Introduction

Clinical psychological science is both the most recognisable and sought after postgraduate training program in psychology. At the same time, it’s also probably the most misunderstood. Every year, the University of Southern Queensland receives over 300 applications for somewhere between 25 and 30 positions in its Master of Clinical Psychology program. It’s highly competitive owing to the large number of applicants and relatively few positions available in the program, and this pattern is common among other clinical psychology graduate programs throughout Australia. The purpose of this chapter is to educate undergraduate students about the many facets of clinical psychology. In this chapter, we’ll define clinical psychology, the scope of practice and research, discuss training paths, and provide examples of careers in clinical psychology. The goal of this chapter is to educate students about clinical psychology, the training needed to become a clinical psychologist, and provide models of how the different facets of clinical psychology are practiced in various settings.

The Science of Clinical Psychology

Clinical psychologists apply the science of human behaviour to real-world concerns, specifically regarding mental health and wellbeing. Clinical psychologists bring principles of the scientific method – namely hypothesis generation, testing, and evaluation – into research, clinical practice and teaching in mental health. Clinical psychologists engage in clinical practice with populations across the lifespan (children, adolescents, early, mid, and later life adults) and social contexts (individuals, couples, families, and organisations) to address a broad array of behavioural and mental disorders including neurodevelopmental, psychotic, mood, sexual, and personality disorders. Clinical psychological science encompasses a wide range of activities with the common goal of improving mental health and wellbeing. These activities can be divided in to at least seven broad areas of clinical practice: research, assessment, diagnosis, prevention, treatment, program evaluation, and consultation. Below, we provide a brief overview of each area of clinical psychological science.

Research

Clinical psychologists routinely apply the principles of research to their practice. As scientist-practitioners, clinical psychologists are firstly research consumers – that is, there’s an expectation that they keep up-to-date with current research and apply it to their practice. There’s an expectation that a clinical psychologist keeps abreast of the current literature pertaining to mental health assessment and treatment, so they provide best practice to their clients. Clinical psychologists also apply research techniques to their practice. For example, assessments are routinely applied at the commencement of treatment or throughout treatment. These tools can take the form of behavioural observation (e.g., frequency counts), clinician administered tools (e.g., Health of the Nation Outcome Scales – see Painter, Buckingham & Stewart, 2018) or self-report questionnaires (e.g., the Depression, Anxiety and Stress Scale). By monitoring the process, clinical psychologists can objectively determine whether clients are improving. Finally, several clinical psychologists also actively participate in research, where they develop or refine assessment and treatment techniques. Over the last 50 years, research-led clinical psychologists in Australia have contributed to the improvements in the management of a range of mental health presentations, including psychosis, anxiety, depression, post-traumatic stress disorder (PTSD), and eating disorders to name a few.

Research in clinical psychology takes as many forms as there are research questions, from asking questions about the genetics of individuals who are prone to specific mental difficulties, to the experiences during therapy of clients seeking treatment. In the sections that follow, we provide numerous examples of how research is integral to the development of clinical assessment tools, diagnosis, intervention, prevention, program evaluation, and consultation. Later in this chapter, we provide specific examples of clinical psychologists’ careers, many of which prominently feature research.

Assessment and Diagnosis

The goal of psychological assessment is to evaluate the nature and scope of the psychological difficulties that a client or clients (e.g., couples, families) are experiencing. The assessment is used to inform the best practice approach to intervention. The information gathered during an assessment can also be used to determine whether the client’s presentation is consistent with a diagnosis, and this is known as a diagnostic assessment. Several methods are used to gather information in an assessment, including interviews where clients are asked questions about their symptomology, functioning, background history, and goals. Other methods of assessment include structured clinical interviews such as the Structured Clinical Interview for the DSM (SCID) (First, Williams, Karg, & Spitzer, 2015; First, Williams, Karg, & Spitzer, 2016), clinical observations, self-report symptom checklists/questionnaires, and standardised tests such as tests of intelligence, achievement, and memory. Each of these assessment tools are developed through the application of the scientific method to develop the pool of questions or tasks that the client completes, how the results are scored, and how responses are interpreted in relation to the referral question. The most widely used clinical assessment tools are psychosocial measures such as the Depression, Anxiety, and Stress Scale (DASS) (Lovibond & Lovibond, 1995), and intelligence tests such as the Weschler Adult Intelligence Scale (WAIS) (Weschler, 1955) for adults aged 16 or above, and the Weschler Intelligence Scale for Children (WISC) (Weschler, 1949) for children aged 6 to 16 years. These measures and tests are validated and adapted for use in many clinical populations.

