PSYCHOLOGY IN ACTION 219

AMERICAN PSYCHOLOGICAL ASSOCIATION. Graduate educa-tion In psychology. Washington, D. C.: APA, 19S9.

AMERICAN PSYCHOLOGICAL ASSOCIATION. Report of thead hoc committee on problems of practician agencyevaluation. Washington, D. C.: APA, 1961. (Mimeo)

EWALT, J. (Ed.) Action for mental health. (Final re-port of the Joint Commission on Mental Illness andHealth.) New York: Basic Books, 1961.

KELLY, E. L. (Ed.) Training in clinical psychology.(Conference on graduate education in clinical psychol-

ogy at Boulder, Colorado, August 1950) New York:Prentice-Hall, 1959.

RAIMY, V. C. (Ed.) Training in clinical psychology. NewYork: Prentice-Hall, 19SO.

SCIIOMELD, W. Logistics in professional psychology. Pa-per 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. NewYork: Harper, 1954.

GRADUATE TRAINING FOR COMMUNITYCLINICAL PSYCHOLOGY

MARSHALL R. JONES AND DAVID LEVINE

University of Nebraska

MUCH attention has been devoted in recentyears to the major problems that our societyis facing in the field of mental health. The

final report of the Joint Commission on Mental Illnessand Health (Ewalt, 1961) defines these problems in de-tail and makes some provocative recommendations fordealing with them. The recommendations for the even-tual abolition of the large state mental hospital infavor of smaller, community-centered intensive treat-ment centers, the support of programmatic researchrather than piecemeal efforts, the suggestions for en-larging the professional mental health manpower pool,and the suggestions for the use of persons fully trainedin a mental health profession as consultants to variousother professional and lay groups, all have importantimplications for the mental health professions, includ-ing clinical psychology. Iscoe (1962) observes that"these radical and progressive steps" involve the psy-chologist's "adopting a new approach, an approach thatis not yet being taught in most graduate schools. . . ."

In our graduate training program in clinical psychol-ogy at the University of Nebraska, we have been forsome time, and especially since the Palo Alto con-ference in 19SS on Psychology and Mental Health(Strother, 1956), trying to train clinical psychologistswho can fit into the sorts of roles that are demandedby this approach and who can be flexible enough to de-velop with the field as it progresses. In this paper wewill review some of the basic principles which seem tous to underlie the training of psychologists for profes-sional careers in the field of mental health, examinethese principles in relation to the developments thathave occurred in this field since World War II, explorethe implications of these factors for graduate training

in psychology in general and clinical psychology in par-ticular, and describe a training program in which weare attempting to apply these principles.

Historically, clinical psychology developed in closerelationship to medicine, and especially to psychiatry.For a time this relationship was so close that clinicalpsychology did not exist to any substantial extent out-side of medical installations, and psychologists in thisarea of endeavor conceptualized their problems in termsof the medical model and adopted a medical nomencla-ture. As professional psychology has developed it hasbecome more and more independent of medicine, hasdeveloped its own techniques and concepts, and hasapplied these increasingly in other, nonmedical areas.Concomitantly, clinical psychology has become increas-ingly aware of the limitations of an illness or diseasemodel for understanding behavior in either its normalor pathological forms, has turned more to psychologi-cal models, and has found itself increasingly interestedin the concept of health—or better—in optimal behav-ior function. As a result, clinical psychologists aredrawing more and more on the basic knowledge of be-havior in general in trying to understand unusual ordeviant behavior and at the same time are contribut-ing to the general knowledge of behavior by their re-search which was instigated by problems arising fromtheir work with deviant behavior. The past 10 years,especially, have seen important changes in the conceptsused by clinical psychologists, the functions they fill,the professional roles they adopt, the nature of theirrelations with other professional groups, and the goalsthey set for themselves. The notion of the clinicalpsychologist as a technician who aids in pinning a psy-chiatric label on a patient is giving way to the notion

220 AMERICAN PSYCHOLOGIST

of the psychologist as a consultant who aids in theoverall evaluation of persons with many different kindsof problems in many kinds of situations. He is calledon by teachers, attorneys, judges, rehabilitation coun-selors, parents, wardens, institution heads, the police,executives, military officers, and many other groups toevaluate people and aid in making decisions involvingthese people. This change in role has led to new kindsof interprofessional relationships, new kinds of respon-sibilities, and an increasing awareness of the breadthof the problems which human beings face.

