of the Joint Commission on Mental Illness and Health (Ewalt, 1961) defines these problems in detail and makes some provocative recommendations for dealing with them. The recommendations for the eventual abolition of the large state mental hospital in favor of smaller, community-centered intensive treatment centers, the support of programmatic research rather than piecemeal efforts, the suggestions for enlarging the professional mental health manpower pool, and the suggestions for the use of persons fully trained in a mental health profession as consultants to various other professional and lay groups, all have important implications for the mental health professions, including clinical psychology. Iscoe (1962) observes that "these radical and progressive steps" involve the psychologist's "adopting a new approach, an approach that is not yet being taught in most graduate schools. . . ." In our graduate training program in clinical psychology at the University of Nebraska, we have been for some time, and especially since the Palo Alto conference in 19SS on Psychology and Mental Health (Strother, 1956), trying to train clinical psychologists who can fit into the sorts of roles that are demanded by this approach and who can be flexible enough to develop with the field as it progresses. In this paper we will review some of the basic principles which seem to us to underlie the training of psychologists for professional careers in the field of mental health, examine these principles in relation to the developments that have occurred in this field since World War II, explore the implications of these factors for graduate training

in psychology in general and clinical psychology in particular, and describe a training program in which we are attempting to apply these principles. Historically, clinical psychology developed in close relationship to medicine, and especially to psychiatry. For a time this relationship was so close that clinical psychology did not exist to any substantial extent outside of medical installations, and psychologists in this area of endeavor conceptualized their problems in terms of the medical model and adopted a medical nomenclature. As professional psychology has developed it has become more and more independent of medicine, has developed its own techniques and concepts, and has applied these increasingly in other, nonmedical areas. Concomitantly, clinical psychology has become increasingly aware of the limitations of an illness or disease model for understanding behavior in either its normal or pathological forms, has turned more to psychological models, and has found itself increasingly interested in the concept of healthor betterin optimal behavior function. As a result, clinical psychologists are drawing more and more on the basic knowledge of behavior in general in trying to understand unusual or deviant behavior and at the same time are contributing to the general knowledge of behavior by their research which was instigated by problems arising from their work with deviant behavior. The past 10 years, especially, have seen important changes in the concepts used by clinical psychologists, the functions they fill, the professional roles they adopt, the nature of their relations with other professional groups, and the goals they set for themselves. The notion of the clinical psychologist as a technician who aids in pinning a psychiatric label on a patient is giving way to the notion

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of the psychologist as a consultant who aids in the development of a concept of positive mental health "in overall evaluation of persons with many different kinds which emphasis is on maximum development of indiof problems in many kinds of situations. He is called vidual potentialities rather than on barely adequate adon by teachers, attorneys, judges, rehabilitation coun- justment" (Raimy, 1950, p. 21). In addition, because selors, parents, wardens, institution heads, the police, the field of clinical psychology was at that time, and executives, military officers, and many other groups to still is, in a state of rapid development, it was likely evaluate people and aid in making decisions involving that any professional person who was trained simply in these people. This change in role has led to new kinds skills, knowledge, and techniques known at that time, of interprofessional relationships, new kinds of respon- and without a sufficiently broad background to enable sibilities, and an increasing awareness of the breadth him to understand the relation of the techniques to the of the problems which human beings face. background of knowledge in psychology in general, ran If psychologists are to fill these functions effectively, the considerable risk of being unable to keep up with they must be well trained in the principles and meth- the rapid developments in the field and thus of becomods of scientific psychology and the traditional tech- ing professionally obsolete within a decade or two after niques of testing and psychotherapy. It is extremely completing his formal training. For these same reaimportant also for them to have a clear understanding sons, we then opposed, and still do, the establishment of community organization and resources, a grasp of of the type of training program which leads to a "prothe subtleties of interprofessional relations, awareness fessional" degree in clinical psychology. of the possible applications of the principles of group Practical considerations which influenced our decisions, dynamics and group structure to conferences of all and which we felt were essentially compatible with our sorts, a concern for the problems of communication, principles, included the fact that we were operating in a knowledge of the contribution which other profes- a relatively small department without potential for any sional groups are making in the area of mental health, significant expansion, that we had the necessary tradiand an awareness and acceptance of a workable code tions, facilities, and staff to give solid training in genof ethics. (A similar point of view has been expressed eral and experimental as well as in clinical psychology, by Strother1958, p. 131.) that we had a psychological clinic under the direction The development of the Clinical Psychology Train- of psychologists which had as its primary purpose the ing Program at the University of Nebraska has been training of psychologists, that it was possible to obtain shaped by the interaction of a few basic principles of the services of psychiatrists and other physicians, and training held by the faculty, and some external condi- other professional persons, as consultants on both servtions over which those of us most directly involved in ice and training problems, that we were operating in a the training program had little or no control. The community large enough to supply a sufficient number training principles which the staff holds are highly com- and variety of subjects for training purposes, and that patible with the "Boulder model" which grew out of there were in the community a large number of agenthe Conference on Training in Clinical Psychology in cies and professional people who sought psychological 1949 (Raimy, 19SO). We have sought from the be- services and were disposed to cooperate with the Psyginning to select and train the type of person who, in chological Clinic in its training as well as its service his professional life, would both contribute to the ad- functions. vancement of knowledge by doing research and who As our program has developed over the last 13 years, would apply his knowledge of psychological principles another fact has gradually become more apparent which, to the solution of human problems. The decision to it seems, makes our type of training even more relevant take this course was influenced by our conviction that and functional. The studies of Albee (1959) and others society as a whole would be best served in this manner, have made it abundantly evident that there is now a by the belief that what is good for society is, in the very serious shortage of present and potential manlong run, good for psychology in general as well as for power in all the mental health fields, including clinical individual clinical psychologists, and by the circum- psychology, and that this situation is not likely to imstances of the university and the community in which prove within the foreseeable future. Indeed, it is more we were to function. likely to get worse. The implications of this situation So far as society as a whole is concerned, our views are several, but they include the one that professional agreed with those set forth in the report on the Boulder personnel in the mental health field must spread their Conference in which it was pointed out that insufficient knowledge and skills over a much broader area or else help was available for persons in immediate need of large numbers of our citizenry who need such services professional psychological assistance, insufficient atten- must go without them. We agree with the recommention was being paid to conditions which lead to the de- dations of the Joint Commission on Mental Illness and mand for this sort of help, and a need existed for the Health that, for the interests of society to be best