Clinicians can then use the information gathered in the assessment process to determine whether the client’s presentation is consistent with a particular diagnosis or diagnoses (where two diagnoses are present it is called ‘comorbid’). Clinicians who are practicing in Australia diagnose using one of two diagnostic manuals: the DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), or the International Classification of Diseases, 11th revision (ICD-11) created by the World Health Organization (WHO) (World Health Organization, 2019). The purpose of determining a diagnosis is to recognise symptom clusters (i.e., groups of symptoms) which best represent the domain of psychological difficulties that the person is experiencing. For example, a clinician may recognise a group of symptoms a client experiences that is indicative of depression or anxiety. The diagnosis is helpful for communicating with other mental healthcare providers, for guiding decisions about intervention and prevention, and for helping the affected person make meaning of the difficulties they’re experiencing. Scientific processes inform the multiple stages of decision-making clinicians engage in when determining a diagnosis, including which symptoms are considered unique features of a specific mental disorder (e.g., that discriminate between groups), what severity of symptoms would indicate a disorder (versus normal range of human emotion), whether the symptoms are having a significantly detrimental impact on the client’s functioning, and the length of time that a symptom or group of symptoms have been present for a particular diagnosis to be considered.

Treatment

Psychological treatments encompass a wide variety of interventions aimed at improving the client’s mental health and overall wellbeing. The most commonly used modern psychological treatments have been driven by empirically supported interventions originating from Behavior Therapy, with Cognitive Behavioural Therapy (CBT) receiving the most empirical support. CBT has been well-established as an effective treatment for a number of mental health conditions, such as depression, anxiety, and PTSD. In the last 20 years, there has been increasing interest in the development of ‘third wave’ CBT therapies, including Dialectical Behavior Therapy (DBT), Schema Therapy (ST), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Cognitive Therapy (MBCT). When working with clients in clinical practice, clinical psychologists typically use empirically supported interventions to help clients improve their wellbeing. A guide such as the Evidence-Based Psychological Interventions in the Treatment of Mental Disorders: A Review of the Literature, fourth edition (APS, 2018) is a useful resource for helping clinicians identify which evidence-based treatments exist for various clinical presentations.

Prevention

Prevention of mental health difficulties is an area of crucial importance. Wherever possible, health practitioners should aim to prevent individuals from experiencing mental health difficulties, rather than solely focusing on the treatment of such difficulties after they have developed. Prevention work can be distinguished from psychological treatment based on the timing of the intervention relative to the client’s symptom development. That is, prevention work is aimed at either reducing the risk of developing mental health difficulties, or enhancing factors that would help to protect someone from having future difficulties. Primary prevention refers to preventing a disorder before it occurs. For example, helping parents develop healthy parenting practices to reduce the likelihood of a child developing a behavioural disorder such as Oppositional Defiant Disorder (ODD). Secondary prevention is aimed at preventing the recurrence of a disorder after it has been diagnosed and treated. For example, a clinical psychologist might be interested in how mindfulness meditation helps those people who have recovered from depression maintain their gains in treatment and prevent recurrence of another depressive episode. Last of all, tertiary prevention refers to efforts to improve the quality of life and reduce disability among those living with a condition. For example, providing social skills training to adults or children with Autism Spectrum Disorder (ASD).

