Foundations of Professional Psychology
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Foundations of Professional
Psychology
The End of Theoretical Orientations and
the Emergence of the Biopsychosocial
Approach
Timothy P. Melchert
Marquette University
Milwaukee, WI, USA
AMSTERDAM BOSTON HEIDELBERG LONDON NEW YORK OXFORD
● ● ● ● ●
PARIS SAN DIEGO SAN FRANCISCO SINGAPORE SYDNEY TOKYO
● ● ● ● ●
Elsevier
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225 Wyman Street, Waltham, MA 02451, USA
First edition 2011
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ISBN: 978-0-12-385079-9
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Contents
Preface xi
Part I Introduction 1
1 The Need for a Unified Conceptual Framework in Professional
Psychology 3
Traditional Approaches to Professional Psychology
Education and Practice 5
Two Critical Questions Facing the Profession 7
Organization of This Volume 8
Basic Definitions 10
Behavioral Health 10
Biopsychosocial Approach 10
Complexity Theory 11
Client Versus Patient 11
Evidence-based Practice 11
General Versus Specialized Practice 12
Mental Health 12
Nonlinear Dynamical Systems Theory 12
Professional Psychology 12
Psychological Intervention 13
Therapist 13
Part II Conceptual and Theoretical Foundations of
Professional Psychology 15
2 Professional Psychology as a Health Care Profession 17
Traditional Approaches to Defining Professional Psychology 17
Defining Professional Psychology 22
Discussion 25
3 The Public We Serve: Their Mental Health Needs
and Sociocultural and Medical Circumstances 27
Behavioral Health Needs 28
Sociocultural and Medical Circumstances and Characteristics 32
Demographic Characteristics 32
vi Contents
Medical Conditions 32
Educational Attainment, Vocational and Financial Status 34
Family Characteristics and Relationships 35
History of Child Maltreatment 36
Legal and Criminal Involvement 37
Religion and Spirituality 37
Implications for Professional Psychology as a Health Care Profession 37
4 Understanding and Resolving Theoretical Confusion in
Professional Psychology 39
The Complicated Theoretical Setting Within Professional Psychology 39
The Evolution of Psychology and the Natural Sciences 41
Complexity of Psychological Phenomena 42
Kuhnian Scientific Revolutions 42
Availability of Conceptual and Technological Tools 44
Clarifying Conceptual Confusion in Psychology 46
Is it Time to Leave Behind the Pre-paradigmatic Era of Psychology? 48
Basic Requirements for a Paradigmatic Conceptual Framework for
Psychology 50
Complexity of Human Psychology 51
Applicability Across All of Professional Psychology 52
Many Effective Treatments 52
Strength of Scientific Foundations of Professional Psychology 52
Conclusions 54
5 The Biopsychosocial Approach: General Systems, Nonlinear
Dynamical Systems, and Complexity Theory 57
Introduction to General Systems, Nonlinear Dynamical Systems, and
Complexity Theory 58
Familiar Examples of Complex Systems for Psychologists 60
The Nature of Change 60
Statistical Interaction 60
Psychometrics 61
Newtonian Mechanics Versus Thermodynamics 61
Definition of Nonlinear Dynamical Systems and Complexity Theory 62
Nonlinear Dynamical Systems and Complexity Theory as
Metatheory 63
Historical Origins of Complexity Theory: Chaos Theory 64
“Logistic Map” and Attractors 65
Bifurcation 66
Other Important Nonlinear Dynamical Systems Concepts 67
Fractals 68
Self-Organization 71
Emergence 71
Contents vii
How Effective Are Nonlinear Dynamical Systems and
Complexity Theory in Psychology? 72
Conclusions 73
6 Ethical Foundations of Professional Psychology 77
The Importance of Foundational Ethical Principles 79
Confusing What Is for What Ought to Be 79
The Universality of Ethics 81
The Question of Moral Status 82
Ethical Theory 83
Consequentialist Approaches 84
Deontological or Kantian Approaches 85
Liberal Individualism 85
Communitarian Approaches 86
An Integrative Approach 87
Principle-Based, Common Morality Approach to Biomedical Ethics 89
Respect for Autonomy 89
Informed Consent 90
Nonmaleficence 91
Beneficence 93
Justice 94
Moral Character 95
Compassion 96
Discernment 96
Trustworthiness 96
Integrity 96
Conscientiousness 97
Conclusions 97
