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introduction to
Clinical Psychology
An Evidence-Based Approach
third edition
 introduction to
Clinical Psychology
An Evidence-Based Approach
third edition

j o h n h un s l e y | c at h e r i n e m . l e e
Copyright © 2014, 2009, 2005 by John Wiley & Sons Canada, Ltd.

All rights reserved. No part of this work covered by the copyrights herein may be reproduced or used in any form or
by any means—graphic, electronic, or mechanical—without the prior written permission of the publisher.

Any request for photocopying, recording, taping or inclusion in information storage and retrieval systems of any part
of this book shall be directed to the Canadian copyright licensing agency, Access Copyright. For an Access Copyright
licence, visit www.accesscopyright.ca or call toll-free, 1-800-893-5777.

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any information that will enable them to rectify any erroneous reference or credit line in subsequent editions.

Care has been taken to ensure that the web links recommended in this text were active and accessible at the time of
publication. However, the publishers acknowledge that web addresses are subject to change.

Library and Archives Canada Cataloguing in Publication

Hunsley, John, 1959-

[Introduction to clinical psychology]
Clinical psychology : an evidence-based approach / John Hunsley, Catherine M. Lee. — Third edition.
Revision of: Introduction to clinical psychology : an evidence-based approach.
Includes bibliographical references and index.

ISBN 978-1-118-62461-6 (pbk.)

1. Clinical psychology—Textbooks. I. Lee, Catherine M. (Catherine Mary), 1955-, author

II. Title. III. Title: Introduction to clinical psychology.

RC467.2.H86 2014 616.89 C2013-906979-8

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To Rob and Nick
 PREFACE

Between us, we have well over half a century of experience in clinical psychology. We share a passion for a
profession that has the potential to make an important contribution to the understanding of human nature
and to the alleviation of human suffering. We have written this book to introduce to students the theories
and practices of clinical psychology and convey the important work done by clinical psychologists. The book
is designed to be helpful not only to those who will go on to careers in clinical psychology, but also to those
who will choose other career paths.

KEY FEATURES
Clinical psychology has evolved greatly in recent decades. In order to convey the nature of the contemporary
practice of clinical psychology, we have incorporated three distinct features through all of the chapters.

Evidence-Based Approach
Concerns about health care costs, together with growing demands from well-informed health care consumers,
have highlighted the need for clinical psychology to adopt evidence-based assessments and interventions.
Unfortunately, many popular theories that have guided clinical practice for decades do not have supporting
evidence. Throughout the text, we present theories and practices and examine the extent to which they are
supported by research. If a technique or strategy is used frequently in practice but has not been supported
empirically, we say so. We believe that our approach reflects the new realities in clinical psychology and the
ongoing commitment of psychologists to deliver services that are the best science has to offer.

Diversity
Clinical psychology must address the needs of a diverse population. We highlight the need for sensitivity
to gender, age, culture, ethnicity, sexual orientation, socioeconomic status, family type, and geographic
location. Throughout the text, we include relevant assessment and treatment examples to illustrate the
importance and the challenges of professional sensitivity to diversity issues in research and practice.

Lifespan Perspective
We have adopted a lifespan perspective throughout the text. We include examples illustrating issues with
respect to children, adolescents, adults, and older adults. As many undergraduate students taking an introduc-
tory course in clinical psychology are unlikely to have decided on the age of clients with whom they eventually
wish to work, it will be appealing to learn about clinical psychology across the lifespan. It is important for
students to appreciate that assessment and treatment plans can vary depending on the age of the individual.

TEXT ORGANIZATION
The text can be divided into three sections. The first section provides an overview of issues that set the stage
for the second section, which is on assessment; and that section, in turn, is the foundation for the third
section on intervention in clinical psychology. In Chapter 1, we provide a definition of clinical psychology,
viii PREFACE