Program Evaluation

Clinical psychologists use their research training to evaluate programs that assess, treat, and prevent behavioural and mental disorders. Clinical psychologists employed in academic settings are involved in the development of new assessment measures and intervention programs. Alternately, they may evaluate existing assessment measures and programs within other populations. For example, if we consider the assessment and treatment of depressive disorders, it’s arguable that the structured clinical interview for the DSM is the gold standard for the assessment of clinical depression. Additionally, it’s well-accepted that cognitive behaviour therapy has the strongest evidence base for the treatment of depression. However, for First Nations Australians, there has been little research into the best assessment and treatment of depression. While the structured clinical interview is considered one of the gold standard assessments for diagnosis in western populations, until recently it was unknown whether this tool was valid or even appropriate for First Nations Australians living in regional communities. Research led by the University of Queensland in partnership with the University of Southern Queensland evaluated the structured clinical interview for DSM in relation to First Nations Australians (Nasir et al., 2018). Clinical psychologist and psychology students administered the structured clinical interview for DSM to over 400 First Nations Australians and found that this tool was indeed a valid instrument in the assessment and diagnosis of depression. They also found that depression is a significant concern in regional First Nations communities. Similarly, while cognitive behaviour therapy has some of the strongest evidence base for the treatment of depression in western communities, there has been little or no research within First Nations communities. Follow up research by the same research team is evaluating a transdiagnostic cognitive behaviour therapy program among First Nations Australians (Toombs et al., 2020).

Clinical psychologists need to do research in order to:

1. develop a proposal
2. write a grant application to obtain funding to do the research
3. develop the protocol to assess mental difficulty symptoms before, during, and after treatment
4. train other mental healthcare providers in the implementation of the treatments
5. supervise the group therapy treatment
6. work with a team to compile and analyse the data
7. disseminate these findings to other professionals
8. work to translate this knowledge so that other clinicians and practitioners learn about these scientifically-supported methods of helping others.

Consultation

Clinical psychologists are also trained in consultation with other healthcare providers in both the general and mental health settings. In general health settings, clinical psychologists work in interdisciplinary settings (with general physicians, physiotherapists, and dietitians) providing input in the psychological factors in health conditions such as chronic pain, diabetes, or cancer. They also may be involved in conducting psychological assessment of competency in the elderly if there are issue such as dementia, and will work with the interdisciplinary team to ensure the patient is safe.

In mental health settings, clinical psychologists may also consult with other mental health professionals (e.g., psychiatrists, social workers, nurses, and occupational therapists), typically in the context of practice on multidisciplinary mental health or health teams, either in hospital or clinic settings. Some of the consultation functions in the mental health setting may include feedback and recommendations associated with psychometric assessment, assessments of capacity particularly regarding mental health court matters, or consultation regarding evaluation in living skills programs within tertiary mental health settings.

In child and adolescent settings such schools, psychologists are often involved in behavioural observations and cognitive assessments of children and young people. These assessments can be used to help inform the interdisciplinary team or teachers and provide structured and tailored programs focused on improving social and emotional wellbeing.

I Think I Want to Train as A Clinical Psychologist!

Two common reasons why students are attracted to clinical psychology are 1) they find human behaviour fascinating and 2) they genuinely want to help people. Of course, in the training of clinical psychology, students learn to use their science to assess human behaviour, and they also learn ways of helping people while maintaining clear and structured therapeutic boundaries which benefit both the client and the clinical psychologist.

Clinical psychologists help others in a number of ways. Some clinical psychologists help people through direct contact with those coping with mental health difficulties – for example, through the assessment or treatment of mood disorders. Some help others more indirectly – for example, through the development, evaluation, and implementation of empirically-validated methods for assessment, treatment, and prevention. Still others contribute to individual wellbeing through the execution and dissemination of foundational scientific research that informs our understanding of the factors that underlie the development of behavioural and mental disorders. Each of these forms of clinical practice informs the other: foundational research conducted by clinical psychologists leads to empirically validated assessment and treatment efforts, which then are implemented by clinical psychologists working directly with clients. Observations made in direct contact with clients are key to hypothesis development regarding the assessment and treatment of mental disorders, and often inspire further insights into better approaches to interventions that ultimately will improve the lives of so many. In these ways, the potential scope of clinical psychology practice is very broad.