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served, professional personnel must be used to a greater extent in consultative roles with parents, teachers, and "caretaker" personnel and relatively less in individual face-to-face relationships with those needing and seeking help. Another implication of the present and potential manpower shortage is that it is even more urgent that we train more of our mental health personnel for research functions and that society's interests will best be served in the long run if we devote an increasing proportion of our resources to research aimed at prevention. It has been pointed out repeatedly that there is little likelihood that society can ever cope effectively with the mental health problem on a treatment basis. Preventive techniques, based on knowledge gained from research, seem by far our most promising course. With these convictions, the resources available to us, and especially the Psychological Clinic under the control of the staff whose primary responsibility is training, we have evolved a training program which seems to us compatible with the needs of society, psychology in general, and individual clinical psychologists. Without sacrificing training in the scientific understanding and use of the psychological tests themselves, we impress upon all students the need to clarify the total referral context before giving psychological tests. Thus, our students are not taught to give a Rorschach, an MMPI, or a WAIS and then interpret it. Rather, they are taught that the human being they are going to meet has a problem of some kind, generally a decision must be madethe person is being tested for a reason. As Towbin (1960) has pointed out, that reason often is obscure and the first job must be to define the problem of the individual within the environment in which he functions. Towbin speaks of the diagnostic triad of the patient, referring psychiatrist, and clinical psychologist; we have found that the referral context more often involves a half dozen people or more. Whereas previously a youngster who misbehaved in school was seen by a psychologist who sent a report to the school psychiatrist who referred him, now our practicum student may have contacts with the teacher, the guidance counselor, principal, school social worker, psychiatrist, parents, and, perhaps, juvenile probation officer in order to define fully the referral question. The practicum student may, and usually does, under the direction of and in cooperation with his supervisor, have a follow-up conference with some or all of these same people to explain and defend his recommendations and take an active part in the overall planning for the person he evaluated. A recent case illustrates the kind of follow-up conference in which one of our students may be involved. A seven-year-old first grader was referred to the clinic because he had been misbehaving at home and his work

