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I direct an APA-accredited program that trains psychological doctors. A psychological doctor, as we conceive it at the JMU Combined Clinical and School Program, is a health service provider who offers distinctive skills and services that stem from their knowledge of the science of human psychology and training as an assessor and interventionist with psychosocial problems. Because the term “psychological doctor” might sound a bit unusual, I explain it here by contrasting it with some other professions and by offering an example of how a psychological doctor who came out of our program might treat a common presentation in a distressed college student.
To set the stage for what a psychological doctor is, let me first contrast it with a few other fields that are quite different from—but also easily confused with—a psychological doctor (hereafter PD). The first thing is to separate a PD from is a (pure) psychological researcher. Although both might go by the heading “psychologist” and both complete doctoral degrees, a pure psychological researcher is actually quite different from a PD. As suggested by the name, a psychological researcher is a research scientist who studies mental processes and behaviors, usually of humans but also sometimes of other animals. Psychological researchers explore a broad array of topic areas, including domains such as: learning, memory and attention; sensation and perception; motivation and emotion; language, thinking and intelligence; personality; lifespan development; human relationships and social and cultural contexts; and psychopathology. Researchers are trained in the fundamentals of behavioral science research methodology, measurement, data management, and statistical analyses, as well as academic writing and publishing, and getting grants. Although psychological researchers might be employed in a wide variety of different settings (e.g., testing companies or businesses), the largest portion are in university settings, and the most basic function of psychological research to advance and share with others the scientific fund of knowledge pertaining to mental processes/behaviors.
The second field that is related but also very different from PDs is psychiatry. Psychiatrists are medical doctors that study and treat psychopathology. They overlap with PDs in this regard, but they have a very different training background. Unlike PDs, psychiatrists are trained first as medical doctors, thus they have expertise in training in the biological and physiological dimensions of health and disease. Following their general training in medicine, they proceed to specialize in diseases/disorders of the psyche. Although psychiatrists used to do psychotherapy, over the past three decades, the primary intervention tools of psychiatry have shifted to be now almost exclusively psychopharmacology (i.e., drug treatment), and surveys of psychiatrists show that about 90% function in this role.
There are also clinical social workers, marriage and family therapists, addictions specialists, and professional counselors. These various specialties are all part of the allied mental health professions and engage in the treatment of psychological and relational distress and impairment in ways that overlap a lot with a PD, but they bring a different set of skills and training. These professionals often do not have the doctorate degree and are not necessarily trained in the science of human psychology in general, or psychopathology and psychological assessment and intervention in particular.
To our way of thinking a PD is a licensed professional psychologist trained in the delivery of health care services. In terms of degrees, the Doctor of Psychology (PsyD), which is the degree our program confers, is the most direct marker of a PD. However, many PhDs (Doctors of Philosophy in Psychology) in clinical, counseling and school psychology are PDs. Our program applauds the recent APA initiative in Health Service Psychology, which essentially offers a blueprint for education and training PDs. As our program noted over a decade ago, Health Service Psychology can be found at the heart of the intersection between clinical, counseling and school psychology. In addition, I would be remiss if I did not point out that although by definition a PD is a health service practitioner, it is also the case that they can be a scholar or researcher. For example, I have competencies both as a practitioner and researcher in human psychology. As with medicine, the field of professional/health service psychology needs folks who research psychopathology, the validity of assessment and the effectiveness of interventions.
In terms of competencies of PDs, the doc program at JMU lists ten fundamental competencies as follows: 1) self-reflective awareness and interpersonal grace; 2) psychological assessment; 3) psychological interventions; 4) knowledge of the science of psychology; 5) Ethics and professional judgment; 6) Interprofessional Collaboration, Consultation and working with Diversity; 7) Professionalism; 8) Personal and Enhancement of the Discipline; 9) Research and Scholarship; and 10) Teaching, leadership and supervision. As this list suggests, there is much more to being a fully functioning PD than competence in psychological assessment and intervention. However, it is nevertheless the case that these are core elements, so let me offer a case example and share how individuals trained from our program might approach the case. Here is the scenario:
Tina is an 18-year-old college freshman. She grew up in a small, rural town in and is a first generation college student and came to college with hopes of being a physician. She did extremely well in high school and has always been very driven and conscientious. However, her first semester did not go very well. She experienced difficulty making friends, and she was uncomfortable with the drinking and party atmosphere. She focused a lot on her studies and studied several hours a day, but she struggled to get the As she expected (her first semester grades were a 3.2). Now she is reporting problems taking tests and staying focused and is worried that she has AD/HD. She is starting to have trouble sleeping, as she can’t fall asleep because she is constantly worrying about what she needs to do the next day. She is also having nightmares about failing out of school. She also is reporting frequent stomach aches, and she is now considering whether she should transfer to a different school because it is closer to home.
If Tina sees a psychiatrist, he or she would likely diagnose Tina according to the DSM-V based on a 20-minute interview (probably with an anxiety disorder) and offer either anti-anxiety or anti-depressant medication, and then track her periodically, hoping that her distressing symptoms will be reduced. If Tina sees a professional counselor, it is likely she will be offered a therapeutic relationship where she can go for 50 minutes a week and be given the opportunity to reflect on her life in the context of a warm, empathic listener who strives to provide a meaningful, growth-oriented relationship that helps Tina find a productive pathway.