The broadness of clinical psychology is, perhaps, among the reasons why students find it challenging to understand what it means to become a clinical psychologist. Many who express interest in pursuing postgraduate training in clinical psychology want to be psychotherapists. Although becoming a registered psychologist with an endorsement in clinical psychology – and exclusively providing psychological therapy services in a private practice setting – is often the desired career destination of individuals enrolling in clinical psychology postgraduate programs, we as authors recommend that newly-graduated clinical psychologists get a breadth of experience in a range of clinical settings before commencing their own private practice. The breadth of clinical psychology means that individuals have many degrees of freedom in sculpting a career in clinical psychology that can be quite varied and unique.

Psychologists usually focus their practice in specific areas such as clinical psychology, counselling psychology, clinical neuropsychology, school psychology, correctional/forensic psychology, health psychology, rehabilitation psychology, or industrial/organisational psychology. Within these areas, a clinical psychologist may work with a variety of individual client populations such as children, adolescents, adults, or seniors, or may focus their attention on families, couples, or organisations. They work in a range of settings including schools, hospitals, medical centres, workplace rehabilitation, social service agencies, drug and alcohol rehabilitation facilities, correctional facilities, and universities. Many psychologists have their own private practices.

Working as a Psychologist in Private Practice

There are many different settings in which a clinical psychologist can practice. Clinical psychologists can work in hospital inpatient and outpatient teams, community health teams, or not-for-profit organisations, or they may choose to work in the private practice sector. There are many benefits and challenges to consider when weighing up the choice of which setting to work in. Each clinical psychologist has different strengths, different interests, and different preferred work modalities which can help inform their decision.

Private practice offers a unique combination of advantages and challenges. Mostly commonly, the appeal of private practice for clinical psychologists is the flexibility in work hours and type of work. Often private practice clinicians are able to choose what days and times they want to work, whether they want to provide assessment or treatment services (or both), and the type of clientele they prefer to see (e.g. children, adults, couples). One of the most notable challenges associated with private practice is that it can be very isolating. While some private practitioners work in teams (known as a group private practice), many work on their own, which can be difficult. Other challenges faced by clinical psychologists in private practice include: setting boundaries around their work-life balance to ensure their private practice work doesn’t spill over into their home life. For those who choose to own a private practice, there’s also the added challenge of having to ensure they have enough referrals and a business model strong enough to make the business viable.

One key challenge faced by clinical psychologists in Australia is navigating the systems of the key funding bodies, such as: Medicare Australia and the National Disability Insurance Scheme (NDIS). Medicare Australia provides funding support to individuals through a scheme known as the Better Access initiative. This is where individuals who are assessed by their general practitioner to meet criteria for a diagnosed mental health condition can be given a Mental Health Treatment Plan (MHTP). This plan enables the client to access financial rebates for a set number of psychology sessions per year, thereby lowering the cost of accessing psychological services. The NDIS provides funding support to individuals with a recognised permanent and significant disability, such as Autism Spectrum Disorder.  Eligible individuals, known as ‘Participants’ under the NDIS, are given annually-approved plans with set amounts of funding, which they can use to access many services, including psychological support.

Clinicians who see clients under a Medicare MHTP or under NDIS funding must ensure they’re well-versed in the complex array of rules and requirements of treating clients under these schemes, as it’s the clinician’s responsibility to ensure funding is used appropriately. A particular challenge can be where the funding body requirements do not align with the Evidence-Based Treatment for a particular presentation. For example, Family-Based Intervention holds Level 1 evidence as a treatment of childhood presentations such as Conduct Disorder and ADHD. However, the Medicare rules don’t allow parent-focused intervention for the treatment of such childhood presentations. It’s critical that clinical psychologists maintain a primary focus on ensuring the provision of Evidence-Based Treatments, despite these challenges.

How Do I Become A Clinical Psychologist?