describing its history and explaining similarities and differences between clinical psychology and other
mental health professions. Chapter 2 addresses the diverse roles of clinical psychologists, all of which are
based on the pillars of science and ethics. The importance of attention to ethical issues is highlighted not just
in this chapter but throughout the text. The third chapter is an overview of issues related to classification
and diagnosis. In this chapter, we introduce two individuals, an adult (Melissa) and an adolescent (Noah),
whose psychological services we describe in subsequent chapters. Chapter 4 presents key issues on research
methods, underlining the ways these methods are employed to address clinically meaningful questions.
In the second section, Chapters 5 to 9 address assessment issues in clinical psychology, highlighting
ethical issues that must guide psychological practice. Chapter 5 provides an overview of the purposes of
psychological assessment, a review of key concepts in psychological testing, and an examination of the
distinction between testing and assessment. Chapter 6 presents information on clinical interviews and clini-
cal observation, emphasizing developmental considerations relevant to these commonly used assessment
methods. Intellectual and cognitive assessments are discussed in Chapter 7. Chapter 8 covers self-report and
projective assessment, with in-depth examination of the usefulness of different assessment strategies. The
challenges of integrating assessment data and making clinical decisions are illustrated in Chapter 9, with
reference to services for Melissa (who was introduced in Chapter 3).
The third section, on intervention, covers both prevention and treatment. Chapter 10 highlights issues in pre-
vention, describing programs designed for at-risk children and youth. In Chapter 11, we provide a brief overview
of approaches to psychological intervention, describing the theoretical foundations of current evidence-based
approaches and presenting data on the nature and course of psychotherapy. Chapters 12 and 13 present an over-
view of current evidence-based treatments for adults (Chapter 12) and for children and adolescents (Chapter 13).
The case of Noah (who was introduced in Chapter 3) is used to illustrate issues in developing treatment plans.
Chapter 14 provides information on evidence-based treatment elements derived from the therapy process and
therapy process-outcome research. Finally, in Chapter 15, we examine issues in the practice of clinical psychol-
ogy in the areas of health psychology, clinical neuropsychology, and forensic psychology.
Two appendices are included. The first lists journals in clinical psychology and should help students
as they research topics in greater depth. The second appendix, entitled Applications to Graduate School, is
designed to help students make decisions about graduate school applications as well as plan an application.

FEATURES OF INTEREST TO THE STUDENT

Within each chapter, many features have been incorporated to aid student learning. This text is designed
to introduce clinical psychology in a reader-friendly and accessible manner, highlighting the varied and
dynamic areas of the discipline.

Chapter Outline
Each chapter begins with an outline that prepares the student for the material to be covered.

Case Examples
In courses in clinical psychology, case examples are the tool through which abstract
material is brought to life. In addition to the extended case presentations in Chapters 3,
9, and 13, case material is embedded throughout the text to illustrate issues in different
 PREFACE ix

developmental periods and with a diverse clientele. Reflecting the terminology in current practice, we alter-
nate our use of the terms “patient” and “client.” All the case examples we describe are based on our clinical
experience. We have blended details about different people into composites to illustrate clinical issues. The
case examples do not, therefore, represent specific individuals and all the names are fictitious.

Viewpoint Boxes
In each chapter, controversial issues and new directions in the field are highlighted in Viewpoint Boxes.
Topics include:

• historically important themes, such as in Distress in Clinical Psychologists and How They Deal with It
and IQ and Its Correlates
• new directions in clinical psychology, such as in Psychological Resilience in the Face of Potential Trauma,
Options for Increasing Psychotherapy Attendance, and Dissemination of Evidence-Based Treatments
• controversies, such as in What Do Psychologists Need to Know about Psychopharmacology?, The Trials
and Tribulations of DSM-5, and How Reliable Are the Findings Reported in Research Studies?
• issues with a lifespan perspective, such as in Issues in Interviewing Older Adults and Treatment of
Childhood Attention-Deficit/Hyperactivity Disorder
• debates around evidence-based assessment, such as in Child Custody Evaluations, Risk Assessment,
and Why Do Questionable Psychological Tests Remain Popular with Some Clinical Psychologists?
• expansion of the practice of clinical psychology to health, such as in Health Promotion and Prevention
Programs for Older Adults and Insomnia: No Need to Lose Sleep Over It!
• current issues in treatment research, such as in Multiple Perspectives on Treatment Goals and Sudden
Gains in Therapy.