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at school was erratic. The referral was made by the Juvenile Probation Officer since custody of the child had been given to the Juvenile Court at the time of his parents' divorce. When making the referral, the Probation Officer had said that the parents were "squabbling over visitation rights." As the case developed, it became clear that the child's father was passive and ineffectual and that the "squabbling" was a serious struggle for power between the child's mother and her ex-mother-in-law. In the course of his evaluation, the student tested the child, his father, mother, and grandmother. At one of the follow-up conferences, not only the child's father and grandmother were present, but also their lawyer and the mother's lawyer. Although all the people involved were sincere in their desire to do what was best for the child, their own attitudes and defenses were often the determining factors in their proposed solution. During this conference the student learned something about forensic psychology, group dynamics, and interviewing techniques in a way which will probably leave a deep impression on him. This broader approach to the psychodiagnostic problem enables us to give the clinical student the opportunity to develop the interpersonal skills and attitudes, not only "to establish rapport" with the person referred, but also to create and maintain constructive relationships with the other people involved in the case. He starts by attending conferences in which the issues about the referral context are discussed, then he observes his supervisor deal with these problems, the various ramifications and possibilities of referrals are clarified, and, finally, he is allowed to participate, under supervision, in the process himself. We feel the student learns that the most brilliant dynamic analysis of an extensive test battery is of little value if the important questions remain unanswered, if the report is written so that it cannot be understood by the referring person, or if the recommendations cannot be implemented. The importance of face-to-face conferences to supplement written reports is brought home to students by their own experiences. Thus we have shifted from teaching psychological tests to teaching the use of psychological tests as an aid to understanding people's problems. Along with this shift has come a greater emphasis on teaching attitudes as compared with teaching skills. In this framework, it is essential for the student to do more than test the patient assigned to him and write a report. The Psychological Clinic serves as a consultant to the community. (Table 1 lists the referral sources which regularly use our clinic.) The student must learn how the community is organized and what his place as a psychologist is in the organization. We have found that these skills, attitudes, and principles can be readily taught in the context of a Psychological Clinic.

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TABLE 1 CLINIC REKERKAL SOURCES
Agency Source Student Health Service University Counseling Service Child Development Laboratory Speech and Hearing Laboratory University High School NROTC Faculty members Student, faculty and employee selfreferrals Self referrals from the community Physicians Attorneys Veterans Service Center National Red Cross Parochial Schools Catholic Social Service Nearby universities and colleges Religious affiliated orphanages and homes

The University of Nebraska

Private agencies, schools, et cetera

Lincoln and Lancaster County Lincoln Public Schools Lancaster County Separate Juvenile agencies Court and Probation Office Lincoln Police Department Lancaster County Dcpt. of Public Welfare Lincoln-Lancaster County Child Guidance Clinic Family Service Association Other counties County Departments of Public Welfare Local Schoolboards, School superintendents, Principals County Courts State Department of Public Welfare Foster Care Unit Crippled Children's Service State Home for Children State Department of Institutions State Mental Hospital State Penitentiary Men's Reformatory State Home for Mentally Retarded Boys Training School Girls Training School State Department of Education Division of Rehabilitation Services Disability Determinations Section Department of Special Education Veterans Administration Lincoln Air Force 15asc

State of Nebraska

Federal agencies

An analogous change has occurred in our treatment or rehabilitation program. A preoccupation with individual psychotherapy has given way to broader approaches in dealing with the problems presented. The involvement of several family members, concern with vocational and educational adjustment, greater use of community resources, and awareness that symptom change is an insufficient criterion of success are indications that we are not treating a specific disease entity, but rather are attempting to help persons reorganize their ways of living. For example, if a child is accepted for play therapy we also have regular therapy sessions with one or both parents, consult with the school or court personnel when advisable, consult with probation officers and social workers in terms of their relationships with the clients, and call in psychiatrists or other professional personnel for consultation whenever a student or supervisor feels this is desirable. We use not only the traditional kinds of group therapy, but

also work with family groups in which a psychologist sees all members of the family simultaneously. At the same time, we continue to use individual psychotherapy as an opportunity not only to teach technique, but also so that the student may compare this technique with other possible ways of dealing with human problems. Because our clinic is identified as a psychological rather than a psychiatric clinic, because of the types of relationships we have with a wide variety of nonmedical agencies, and because of some increase in awareness of the public that to seek help with one's personal problems of adjustment does not necessarily brand one as sick or crazy, we get the opportunity to see an increasing number of persons whose problems are in the incipient and less complex stages. This presents more opportunity to provide training in helping techniques which have a considerably heavier component of preventive rather than major remodeling aspects than is the case in clinics which see only the more seriously disturbed persons. It also presents an opportunity for the student to learn directly about the relatively greater advantages and efficiency of early identification and coping with behavior problems. Still another advantage of the Department Psychological Clinic is the increased communication with general, theoretical, and experimental psychology which is possible in this framework. The student gains experience in understanding the immediate clinical problem in terms of a more general theoretical framework. For example, the effect of social class or subculture on behavior takes on special significance for the student when he tests a child from an Indian tribe while he is discussing the theoretical issues in a seminar in social psychology. Since the clinic is organized so that it serves both as a service and a research facility, the student clinician learns both clinical and research skills and techniques in the setting of the clinic. The members of the clinic staff serve as models who do both research and clinical service, and considerable effort is expended in the training program to demonstrate to the student the advantages of this combination. An important aspect in practicum training is the weekly staff conference which is attended by all students in the clinical training program. At the beginning of the academic year, each of these conferences is devoted to a different referral source: the public schools, juvenile court, rehabilitation services, and so on, and representatives of these organizations attend. Students are introduced to the people with whom they will work most closely. Representatives from the agencies discuss the legal and economic foundation of their agencies, describe their functions in the community, and indicate the manner in which they use the Psychological Clinic. A period of discussion is followed by brief