The road to becoming a clinical psychologist is not a short or easy one. Students who are interested in becoming a clinical psychologist should ensure they’re confident this is the right path to pursue and remain committed to the journey that lies ahead. We recommend students speak to their university lecturers who work in the area, and to any friends, family, or anyone else you know who work as a clinical psychologist to gain a better understanding and insight into what life as a clinical psychologist is like. But, if you have a passion for helping people, and enjoy learning about and applying scientific principles, then a career in clinical psychology may be just right for you.

To become a clinical psychologist in Australia, you must first complete four years of accredited undergraduate psychology training. From there, the most direct path to becoming a clinical psychologist is to complete a two-year postgraduate degree in the area of clinical psychology, followed by the clinical registrar program, a two-year supervised practice period. Supervised practice refers to working in a paid role as a registered psychologist, while receiving regular (typically weekly or fortnightly) supervision from a registered clinical psychology supervisor. Supervision is a term used to describe where a psychologist meets with a typically senior psychologist for one to two hours a week or fortnight to discuss their cases, develop their knowledge and skills, and receive guidance on their practice.

Postgraduate Training Explained

Training in clinical psychology begins at the postgraduate level. Students must successfully complete an Australian Psychology Accreditation Council (APAC) approved four-year sequence in undergraduate psychology to be eligible to commence postgraduate training in clinical psychology. This usually take the form of an honours undergraduate degree or a three-year sequence in psychology plus a graduate diploma in psychology.

Once students have completed their undergraduate training, they’re eligible to apply for registration as a provisional psychologist with the Australian Health Practitioner Regulation Agency (AHPRA), as part of one of three pathways:

1. Two-year Master of Clinical Psychology, three-year Doctor of Psychology or three-year combined Master of Clinical Psychology/PhD
2. 5+1 pathway: one-year Master of Professional Psychology, followed by a one-year industry-based internship
3. 4+2 pathway: four-year undergraduate degree, followed by a two-year industry-based internship (note that this pathway is closing in 2022).

Option 1 – As noted above, the most direct path to becoming a clinical psychologist, is option 1, where students would complete the two-year masters degree, a three-year Doctor of Philosophy in clinical psychology (DPsych), or a 4 year combined Master of Psychology/PhD. Graduates from these programs are then expected to complete a clinical psychology registrar program ranging from one year for the DPsych program, 18 months for the combined master/PhD, and two years for the Master of Clinical Psychology.

Option 2 – Known as the ‘5+1 pathway’, this  refers to five years of university study in psychology, followed by a one-year industry-based internship. At the completion of this pathway, students are eligible to apply for general registration as a psychologist. To become a clinical psychologist, they would need to return to university study to complete either a two-year masters degree, a three-year doctorate, or if they’ve worked as a general psychologist for 12 months of more, a one-year clinical psychology sixth year program (sometimes known as a bridging or standalone clinical psychology masters program).

Option 3 – Known as the ‘4+2 pathway’, this refers to four years of undergraduate training, followed by a two-year industry-based internship. It’s important to note that this pathway will be retired as of  January 1 2029. This means the Board will not accept any more applications for provisional registration to undertake the 4+2 internship program (the two-year internship) after 30 June 2022. The 4+2 pathway provides a pathway to general registration only. To become a clinical psychologist, the student would need to return to university training to complete the bridging or standalone sixth year program in clinical psychology (as noted above for the 5+1 pathway).

Most student who undertake training to become a clinical psychologist undertake the Master of Clinical Psychology. This program takes two years to complete and students who graduate may apply for the registrar program. In the master’s degree, students take foundational courses in ethics, psychopathology, statistics and research design, assessment, and treatment. Many institutions still require students to complete a master’s thesis, however the 2018 APAC guidelines no longer require a traditional thesis. Most importantly, students are required to undertake 1,000 hours of supervised practice in at least three different settings. Students will be required to undertake their first practicum at the university or training institute psychology clinic, where they perform clinical services in the form of psychotherapy, psychological assessment, and group work. They’re closely supervised and supported by university staff. In the second year of training, students complete practice in industry and are supervised by industry supervisors, and by the end of the second year students are expected to be able to undertake the caseload of a generally registered psychologist. Students who complete the DPsych undertake additional coursework, a larger thesis, and an additional practicum (1,500 hours). Students who complete the combined master’s/PhD undertake a PhD, as well as the Master of Clinical Psychology coursework and practica. At the completion of any three of these postgraduate programs the graduate can apply for general registration as a psychologist and to become a clinical psychology registrar where they will undertake the final period of clinical supervision required to become an endorsed clinical psychologist.