If psychologists are to fill these functions effectively,they must be well trained in the principles and meth-ods of scientific psychology and the traditional tech-niques of testing and psychotherapy. It is extremelyimportant also for them to have a clear understandingof community organization and resources, a grasp ofthe subtleties of interprofessional relations, awarenessof the possible applications of the principles of groupdynamics and group structure to conferences of allsorts, a concern for the problems of communication,a knowledge of the contribution which other profes-sional groups are making in the area of mental health,and an awareness and acceptance of a workable codeof ethics. (A similar point of view has been expressedby Strother—1958, p. 131.)

The development of the Clinical Psychology Train-ing Program at the University of Nebraska has beenshaped by the interaction of a few basic principles oftraining held by the faculty, and some external condi-tions over which those of us most directly involved inthe training program had little or no control. Thetraining principles which the staff holds are highly com-patible with the "Boulder model" which grew out ofthe Conference on Training in Clinical Psychology in1949 (Raimy, 19SO). We have sought from the be-ginning to select and train the type of person who, inhis professional life, would both contribute to the ad-vancement of knowledge by doing research and whowould apply his knowledge of psychological principlesto the solution of human problems. The decision totake this course was influenced by our conviction thatsociety as a whole would be best served in this manner,by the belief that what is good for society is, in thelong run, good for psychology in general as well as forindividual clinical psychologists, and by the circum-stances of the university and the community in whichwe were to function.

So far as society as a whole is concerned, our viewsagreed with those set forth in the report on the BoulderConference in which it was pointed out that insufficienthelp was available for persons in immediate need ofprofessional psychological assistance, insufficient atten-tion was being paid to conditions which lead to the de-mand for this sort of help, and a need existed for the

development of a concept of positive mental health "inwhich emphasis is on maximum development of indi-vidual potentialities rather than on barely adequate ad-justment" (Raimy, 1950, p. 21). In addition, becausethe field of clinical psychology was at that time, andstill is, in a state of rapid development, it was likelythat any professional person who was trained simply inskills, knowledge, and techniques known at that time,and without a sufficiently broad background to enablehim to understand the relation of the techniques to thebackground of knowledge in psychology in general, ranthe considerable risk of being unable to keep up withthe rapid developments in the field and thus of becom-ing professionally obsolete within a decade or two aftercompleting his formal training. For these same rea-sons, we then opposed, and still do, the establishmentof the type of training program which leads to a "pro-fessional" degree in clinical psychology.

Practical considerations which influenced our decisions,and which we felt were essentially compatible with ourprinciples, included the fact that we were operating ina relatively small department without potential for anysignificant expansion, that we had the necessary tradi-tions, facilities, and staff to give solid training in gen-eral and experimental as well as in clinical psychology,that we had a psychological clinic under the directionof psychologists which had as its primary purpose thetraining of psychologists, that it was possible to obtainthe services of psychiatrists and other physicians, andother professional persons, as consultants on both serv-ice and training problems, that we were operating in acommunity large enough to supply a sufficient numberand variety of subjects for training purposes, and thatthere were in the community a large number of agen-cies and professional people who sought psychologicalservices and were disposed to cooperate with the Psy-chological Clinic in its training as well as its servicefunctions.

As our program has developed over the last 13 years,another fact has gradually become more apparent which,it seems, makes our type of training even more relevantand functional. The studies of Albee (1959) and othershave made it abundantly evident that there is now avery serious shortage of present and potential man-power in all the mental health fields, including clinicalpsychology, and that this situation is not likely to im-prove within the foreseeable future. Indeed, it is morelikely to get worse. The implications of this situationare several, but they include the one that professionalpersonnel in the mental health field must spread theirknowledge and skills over a much broader area or elselarge numbers of our citizenry who need such servicesmust go without them. We agree with the recommen-dations of the Joint Commission on Mental Illness andHealth that, for the interests of society to be best

PSYCHOLOGY IN ACTION 221

served, professional personnel must be used to a greaterextent in consultative roles with parents, teachers, and"caretaker" personnel and relatively less in individualface-to-face relationships with those needing and seek-ing help.