7 A Unified Conceptual Framework for Professional Psychology 99
Underlying Assumptions of the Proposed Unified Framework 100
A Unified Framework 103
Implications of a Unified Biopsychosocial Framework for
Professional Psychology 106
Discussion 110
Part III Conceptualizing Psychological Treatment from
a Biopsychosocial Perspective 113
8 Assessment 115
Overall Purposes of Psychological Assessment 116
Areas Included in Psychological Assessment 119
Sources of Assessment Information 123
Thoroughness of the Assessment Information 127
viii Contents
Assessing Severity of Patient Needs 128
Integrating Assessment Data 133
Prioritizing Needs 133
Overall Complexity of Needs 135
Integrating Assessment Information 136
Conclusions 138
Case Example: A Cognitive-Behavioral Versus a Biopsychosocial
Approach to Assessment with a Mildly Depressed Patient 142
Cognitive-Behavioral Approach to Assessment 142
Biopsychosocial Approach to Assessment 143
9 Treatment Planning 147
A Critical Preliminary Issue 148
Treatment Planning from a Biopsychosocial Perspective 151
Starting at the Beginning: Deciding Whether to Intervene 151
Addressing Severity and Complexity of Need 153
Level of Care Decision Making 154
Graduated, “Stepped” Models of Intervention 155
Collaborative Care 157
Contextual Factors 157
Ongoing Care and Follow-Up 158
Range of Alternative Interventions 158
Case Example: A Biopsychosocial Approach to Treatment
Planning With a Mildly Depressed Patient 165
10 Treatment 167
Is Psychotherapy Effective? 168
Are the Benefits of Psychotherapy Clinically Significant? 169
Do the Benefits of Psychotherapy Last? 170
How Does the Effectiveness of Psychotherapy
Compare with Medications? 170
Does Psychotherapy Work for All Patients? 171
What Factors Account for the Effectiveness of Psychotherapy? 172
How Important Are the Skills of the Individual Therapist in
Explaining Therapy Effectiveness? 174
Can the Number of Treatment Failures Be Reduced? 175
A Biopsychosocial Perspective on Treatment 176
Broadening of Case Conceptualization 177
Broadening of Treatment Options 178
Increased Collaboration with Other Professionals and
Third Parties 179
Systematic Monitoring of Treatment Outcomes 179
Conclusions 180
Case Example: A Biopsychosocial Approach to Psychotherapy
with a Mildly Depressed Patient 181
Contents ix
11 Outcomes Assessment 183
Growing Importance of Outcomes Assessment 183
Outcomes Assessment in Health Care Generally 186
Generic Measures 187
Condition-Specific Measures 187
Outcomes Assessment in Behavioral Health Care 188
Selecting Outcome Measures 188
Sources of Outcome Data 191
Schedule for Collecting Data 192
Follow-Up 192
The Biopsychosocial Approach to Outcomes Assessment 192
Case Example: Assessing Treatment Outcomes from a
Biopsychosocial Approach with a Mildly Depressed Patient 194
Additional Foci of Outcome Assessment 195
Patient Satisfaction 195
Cost Effectiveness 195
Conclusions 197
Part IV Additional Implications for Professional
Psychology 199
12 Prevention and Public Health Perspective on Behavioral Health 201
The Importance of a Public Health Perspective on Behavioral Health 201
Basic Concepts 204
Risk and Protective Factors 205
Effectiveness of Preventive Interventions 207
Conclusions 208
13 Conclusions and Implications for Professional Psychology
Education, Practice, and Research 211
Conclusions Regarding the Two Critical Issues Needing Resolution
in Professional Psychology 212
Professional Psychology in the Midst of Remarkable
Scientific Progress 214
Implications for Education and Licensure 216
Implications for Professional Practice 219
Implications for Research and Science 220
Conclusions 221
References 225
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Preface
Psychology has been remarkably successful both as a scholarly discipline and a
field of clinical practice. It has had a transformative effect on important areas in
health care, the social sciences, education, public policy, business, organizations,
and even culture in general. As a result, society’s understanding of mental health
and psychological functioning has evolved dramatically and mental health treat-
ment has provided relief to countless individuals.