Profile Boxes
To bring to life the reality of being a clinical psychologist, we have featured 24 individuals in Profile Boxes.
We invited Canadian clinical psychologists at different stages of their careers to answer questions about be-
ing a clinical psychologist. In addition, to give students a sense of the varied activities in which psychologists
engage, we asked three psychologists who work in different types of settings to describe a typical work week.
We invited colleagues whom we consider fine examples of clinical psychologists, and we chose people whom
we hope students will find inspiring. Students reading the Profile Boxes will better appreciate the wide range
of activities in which clinical psychologists engage, the range of challenges they address in their work, and
the creativity with which psychological principles are applied to reduce human suffering and improve
psychosocial functioning.
We have also included a profile about a graduate student in clinical psychology, to give students a sense
of the life of a clinical psychology graduate student.

Critical Thinking Questions

Key questions have been designed to promote discussion and debate on both traditional and
emerging issues in clinical psychology. These questions appear in the margins marked with a head
with a question mark icon.
x PREFACE

Think About It!

Throughout each chapter, we have also included questions that encourage students to con-
sider specific text material more deeply and more personally. These questions, which are
marked with a thought bubble icon, usually ask the reader to consider the impact that a
certain professional or empirical issue could have on someone’s life. There are also questions
that encourage students to consider how the manner in which clinical psychologists make
decisions about professional services is similar to and different from the manner in which
people make routine decisions.

Summary and Conclusions

At the end of each chapter, a section draws together the material discussed in the chapter.

Key Terms and Key Names

Throughout each chapter, important names and key terms are highlighted in bold. In addition, key term
definitions are included in the margin. These are important study aids to highlight the most salient points
of each chapter.

Additional Resources
For students who wish to explore an issue in greater depth, additional resources have been cited for various
journals and books. The Check It Out! feature provides website links that allow readers to find out more
about important issues raised in the chapter.

CHANGES IN THE THIRD EDITION

As clinical psychology is a rapidly evolving profession, in this third edition we have updated the scientific
and professional literature we review to highlight recent changes in the field.
In Chapter 1, this involved providing new estimates about the economic costs of mental disorders and
the numbers of mental health care specialists (including clinical psychologists). Chapter 2 has updated infor-
mation about the professional activities and theoretical orientations of clinical psychologists, characteristics
of training programs and their graduates, accreditation standards, and registration/licensure. A new profile
on a “week in the life of a graduate student” has also been added. Information on both DSM-5 and ICD-10
diagnostic systems is included in Chapter 3, along with updated information on the epidemiology of mental
disorders. To encourage the critical evaluation of scientific research, Chapter 4 has new Viewpoint Boxes
addressing media reporting of research and the reliability of research results.
New assessment-related information has been included in Chapters 5 to 9. This includes a discussion
of the continuing growth of evidence-based assessment, information on the updated Wechsler scales, and
details of updated versions of frequently used self-report measures. Also, Chapter 6 has been reorganized
to help readers be better prepared for learning about the challenges in assessing clients across the lifespan.
The chapters on prevention and treatment (Chapters 10 to 14) include new evidence of the impact of a
number of prevention programs, information on the American Psychological Association resolution about
the effectiveness of psychotherapy, an expanded listing of evidence-based treatments, details on a range of
clinical practice guidelines, and results from a task force on evidence-based psychotherapy relationships.
 PREFACE xi

Chapters 12 and 13 have been revised to provide updated information on evidence-based treatments and
the results of treatment efficacy and effectiveness research for clients across the lifespan. In Chapter 15, we have
expanded information on the management of both chronic pain and insomnia, added information on the use of
neuropsychological assessment to evaluate the capacity of older adults to live independently and manage their
lives, and updated details on forensic risk assessment tools and challenges in their interpretation.
Overall, 7 new Viewpoint Boxes and 20 new Profile Boxes have been added. We have also increased the
use of clinical case material to illustrate important points discussed in the text, and focused increased atten-
tion on diversity issues. Furthermore, to improve the readability and comprehensibility of the material, we
have enhanced the cross-referencing across chapters.