Another implication of the present and potential man-power shortage is that it is even more urgent that wetrain more of our mental health personnel for researchfunctions and that society's interests will best be servedin the long run if we devote an increasing proportionof our resources to research aimed at prevention. Ithas been pointed out repeatedly that there is little like-lihood that society can ever cope effectively with themental health problem on a treatment basis. Preven-tive techniques, based on knowledge gained from re-search, seem by far our most promising course.

With these convictions, the resources available to us,and especially the Psychological Clinic under the con-trol of the staff whose primary responsibility is train-ing, we have evolved a training program which seemsto us compatible with the needs of society, psychologyin general, and individual clinical psychologists.

Without sacrificing training in the scientific under-standing and use of the psychological tests themselves,we impress upon all students the need to clarify thetotal 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 tomeet has a problem of some kind, generally a decisionmust be made—the person is being tested for a reason.As Towbin (1960) has pointed out, that reason often isobscure and the first job must be to define the problemof the individual within the environment in which hefunctions. Towbin speaks of the diagnostic triad ofthe patient, referring psychiatrist, and clinical psy-chologist; we have found that the referral contextmore often involves a half dozen people or more.Whereas previously a youngster who misbehaved inschool was seen by a psychologist who sent a report tothe school psychiatrist who referred him, now our prac-ticum student may have contacts with the teacher, theguidance counselor, principal, school social worker, psy-chiatrist, parents, and, perhaps, juvenile probation offi-cer in order to define fully the referral question. Thepracticum student may, and usually does, under the di-rection of and in cooperation with his supervisor, havea follow-up conference with some or all of these samepeople to explain and defend his recommendations andtake an active part in the overall planning for the per-son he evaluated.

A recent case illustrates the kind of follow-up con-ference in which one of our students may be involved.A seven-year-old first grader was referred to the clinicbecause he had been misbehaving at home and his work

at school was erratic. The referral was made by theJuvenile Probation Officer since custody of the childhad been given to the Juvenile Court at the time ofhis parents' divorce. When making the referral, theProbation Officer had said that the parents were "squab-bling over visitation rights." As the case developed,it became clear that the child's father was passive andineffectual and that the "squabbling" was a seriousstruggle for power between the child's mother and herex-mother-in-law. In the course of his evaluation, thestudent tested the child, his father, mother, and grand-mother. At one of the follow-up conferences, not onlythe child's father and grandmother were present, butalso their lawyer and the mother's lawyer. Althoughall the people involved were sincere in their desire todo what was best for the child, their own attitudes anddefenses were often the determining factors in theirproposed solution. During this conference the studentlearned something about forensic psychology, groupdynamics, and interviewing techniques in a way whichwill probably leave a deep impression on him.

This broader approach to the psychodiagnostic prob-lem enables us to give the clinical student the oppor-tunity to develop the interpersonal skills and attitudes,not only "to establish rapport" with the person re-ferred, but also to create and maintain constructive re-lationships with the other people involved in the case.He starts by attending conferences in which the issuesabout the referral context are discussed, then he ob-serves his supervisor deal with these problems, thevarious ramifications and possibilities of referrals areclarified, and, finally, he is allowed to participate, un-der supervision, in the process himself. We feel thestudent learns that the most brilliant dynamic analysisof an extensive test battery is of little value if the im-portant questions remain unanswered, if the report iswritten so that it cannot be understood by the referringperson, or if the recommendations cannot be imple-mented. The importance of face-to-face conferences tosupplement written reports is brought home to studentsby their own experiences.

Thus we have shifted from teaching psychologicaltests to teaching the use of psychological tests as anaid to understanding people's problems. Along withthis shift has come a greater emphasis on teaching atti-tudes as compared with teaching skills. In this frame-work, it is essential for the student to do more thantest the patient assigned to him and write a report.The Psychological Clinic serves as a consultant to thecommunity. (Table 1 lists the referral sources whichregularly use our clinic.) The student must learn howthe community is organized and what his place as apsychologist is in the organization. We have foundthat these skills, attitudes, and principles can be readilytaught in the context of a Psychological Clinic.