If, however, she sees me as her PD, she encounters yet another approach to mental health and treatment. My approach is in some ways similar to the psychiatrist in the sense that I have a formal body of knowledge that I will use to understand Tina and develop a working conceptualization (what the psychiatrist calls a ‘diagnosis’) and systematic intervention. However, I do not use medication, and I am much more likely to think about, identify, and work with psychosocial processes than the psychiatrist. Like the professional counselor, I will develop an intimate, growth promoting relationship with Tina and would likely see her once a week for treatment. However, unlike most counselors, I identify as an expert in psychological functioning (ranging from severe psychopathology to human flourishing) and am likely to be much more directive and systematic in guiding Tina’s understanding of herself and the intervention. In addition, unlike most counselors, I use a formal process of assessment that is grounded both in the science of human psychology and empirical methods like measurement and research design.
If Tina were to see me, I would likely begin the process by conducting a “psychological check-up”. This involves first her completing a series of empirically validated measures that assess the following major domains: 1) her overall sense of well-being and specific dimensions such as her sense of autonomy, mastery of the environment, purpose, physical health and fitness, and other areas; 2) Her emotions (e.g., frequency of positive to negative feelings) and the ways she tries to regulate them; 3) her self-concept, identity, and beliefs and values about her place in the world; 4) her relational style and experience of relational value and history of attachment/parental relations; 5) her personality trait profile; 6) her regular habits of eating, sleeping, exercise, and substance use; and 7) screens for certain forms of psychopathology (e.g., depression, anxiety, substance abuse, attention deficits, trauma history).
She would fill out these measures prior to our meeting for the first time. I would then conduct an intake interview, which would be guided in part by the results from the quantitative assessment. After all the necessary paperwork and such, I would begin by saying something like, “As you know, you filled out a bunch of forms on line on your well-being, emotions, relationships and such. I have data from those and they will help me be sure I have a full sense of who you are. Before I discuss some of the information from those forms, let’s start by you telling me in your own words what brings you in and how you hope I might help.”
After she narrates her story and presenting problem some, I start offering her feedback from the quantitative results and get her thoughts. For example, I might say things like: “Tina, you filled out a questionnaire that asked you about the frequency with which you experienced negative emotions over the past week. It seemed like you were experiencing quite a lot of negative feelings relative to most college students, especially feelings of fear, nervousness and anxiety. I heard those themes in your narrative also. Does that sound right to you?”
As I gather more and more information, normally a conceptualization will begin to emerge, often in the first session. We teach our doctoral students to engage in “directive empathy” (see here for another example), which is the process by which the practitioner guides the patient to understand and organize their experience via a working conceptual model of human psychology, which for me is directly informed by the unified approach. To engage effectively in directive empathy the practitioner must be clear in their own mind what they see, explain it in way that the patient can understand and be highly attuned to the patient’s reaction and, of course, be generally on target. For example, after listening to Tina’s story for a half an hour or so, I might say something along the lines of the following via directive empathy:
“First off, I am sorry that things have been pretty rough for you. College has not unfolded the way you hoped and that, of course, is pretty distressing. Let me see if the following narrative captures what it is you have been experiencing. When you got here, you had high hopes that you would perform well and be on your way to becoming a physician. You not only had hopes, but also had a bit of pressure to do well. You have always had a strong achievement drive and you also felt that you did not want to let your parents down. However, college was a very different environment than you expected. There were lots of new ideas, people engaged in lots of somewhat rebellious or loose activities, and you were not sure you fit in. Initially, you tried to suppress the bad feelings you were having. You told yourself not to worry that everything would work out fine as long as you just focused on the positive. However, more and more you felt alienated and out of place. We humans have deep needs to be known and valued by others and to belong and you were feeling very little of that, especially relative to the love you felt at home. Then when you struggled a bit in achieving, your world felt as if it was collapsing in on you. You feared deep down that your struggles meant you were not up to the demands of college and that you would be “discovered” and that you would be sent home, disappointing everyone. This thought was so scary that you tried to push it out of your mind, tried to tell yourself that if you just tried harder, it would be ok. But you were already trying has hard as you could and you were so stressed that your performance suffered even more and thus you found yourself trapped by a vicious cycle. And now, as you see your academic performance getting worse by the week, you are freaking out, feeling that all your plans for your life are on the verge of being ruined. I know you have been trying to hide these feelings from others, and even from yourself, but does this sound right, in terms of what has been going on deep inside over the past couple of months?”
If my formulation on target, then she should be quite emotional and say something like, “Yes, that is exactly it. I have been trying to keep it together, but I have been totally fearing that my whole life is coming apart”.
Then I say something like, “Well, I am very glad you came in then. You are caught in a vicious psychological cycle where you are both having negative emotions and also are fearing those negative emotions and trying to suppress them, but you can’t and they are spilling out and freaking you out. I think I can help you understand what these feelings mean, why it makes sense that you tried to cope with them via avoidance and why that avoidance has sort of backfired and trapped you. Via this understanding, we can then chart a new pathway I believe has a good chance of reversing the trend and getting you on track toward a more adaptive way of being. Next week we will continue to get a better and deeper understanding of your emotional life, identity, and relationships and I will share with you more details about what things you can learn that have been reliably shown to reduce your distress and develop healthier ways of coping. How does that sound?”
This example demonstrates how we envision PDs using knowledge of human psychology, validated psychological assessment methods and procedures, excellent relationship and interviewing skills to quickly and reliably develop deep, rich and meaningful conceptualizations that lend themselves toward clear evidence-based intervention pathways that are monitored and outcome informed.