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follow-up studies of cases on which the students have ence in these settings. The fact remains, however, that worked in previous years. These sessions teach the it is possible to accomplish certain things in the trainstudent the essentials of community organization and ing of clinical psychologists in a psychologically oridemonstrate the role the psychological evaluations have ented clinic that are rarely or never possible in other had in the lives of human beings. Later in the aca- settings. It is increasingly apparent also that clinical demic year, these conferences become case oriented. psychology has something to offer many other segments A student will present a case on which he is working of society, and training a clinical psychologist in the and representatives of all interested agencies are in- context of another professional school may tend to vited to attend. The goal of these conferences is the limit his point of view. Finally, we are of the opinion integration of all available information on the client that clinical psychology is still a rapidly growing and with a view toward a recommendation which utilizes rapidly changing profession, that new knowledge and the most appropriate community resources and facilities. experience are going to make necessary important One change in the nature of our referral sources over changes in training in this area in the next decade or the years which deserves notice is the increasing num- two, that this type of flexibility is most obtainable if ber of requests from legal agencies. The clinic con- clinical psychologists are broadly trained in general and tinues to get many referrals from psychiatrists and experimental psychology as well as in clinical skills and other physicians, but there are an increasing number techniques, and that this type of training is most easily from judges, police officers, welfare workers, and penal accomplished in graduate psychology departments with officers. School referrals seem also to be increasing. the major portion of the training program under the Clinical psychology is being offered an increasing direct control of psychologists. amount and variety of responsibility by the public. In summary, it is our opinion that the demands of An important advantage that we have noted is that society, the best interests of the profession of psythe contact which our students have with a wide va- chology and of individual clinical psychologists, and riety of community agencies and personnel furnishes the practical limitations within which we must operate an excellent basis for teaching professional conduct and in our culture at this time, point to the need for cliniethics in terms of concrete, live situations in which the cal psychologists who have a sound training in general students are themselves often involved. psychology, who have competency and interest in both One final point: A by-product of this type of com- research and clinical skills, who can be expected to munity clinic and its close cooperation with many agen- make some contribution to the advancement of knowlcies is that it has led to a demonstration of the func- edge, and who can work effectively with a large numtions which a psychologist can perform in these agen- ber of other persons and agencies in a consultative cacies. Several agencies have been able to follow up by pacity to help a larger number of persons than can creating positions on their own staffs for psychologists. ever be helped directly by psychologists in face-to-face What are the implications of all this? One of the situations. We believe we have developed a training most important decisions clinical psychology has made program which makes some progress toward training has been the decision to train clinical psychologists persons of this sort. within the context of the graduate college and the department of psychology, rather than in association with REFERENCES other professional schools. We are of the opinion that to attempt to train clinical psychologists within the ALBEE, G. W. Mental health and manpower trends. New York: Basic Books, 1959. framework of a medical school or a teacher's college would tend to minimize the importance of basic psy- EWALT, J. (Ed.) Action for mental health. (Final report of the Joint Commission on Mental Illness and chology in such training. In much the same way, pracHealth.) New York: Basic Books, 1961. ticum training of clinical psychologists in hospitals and ISCOK, I. Editorial. /. din. Psychol., 1962, 18, 110. clinics whose main function is service, tends to make RAIMY, V. (Ed.) Training in clinical psychology. New the training needs secondary to the service needs of the York: Prentice-Hall, 1950. organization. This is not to say that we are not cog- STROTHER, C. R. (Ed.) Psychology and mental health. nizant of the very great contribution that many hosWashington, D. C.: American Psychological Association, pitals and medically oriented clinics have made to the 19S6. training of clinical psychologists and we believe that TOWBIN, A. P. When arc cookbooks useful? Amer. Psychologist, 1960, IS, 119-123. every clinical psychologist must have extensive experi-