222 AMERICAN PSYCHOLOGIST

TABLE 1

CLINIC REKERKAL SOURCES

Agency

The University of Nebraska

Private agencies, schools, etcetera

Lincoln and Lancaster Countyagencies

Other counties

State of Nebraska

Federal agencies

Source

Student Health ServiceUniversity Counseling ServiceChild Development LaboratorySpeech and Hearing LaboratoryUniversity High SchoolNROTCFaculty membersStudent, faculty and employee self-

referrals

Self referrals from the communityPhysiciansAttorneysVeterans Service CenterNational Red CrossParochial SchoolsCatholic Social ServiceNearby universities and collegesReligious affiliated orphanages and

homes

Lincoln Public SchoolsLancaster County Separate Juvenile

Court and Probation OfficeLincoln Police DepartmentLancaster County Dcpt. of Public

WelfareLincoln-Lancaster County Child

Guidance ClinicFamily Service Association

County Departments of Public WelfareLocal Schoolboards, School superin-

tendents, PrincipalsCounty Courts

State Department of Public WelfareFoster Care UnitCrippled Children's ServiceState Home for Children

State Department of InstitutionsState Mental HospitalState PenitentiaryMen's ReformatoryState Home for Mentally RetardedBoys Training SchoolGirls Training School

State Department of EducationDivision of Rehabilitation ServicesDisability Determinations SectionDepartment of Special Education

Veterans AdministrationLincoln Air Force 15asc

An analogous change has occurred in our treatmentor rehabilitation program. A preoccupation with indi-vidual psychotherapy has given way to broader ap-proaches in dealing with the problems presented. Theinvolvement of several family members, concern withvocational and educational adjustment, greater use ofcommunity resources, and awareness that symptomchange is an insufficient criterion of success are indica-tions that we are not treating a specific disease entity,but rather are attempting to help persons reorganizetheir ways of living. For example, if a child is ac-cepted for play therapy we also have regular therapysessions with one or both parents, consult with theschool or court personnel when advisable, consult withprobation officers and social workers in terms of theirrelationships with the clients, and call in psychiatristsor other professional personnel for consultation when-ever a student or supervisor feels this is desirable. Weuse not only the traditional kinds of group therapy, but

also work with family groups in which a psychologistsees all members of the family simultaneously. At thesame time, we continue to use individual psychotherapyas an opportunity not only to teach technique, but alsoso that the student may compare this technique withother possible ways of dealing with human problems.

Because our clinic is identified as a psychologicalrather than a psychiatric clinic, because of the typesof relationships we have with a wide variety of non-medical agencies, and because of some increase inawareness of the public that to seek help with one'spersonal problems of adjustment does not necessarilybrand one as sick or crazy, we get the opportunity tosee an increasing number of persons whose problemsare in the incipient and less complex stages. This pre-sents more opportunity to provide training in helpingtechniques which have a considerably heavier com-ponent of preventive rather than major remodeling as-pects than is the case in clinics which see only the moreseriously disturbed persons. It also presents an oppor-tunity for the student to learn directly about the rela-tively greater advantages and efficiency of early identifi-cation and coping with behavior problems.

Still another advantage of the Department Psycho-logical Clinic is the increased communication with gen-eral, theoretical, and experimental psychology which ispossible in this framework. The student gains experi-ence in understanding the immediate clinical problem interms of a more general theoretical framework. Forexample, the effect of social class or subculture on be-havior takes on special significance for the studentwhen he tests a child from an Indian tribe while he isdiscussing the theoretical issues in a seminar in socialpsychology.

Since the clinic is organized so that it serves both asa service and a research facility, the student clinicianlearns both clinical and research skills and techniquesin the setting of the clinic. The members of the clinicstaff serve as models who do both research and clinicalservice, and considerable effort is expended in the train-ing program to demonstrate to the student the advan-tages of this combination.