This chapter has been adapted by:

• Crystal McMullen DPsych (Clinical Psychology), School of Psychology and Counselling, University of Southern Queensland
• Gavin Beccaria DPsych (Clinical Psychology), School of Psychology and Counselling, University of Southern Queensland
• Justin Kenardy PhD, Professor Emeritus, School of Psychology, University of Queensland

It has been adapted from Chivers, M. L., Bowie, C., Buchanan, S., Clifford, T., Goodman, J., Kilik, L., Logan, M., Pukall, C., & Seto, M., C. (2019). Clinical psychological science. In M. E. Norris (Ed.), The Canadian Handbook for Careers in Psychological Science. Kingston, ON: eCampus Ontario. Licensed under CC BY NC 4.0. Retrieved from https://ecampusontario.pressbooks.pub/psychologycareers/chapter/clinical-psychological-science/

Send us your feedback: We would love to hear from you! Please send us your feedback.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychiatric Association. (2018). Structured clinical interview for DSM-5. https://www.appi.org/products/structured-clinical-interview-for-dsm-5-scid-5

Australian Psychological Society (APS). (2018). Evidence-based psychological interventions in the treatment of mental disorders: A review of the literature (4th ed.). https://psychology.org.au/about-us/what-we-do/advocacy/position-papers-discussion-papers-and-reviews/psychological-interventions-mental-disorders

Chivers, M. L., Bowie, C., Buchanan, S., Clifford, T., Goodman, J., Kilik, L., Logan, M., Pukall, C., & Seto, M., C. (2019). Clinical psychological science. In M. E. Norris (Ed.), The Canadian handbook for careers in psychological science. eCampusOntario. https://ecampusontario.pressbooks.pub/psychologycareers/chapter/clinical-psychological-science/

First, M. B., Williams, J. B., Karg, R. S., & Spitzer, R.L. (2015). Structured clinical interview for DSM-5 –Research version (SCID-5 for DSM-5, Research Version; SCID-5-RV). American Psychiatric Association. https://www.appi.org/products/structured-clinical-interview-for-dsm-5-scid-5

First, M. B., Williams, J. B., Karg, R. S., & Spitzer, R.L. (2016). Structured clinical interview for DSM-5 disorders – Clinician version (SCID-5-CV). American Psychiatric Association. https://www.appi.org/products/structured-clinical-interview-for-dsm-5-scid-5

James, M., Painter, J., Buckingham, B., & Stewart, M. W. (2018). A review and update of the Health of the Nation Outcome Scales (HoNOS). BJPsych Bulletin, 42(2), 63–68. https://doi.org/10.1192/bjb.2017.17

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U

Nasir, B. F., Toombs, M. T., Kondalsamy-Chennakesavan, S., Kisely, S., Gill, N. S., Hayman, N. …Nicholson, G. C. (2018). Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: A cross-sectional study. BMJ Open, 8(6). http://dx.doi.org/10.1136/bmjopen-2017-020196

Toombs, M. T., Nasir, B.F., Kisely, S.,Kondalsamy-Chennakesavan, S.,  Hides, L., Gill, N. S., … Nicholson, G. C. (2020). Australian Indigenous model of mental health care based on transdiagnostic cognitive behavioural therapy co-designed with the Indigenous community: Protocol for a randomised controlled trial. BJPsych Open, 6(3), Article e33. https://doi.org/10.1192/bjo.2020.16

World Health Organization. (2019). International statistical classification of diseases and related health problems (11th rev.). https://icd.who.int/en/