ACKNOWLEDGEMENTS
We have appreciated the support and guidance of many people during the preparation of the third edition
of this book. Thanks are due to Rodney Burke, the acquisitions editor, who championed the importance of
a written-in-Canada text on contemporary clinical psychology. We are grateful to Georgina Montgomery, our
copy editor for this edition, and production editor Yee Lyn Song who coordinated the phases of production
with efficiency. We are grateful for the helpful feedback provided by Robert Hunsley and Majeeda Khan and
the capable research assistance provided by Robert Hunsley and Kathryn LaRoche. The book is enriched by
the contributions of the psychologists who agreed to be profiled. We appreciate their cooperation and willing-
ness to talk about their careers, and special thanks go to them. They are Drs. Melanie Barwick, Peter Bieling,
Christopher Bowie, Clarissa Bush, Christine Chambers, David A. Clark, Karen Dyck, Jennifer Frain, Heather
Hadjistavropoulos, David Hodgins, Charlotte Johnston, Martin Lalumière, Christopher Mushquash, Randy
Paterson, Martin D. Provencher, Adam Radomsky, Graham Reid, Don Saklofske, Katreena Scott, Colette Smart,
Michael Sullivan, Henny Westra, Jonathan Weiss, and Sheila Woody. We deeply appreciate the contribution
of graduate student Emma MacDonald.
Last, but not least, we are grateful for the ongoing support of friends and family.
 ABOUT THE AUTHORS

John Hunsley received a Ph.D. from the University of Waterloo in 1985.

He is a full professor in the clinical psychology program at the University
of Ottawa and is the director of the program. Dr. Hunsley teaches gradu-
ate courses in clinical research methods and psychological assessment.
Dr. Hunsley’s research interests focus on evidence-based psychological
practice, the delivery of psychological services, and the scientific basis
of psychological assessment. He has authored over 110 articles, chapters,
and books on these topics. Dr. Hunsley is a Fellow of the Association
of State and Provincial Psychology Boards, the Canadian Psychological
Association (CPA), and the CPA Clinical Psychology Section. He has
received the CPA Award for Distinguished Contributions to Education
and Training in Psychology. From 2007 to 2011, he served as the editor
of Canadian Psychology. He has also served on the editorial board of
Assessment, Journal of Personality Assessment, Professional Psychology:
Research and Practice, and Scientific Review of Mental Health Practice.

Catherine M. Lee earned a Ph.D. from the University of Western

Ontario in 1988. She is a full professor of psychology at the University
of Ottawa. Dr. Lee teaches graduate courses in evidence-based services
for children and families and an undergraduate course on Clinical
Psychology, as well as supervising practicum students and interns at the
Centre for Psychological Services and Research. Her research interests
focus on the provision of evidence-based services to promote positive
parenting. She has authored over 70 articles, chapters, and books on
this and related topics. Dr. Lee is a Fellow of the Canadian Psychological
Association (CPA) and the CPA Clinical Psychology Section. She is an
ad hoc reviewer for many granting agencies and scholarly journals
and she serves on the editorial boards of Clinical Child and Family
Psychology Review and Cognitive and Behavioral Practice. She is the
former chair of the Clinical Psychology Section of the CPA and was
President of the CPA in 2008–2009. She is a site visitor for the Canadian
Psychological Association Accreditation Panel.
 BRIEF TABLE OF CONTENTS

CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY 1

CHAPTER 2 CONTEMPORARY CLINICAL PSYCHOLOGY 45

CHAPTER 3 CLASSIFICATION AND DIAGNOSIS 87

CHAPTER 4 RESEARCH METHODS IN CLINICAL PSYCHOLOGY 125

CHAPTER 5 ASSESSMENT: OVERVIEW 167

CHAPTER 6 ASSESSMENT: INTERVIEWING AND OBSERVATION 205

CHAPTER 7 ASSESSMENT: INTELLECTUAL AND COGNITIVE MEASURES 243

CHAPTER 8 ASSESSMENT: SELF-REPORT AND PROJECTIVE MEASURES 279

CHAPTER 9 ASSESSMENT: INTEGRATION AND CLINICAL DECISION-MAKING 321

CHAPTER 10 PREVENTION 355

CHAPTER 11 INTERVENTION: OVERVIEW 391

CHAPTER 12 INTERVENTION: ADULTS AND COUPLES 429

CHAPTER 13 INTERVENTION: CHILDREN AND ADOLESCENTS 469

CHAPTER 14 INTERVENTION: IDENTIFYING KEY ELEMENTS OF CHANGE 505

CHAPTER 15 CLINICAL HEALTH PSYCHOLOGY, CLINICAL NEUROPSYCHOLOGY, AND

FORENSIC PSYCHOLOGY 539

APPENDIX 1 MAJOR JOURNALS RELEVANT TO CLINICAL PSYCHOLOGY 573

APPENDIX 2 APPLICATIONS TO GRADUATE SCHOOL 579

REFERENCES 589

NAME INDEX 613

SUBJECT INDEX 627

 TABLE OF CONTENTS

CHAPTER 1 THE EVOLUTION OF CLINICAL PSYCHOLOGY 1

Introduction 1
Defining the Nature and Scope of Clinical Psychology 4
Viewpoint Box 1.1 Mental Health Commission of Canada 5
Profile Box 1.1 Dr. Jennifer Frain 6
Evidence-Based Practice in Psychology 10
Mental Health Professions 13
Counselling Psychology 14
School Psychology 16
Psychiatry 17
Clinical Social Work 19
Other Mental Health Professions 20
Availability of Mental Health Service Providers 22
A Brief History of Clinical Psychology 23
The Roots of Clinical Psychology 24
The History of Assessment in Clinical Psychology 25
The History of Intervention in Clinical Psychology 34
The History of Prevention in Clinical Psychology 41
The Future 41
Summary and Conclusions 42

CHAPTER 2 CONTEMPORARY CLINICAL PSYCHOLOGY 45

Introduction 45
Activities of Clinical Psychologists 46
Assessment and Diagnosis 48
Profile Box 2.1 Dr. Clarissa Bush 48
Profile Box 2.2 Dr. Sheila Woody 51
Intervention 52
Viewpoint Box 2.1 What Do Psychologists Need to Know about Psychopharmacology? 53
Profile Box 2.3 Dr. Randy Paterson 56
Prevention 58
Consultation 59
Profile Box 2.4 Emma MacDonald 60
Research 61
Teaching and Supervision 62
Administration 65
Employment Settings 65
The Two Pillars of Clinical Psychology: Science and Ethics 66
Viewpoint Box 2.2 Distress in Clinical Psychologists and How They Deal with It 71
xviii TABLE OF CONTENTS

Training in Clinical Psychology 73

Models of Training in Clinical Psychology 74
Accreditation of Clinical Psychology Programs 76
Licensure in Clinical Psychology 80
Summary and Conclusions 83

CHAPTER 3 CLASSIFICATION AND DIAGNOSIS 87

Introduction 87
Defining Abnormal Behaviour and Mental Disorders 90
Developmental Psychopathology 92
Diagnosis 92
Defining Disorder 94
Profile Box 3.1 Dr. Christopher Bowie 95
Prevalence of Mental Disorders 97
Understanding the Development of Mental Disorders 101
Viewpoint Box 3.1 Psychological Responses to Natural Disasters 103
The Diagnostic and Statistical Manual of Mental Disorders (DSM) System 106
The Evolution of the DSM 106
Viewpoint Box 3.2 The Trials and Tribulations of DSM-5 108
The DSM-5 109
The International Statistical Classification of Diseases and Related Health Problems (ICD) System 112
Limitations of Diagnostic Systems 114
Defining Abnormality (Revisited) 114
Diagnostic Reliability 115
Heterogeneity of Symptom Profiles 116
Diagnostic Validity 117
Comorbidity 118
Viewpoint Box 3.3 Psychological Resilience in the Face of Potential Trauma 119
Categorical versus Dimensional Classification 120
Summary and Conclusions 122

CHAPTER 4 RESEARCH METHODS IN CLINICAL PSYCHOLOGY 125

Introduction 125
Profile Box 4.1 Dr. Adam Radomsky 129
Generating Research Hypotheses 130
Ethics in Research 134
Research Designs 139
Viewpoint Box 4.1 If It Is Reported in the Media, It Must Be True—Right? 140
Case Studies 144
Single Case Designs 145
Correlational Designs 147
Quasi-Experimental Designs 150
Experimental Designs 151
Profile Box 4.2 Dr. David Hodgins 152
Meta-Analysis 154
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