An important aspect in practicum training is theweekly staff conference which is attended by all stu-dents in the clinical training program. At the beginningof the academic year, each of these conferences is de-voted to a different referral source: the public schools,juvenile court, rehabilitation services, and so on, andrepresentatives of these organizations attend. Studentsare introduced to the people with whom they will workmost closely. Representatives from the agencies dis-cuss the legal and economic foundation of their agen-cies, describe their functions in the community, andindicate the manner in which they use the Psychologi-cal Clinic. A period of discussion is followed by brief

PSYCHOLOGY IN ACTION 223

follow-up studies of cases on which the students haveworked in previous years. These sessions teach thestudent the essentials of community organization anddemonstrate the role the psychological evaluations havehad in the lives of human beings. Later in the aca-demic year, these conferences become case oriented.A student will present a case on which he is workingand representatives of all interested agencies are in-vited to attend. The goal of these conferences is theintegration of all available information on the clientwith a view toward a recommendation which utilizesthe most appropriate community resources and facilities.

One change in the nature of our referral sources overthe years which deserves notice is the increasing num-ber of requests from legal agencies. The clinic con-tinues to get many referrals from psychiatrists andother physicians, but there are an increasing numberfrom judges, police officers, welfare workers, and penalofficers. School referrals seem also to be increasing.Clinical psychology is being offered an increasingamount and variety of responsibility by the public.

An important advantage that we have noted is thatthe contact which our students have with a wide va-riety of community agencies and personnel furnishesan excellent basis for teaching professional conduct andethics in terms of concrete, live situations in which thestudents are themselves often involved.

One final point: A by-product of this type of com-munity clinic and its close cooperation with many agen-cies is that it has led to a demonstration of the func-tions which a psychologist can perform in these agen-cies. Several agencies have been able to follow up bycreating positions on their own staffs for psychologists.

What are the implications of all this? One of themost important decisions clinical psychology has madehas been the decision to train clinical psychologistswithin the context of the graduate college and the de-partment of psychology, rather than in association withother professional schools. We are of the opinion thatto attempt to train clinical psychologists within theframework of a medical school or a teacher's collegewould tend to minimize the importance of basic psy-chology in such training. In much the same way, prac-ticum training of clinical psychologists in hospitals andclinics whose main function is service, tends to makethe training needs secondary to the service needs of theorganization. This is not to say that we are not cog-nizant of the very great contribution that many hos-pitals and medically oriented clinics have made to thetraining of clinical psychologists and we believe thatevery clinical psychologist must have extensive experi-

ence in these settings. The fact remains, however, thatit is possible to accomplish certain things in the train-ing of clinical psychologists in a psychologically ori-ented clinic that are rarely or never possible in othersettings. It is increasingly apparent also that clinicalpsychology has something to offer many other segmentsof society, and training a clinical psychologist in thecontext of another professional school may tend tolimit his point of view. Finally, we are of the opinionthat clinical psychology is still a rapidly growing andrapidly changing profession, that new knowledge andexperience are going to make necessary importantchanges in training in this area in the next decade ortwo, that this type of flexibility is most obtainable ifclinical psychologists are broadly trained in general andexperimental psychology as well as in clinical skills andtechniques, and that this type of training is most easilyaccomplished in graduate psychology departments withthe major portion of the training program under thedirect control of psychologists.

In summary, it is our opinion that the demands ofsociety, the best interests of the profession of psy-chology and of individual clinical psychologists, andthe practical limitations within which we must operatein our culture at this time, point to the need for clini-cal psychologists who have a sound training in generalpsychology, who have competency and interest in bothresearch and clinical skills, who can be expected tomake some contribution to the advancement of knowl-edge, and who can work effectively with a large num-ber of other persons and agencies in a consultative ca-pacity to help a larger number of persons than canever be helped directly by psychologists in face-to-facesituations. We believe we have developed a trainingprogram which makes some progress toward trainingpersons of this sort.

REFERENCES

ALBEE, G. W. Mental health and manpower trends. NewYork: Basic Books, 1959.

EWALT, J. (Ed.) Action for mental health. (Final re-port of the Joint Commission on Mental Illness andHealth.) New York: Basic Books, 1961.

ISCOK, I. Editorial. /. din. Psychol., 1962, 18, 110.RAIMY, V. (Ed.) Training in clinical psychology. New

York: Prentice-Hall, 1950.STROTHER, C. R. (Ed.) Psychology and mental health.

Washington, D. C.: American Psychological Association,19S6.

TOWBIN, A. P. When arc cookbooks useful? Amer. Psy-chologist, 1960, IS, 119-123.