How to Become a Clinical Psychologist (4) - the Path to become a Scientist-Practitioner

"Graduation is just the beginning." Every professor echoed this sentiment when I completed my Clinical Psychology training. "It's akin to having an admission ticket." But what exactly were we, as new graduates, gaining entry to?

I was trained under the "Scientist-Practitioner" model. The goal in my mind was to become a psychology professional practitioner who can make independent clinical decisions and provide effective interventions, all based on scientific knowledge in Psychology. Reflecting on it, this was my journey:

1. When first working in a clinical setting, I started off adhering to protocols, templates, and guidelines whenever possible. This is the simplest method to become acquainted with the standard practices. Follow the assessment protocols. Attend different training workshops. Memorize the scripts provided in therapy textbooks. Follow the treatment manuals. When things do not work as planned, consult with colleagues and supervisors.

2. I always keep an inquisitive mindset. I attempt to understand why the steps in the protocols are arranged in a specific manner and why certain wordings are chosen over others. This applies to both assessment and treatment manuals. These efforts distinguish a psychometrician/psychotherapist from a clinical psychologist. A clinical psychologist understand not only the steps they practice but also the rationale and reasons behind them. This awareness helps me be mindful of the language I use, structure a session effectively, and adapt to different scenarios during sessions.

3. Frequently, there are no established protocols, manuals or guidelines, so I have to research and develop my own protocols. I began with minimal information on topics like child custody evaluation, sex offender treatment, alcoholism, neuropsychological assessment of neurological conditions, neurorehabilitation, etc. I found it helpful to start by searching for textbooks or chapters, as they typically provide a comprehensive overview of specific client groups or clinical conditions, from assessment to treatment. I then examine the most recent published reviews and meta-analyses, focusing on papers from the last 10 years or less. By this stage, I can usually identify various assessment models and tools, as well as evidence-based treatment methods and techniques. This is when I delve deeper into the specifics.

4. The deeper I delve into details, the more new information I need to absorb. I find it beneficial to jot down brief notes after reading an article. My note library includes nearly all the articles I've read since graduating. I update the sections to reflect changes in the DSM taxonomy.

5. I also attended more and more workshops and training on different therapies and assessment methods. Of course we don't have infinite time and resources. If something is already backed up with evidence, there is no excuse not to learn it. However, it does not mean that I avoided therapies that seemed a bit "non-normative". I learnt family therapy, solution-focused therapy, Ericksonian and traditional hypnosis, besides CBTs for different specific psychopathological conditions, EMDR, EFT, motivational interviewing and more. I acquired skills from these different therapies. Now, I utilize a neuroscience-informed cognitive-behavioral-emotional framework to understand psychological conditions. Nevertheless, I find that many therapeutic techniques from other approaches fit well within my framework. While I may not use the same terminology and conceptualizations from these various approaches, I do apply their techniques.

6. The inquisitive mindset is ever-present as I imitated the "masters" of various approaches. It was not uncommon that the pioneers or creators of these approaches often asserted that their approaches were effective for numerous conditions, sounding like it was a panacea. I reminded myself not to become devoted to a single type of therapy. Instead, I focus on examining scientific evidence.

7. I returned to fundamental science, specifically what I learned during my undergraduate studies in psychology, covering areas like cognitive psychology, biological psychology, and social psychology. The scientific discoveries in basic psychology, rather than the theories or models people create, lay the foundation for Clinical Psychology. For instance, why does the presentation rate of digits matter in terms of the process of working memory? Clinical Psychologists frequently deal with emotions. But what exactly are emotions? How are they triggered and maintained? What are thoughts? Are they the antecedent or the consequence of a feeling? The empirical answers to these questions determine how we can change someone's feelings and maladaptive thoughts. How much do we understand about unconscious processing, such that the way I start a session can affect the client's perception about himself/herself later in the session? Evidence-based practice is not just about adopting an approach supported by research; it's about understanding whether a particular component works, and why and how it works, especially in our brain. When I first learned Mindfulness-Based Stress Reduction, I was puzzled about whether focusing on breathing when experiencing anxiety during meditation aligned with the finding that avoiding fear perpetuates fear. I did not know the answers then, but now we do. We also know when to use relaxation techniques and when to apply mindfulness-based meditation after understanding the components and mechanisms of fear, anxiety, and distress. Another example is understanding what memories are and how they are represented in our brain. Can memories be altered, or what are the targets of change when we aim to change memories, particularly traumatic ones? To change the targets associated with a memory, we now understand that the memory and its associations must be "activated." Telling someone they are safe now, while they sit calmly in a therapy room, does not help when they are trapped in the memory of childhood physical abuse. A related issue is using imagery to "modify" traumatic memories. Traditionally, we encouraged clients to conduct behavioral experiments to gather "objective" data to counter the maladaptive beliefs. However, it was also found that imagery, though not real, can help. When we understand the science of memories, these questions can be easily answered. So, when I returned to fundamental psychological science, I stopped specifying which approach I was using. I do not dismiss any approach, as long as the techniques and formulations align with science, even if they use different terminology.

8. Science often seems cold and stern, but it is our responsibility to make it effective for our clients. Being a scientist-practitioner involves continuously testing our hypotheses about a client's condition and adjusting our strategies accordingly. This requires a high sensitivity to the client's responses. Guided by scientific knowledge, I must also consistently receive feedback from the clients. It's akin to wrapping a gift to present to the client so that they accept it (a metaphor by Geoffrey Zeig, 2006). I use different languages and terminology that align with a client's worldview if needed, as long as it fits the scientific conceptualization and understanding of psychological processes. It is not necessary stick to the language originally adopted by a particular orientation. Client feedback encompasses not only their explicit verbal responses but also implicit responses, both verbal and nonverbal, and most importantly, whether the client's condition has improved. Client feedback, especially immediate responses and change of psychological conditions, is one of the pieces of evidence a scientist-practitioner seeks to guide the intervention.

   
   

The journey described above is not linear. Rather, it is recursive, with steps that are revisited multiple times. Naturally, I now dedicate more time to the later steps than to the initial ones. It requires patience. My journey might differ from yours, yet I hope that graduates understand that being a responsible and competent Clinical Psychology practitioner is a lifelong pursuit.