Despite all of its remarkable successes across the research and practice domains,
the growth and development of the field have also been quite complicated and con-
tentious. Throughout its history, there has been major competition and conflict
between theoretical camps and schools of thought. Though the conflict has sub-
sided in recent years, students, faculty, and clinicians are certainly all familiar with
the deep divides that have existed, and continue to exist, between adherents of dif-
ferent theoretical orientations, researchers and practitioners, qualitatively and quan-
titatively oriented researchers, and between adherents of the different approaches to
education and practice.
This book addresses why the field developed in this complicated manner and
whether it is now possible to resolve and move beyond the conflicts and competi-
tion of the past by adopting a fundamentally different approach to conceptualizing
education and practice in the profession. The book examines the basic theoretical
and conceptual foundations underlying professional psychology and evaluates the
adequacy of those foundational frameworks in light of current scientific evidence
and health care practices. It concludes that several important educational and clini-
cal practices are outdated and that the basic conceptual foundations of the field
need to be revised in order to be consistent with current scientific knowledge
regarding human development, functioning, and behavior change. Updating these
conceptual frameworks will help to resolve many long-standing conflicts as well as
provide a coherent, unified perspective for moving the field forward.
The basic motivation for writing this book rose out of frustrations I have had
ever since entering graduate school. During my coursework and when I applied for
practicum placements, internship, and my first faculty position, I was routinely
asked about my theoretical orientation to practice in the field. Though I could see
value in being asked to explain my personal views on the nature of personality,
psychopathology, and psychotherapy, it seemed obvious that these were impossibly
difficult questions to answer. Far more intelligent and learned people than I have
attempted to describe the nature of human psychology, and clearly their answers
were controversial and were often viewed as seriously flawed. The various theories
developed by Freud, Watson, Rogers, Ellis, more recent theorists, or biologically
xii Preface
oriented psychiatrists, all appeared to be limited and were often harshly criticized
or even ridiculed by those who endorsed competing orientations. In light of all this
criticism, it seemed unlikely that any of the theoretical orientations was scientifi-
cally valid. Of course, professional psychology was supposed to be based on sci-
ence, and yet one had to assume that science would not support multiple competing
theories for understanding psychological phenomena. Nonetheless, I was expected
to pick one of these as my personal orientation. Some professors suggested that if I
found the existing orientations lacking, I could modify or combine them, or even
come up with a new one of my own. In addition, new theoretical orientations were
being developed and published regularly. This obviously was not an easy situation
for a graduate student to navigate. There has been progress since that time in
resolving aspects of this problem, but students today are still being asked these
same types of questions. For instance, the uniform Application for Psychology
Internships that is used by almost all of the psychology internship programs listed
by the Association of Psychology Postdoctoral and Internship Centers (APPIC)
requires applicants to complete the following essay item: “Please describe your the-
oretical orientation and how this influences your approach to case conceptualization
and intervention” (APPIC, 2009, p. 22).
There is, however, a very solid science-based solution to this problem. This
book examines problems like the ones described above in light of current scientific
knowledge and health care practice, and concludes that several of the theoretical
underpinnings of the field need to be updated. The book then presents a compre-
hensive solution to these problems. It does not propose another theoretical orienta-
tion, at least not in the traditional sense that that term has been used in the field.
Instead, it argues for a comprehensive metatheoretical framework that is firmly
grounded in the scientific understanding of human development, functioning, and
behavior change. Though many aspects of psychology are still far from being
understood in detail, the scientific understanding of psychology has advanced to
the point where it can now support a unified biopsychosocial approach. This
approach has already begun replacing traditional practices in a variety of areas
within professional psychology, but there has not yet been a comprehensive
description of how this approach applies for the field as a whole. After discussing
the nature of a unified biopsychosocial approach to professional psychology, the
book goes on to discuss the main implications of this approach for education, prac-
tice, and research.
This book addresses the field of professional psychology as a whole. Despite the
different sets of knowledge and skills needed by psychologists working in the vari-
ous general and specialized areas of practice in the field, there is a critical need for
a unified science-based foundational framework that applies to all populations, all
disorders, all behavior, and the whole field of professional psychology.
The book also takes a careful, systematic approach to analyzing the conceptual
foundations of the field. It begins by examining the lack of clarity in the basic defi-
nitions used to identify the nature and purpose of professional psychology. It then
goes on to identify the main reasons for the confusing theoretical landscape within
the field and the development of the many competing theoretical orientations for
Preface xiii
understanding personality, psychopathology, and psychotherapy. After evaluating
the requirements of a satisfactory solution to these problems, the book then goes on
to show how a unified, biopsychosocial approach meets those requirements and
applies to all human behavior and across all the general and specialized areas of
professional practice. The book also shows how the biopsychosocial approach can
be applied across the whole behavioral health care treatment process from intake
assessment through the evaluation of the outcomes of treatment.
A primary audience for this book includes professional psychology graduate stu-
dents and their faculty. The book advocates for a major updating of the conceptual
frameworks that are used for structuring and organizing education, practice, and
research in the field, issues that are centrally important in graduate education. The
book can also be used in master’s programs and with advanced undergraduate psy-
chology majors to address the same questions. The book is also intended for estab-
lished practitioners who are very experienced and familiar with the confusing
conceptual landscape of the profession.
I am grateful to the many individuals who assisted me with the development of
the ideas in this book and in preparing the text. Wrestling with the problems
addressed in this book started many years ago in my own graduate education, most
notably with my first doctoral advisor, Kent Burnett. It continued with my faculty
colleagues over the years, and especially Todd Campbell, who shared with me the
responsibility for directing all of our master’s and doctoral training programs for
many years. Lari Meyer completed her dissertation research under my supervision
and her research figures prominently in Chapter 8. My wife, Susan Schroeder, is a
highly skilled therapist who provides an excellent model for practicing psychother-
apy in an integrated biopsychosocial manner. I also thank Lee Hildebrand,
Augustine Kalemeera, Rebecca Mayor, Robert Nohr, and Lucia Stubbs, who shared
their critiques of the book. I am indebted to all of these very fine individuals.
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Part I
Introduction
This part of the book is comprised of Chapter 1 which introduces the problems
that will be examined and explains the organization of the book. It also presents
definitions of common terms and concepts that will be relied on throughout the
text.
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1 The Need for a Unified Conceptual
Framework in Professional
Psychology
Psychology has been remarkably successful as a scientific discipline since its
founding in the late 1800s. Since World War II, the application of psychological
science in clinical practice has been tremendously successful as well. Already in
1961, E. Lowell Kelly, the past president of the American Psychological
Association (APA) Division of Clinical Psychology at that time, declared that the
growth of clinical psychology was “well nigh phenomenal. Before World War II,
clinical psychologists were few in number, poorly paid, and had but little status . . . .
Ours is a success story without counterpart in the history of professions” (p. 9).
Professional psychologists played a small role in health care before 1945 when the
first licensure law for psychologists was enacted in the United States. Since then, the
field has grown dramatically and now plays a major role in behavioral health care
(e.g., there are now over 85,000 licensed psychologists in the United States; Duffy
et al., 2006).
Despite the dramatic success of professional psychology, the field has also been
marked by substantial controversy and conflict. There has been remarkable diver-
sity in the theoretical orientations used to understand human psychology and the
goals and processes of psychotherapy, and there has been deep conflict and compe-
tition between theoretical camps and schools of thought throughout the entire his-
tory of the field. Conflicts between schools and camps have subsided in recent
years as a result of the development of integrative approaches to psychotherapy
and other factors (these issues will all be discussed more fully in subsequent chap-
ters). Nonetheless, the field is still characterized by wide diversity in the conceptu-
alization of personality, psychopathology, and mental health treatment.
Explaining the nature of human psychology and the processes involved in psy-
chotherapy and behavior change has proven to be a formidable challenge for
behavioral scientists. Research has provided reliable explanations for many psycho-
logical processes, but other aspects of the tremendous complexity of human psy-
chology have been difficult to unravel and are currently understood only in broad
outline. This is particularly true for the more complicated processes that are often
the focus of psychotherapy. Detailed descriptions of many basic psychological phe-
nomena are widely accepted (e.g., with regard to sensation, perception, and the
basic processes of cognition, affect, learning, and development), but there remains
Foundations of Professional Psychology. DOI: 10.1016/B978-0-12-385079-9.00001-1
© 2011 Elsevier Inc. All rights reserved.
4 Foundations of Professional Psychology
a great deal to be learned about many highly complex processes such as the devel-
opment of personality characteristics, the causes of psychopathology, the nature
and assessment of intelligence and personality, and the mechanisms that account
for psychotherapeutic change.
Professional psychology may be reaching a transition point, however. In recent
years, research examining several aspects of psychological development and func-
tioning has been progressing steadily. Major advances in areas ranging from geno-
mics to sociocultural factors are improving our understanding of many important
aspects of psychological development and functioning. Research has also verified
the effectiveness of psychotherapeutic interventions at levels that compare favor-
ably with those in medical, educational, and other types of human services.
A particularly important development is the improved validity of recent research
findings. The results of recent research are not being challenged like they were in
the past because the quality of research methodology has improved significantly.
There is now broad acceptance of the need for stronger evidence to support the
validity of inferences and conclusions, both in terms of research as well as clinical
practice. The time is past when it was generally acceptable to argue for the superi-
ority of one’s theoretical or therapeutic approach only on the basis of one’s past
experience or data from uncontrolled research studies, rationales that naturally led
quickly to disagreements and controversies. Standards regarding the validity of
assessment findings, therapy outcomes, and research conclusions are all higher than
they were even a decade ago.
Consensus has not yet emerged regarding several important areas of disagree-
ment in the field, but there is no question that the tenor of recent professional dis-
agreements is much different from those in the past. The 1990s, for example, were
marked by highly contentious controversies involving repressed memories of child
abuse, empirically validated treatments, the validity of quantitative versus qualita-
tive research findings, and new treatments such as Eye Movement Desensitization
and Reprocessing and psychotherapy for multiple personality disorder. The inten-
sity of current disagreements pales in comparison.
Given these signs that professional psychology may be entering a new period in
its development as a profession, it is important to revisit the basic frameworks that
are used to conceptualize and organize education and practice in the field. The
foundational conceptual frameworks that any profession uses, whether implicit or
explicit, have a major impact on education, research, and practice. Each profession
needs to ensure that those frameworks remain current with scientific and other
developments, both within and outside the profession. Given recent developments
in science, health care practice, and society generally, now is a good time for pro-
fessional psychology to reexamine these issues.
There are several indications that the basic frameworks the field has traditionally
used to conceptualize education and practice in professional psychology need to be
updated. The next section describes several of the problems and sources of confu-
sion that arise from the use of these frameworks. The educational setting within
which graduate students begin their entry into the profession provides a useful con-
text for illustrating the pervasiveness and significance of these problems.
