We would like to point out that at present, the National Health System (reorganized and restructured by a General Health Law in 1986) offers full health coverage to 98% of the Spanish population. Psychologists are being employed in the Public Health Network and in Mental Health Care units and teams and must cover two interdependent areas: primary care and specialized care. Mental Health Care teams are a technostructure of experts dealing with patients and their cases on a micro level (Escudero & Olabarria, 1986).

A new field of expertise has emerged: one that covers certain aspects traditionally belonging to Clinical Psychology (such as diagnostic and assessment functions, psychological treatment, etc.) and other aspects which require new types of sociotechnical qualifications and contributions. These aspects involve interdisciplinary work in and with the community, health promotion and prevention, support for specialized services in hospitals, working with other experts in Primary Care Centres, engaging and supporting the network of Social Services, new psychological instruments and equipments to deal with chronic conditions. All of this has developed from an interdisciplinary point of view, where "the team is not simply the sum or juxtaposition of professionals with different skills, but a workgroup with a highly degree of functional expertise, a result of the integration of the professionals' contributions to achieve those goals" (García, 1990).

In this way, by placing Clinical Psychology within the framework of health organizations and in reference to a Health Care model, the path has been cleared for establishing intervention priorities hierarchically, and for creating new areas of action as a consequence of technical and social responsibility. This may be the beginning of the institutionalization of different working tasks or of the bureaucratization of clinical psychology within the health system. The practitioner represents public interests, either directly as an official in the health structure or indirectly as a free professional (Olabarría, 1990).

Undoubtedly and inevitably, a general goal is to bypass the psychiatric care units in hospitals, following the recommendations of the World Health Organization (WHO), the Regional Office for Europe, which establishes as a goal the reduction of psychiatric hospital assistance (WHO, 1986). In only a few years, this has caused a change, valued positively by the WHO: the reduction by over 50% of psychiatric hospitals in Europe.

In this context here follow some Spanish data: The Psychiatric Hospital of Oviedo housed 1082 patients in 1980; a decade afterwards it has only 270 (Aparicio and Garcia, 1990). The public psychiatric hospital population in Andalusia was 4800 in 1976; by 1985, it was reduced to 3563 and by 1988, to 2099 patients (Instituto Andaluz de Salud Mental, 1990). Moreover, as Sampaio-Faria (1991) points out, there is a "growing demand in the services, deriving from an ever-increasing number of people exposed to, yet unprepared to manage, stress-related problems and psychosocially harmful factors... as well as the appearance of disorders... associated with ageing, and chronic physical illnesses..." There are,therefore, many old and new problems and demands to be met by Clinical Psychology in Spain, within the framework of "a process that has brought about the realization of current and appropriate techniques and methodologies which should guarantee an adequate level of care, while requiring the need for quality-training in techniques and instruments, as well as more theoretical groundwork to set a firm foundation for these actions" (Olabarría, 1987).

Let us now look at the main activities which face clinical psychologists in Spain, and what urgent tasks lie before them.

Many of the current activities of clinical psychologists in public service care networks are determined by their position in the health organization (mostly, though not exclusively, in the Mental Health Service network), and by the general criteria that govern the actions of these networks.

We list the following as general criteria:

a) To work towards eliminating psychiatric hospitals, facilitating the provision of alternative services to in-patients.

b) To favour the area of community care, which should always guarantee continuity of care for the population of a given territory.

c) To guarantee full integration in the general health network, avoiding the segregation or marginalization of the population in the Mental Health network.

d) To establish support for Primary Care (training of professionals, coordination, supervision, etc.), with operational and diversified formulas.

e) To establish, in any given territory, a diversity of service and intervention, which would adjust flexibly to existing problems and social demands.

f) To guarantee coordination and support among the different general hospital services, where psychological factors play an important role in the process of becoming ill, as well as in that of recovering.

g) To contribute to establishing an interdisciplinary vision of the intervention field.

1. Mental Health Centres (the basis of the system) for local community care, both out-patient and home-treatment, which are responsible for the population of a given territory. Its team is interdisciplinary and includes, significantly, clinical psychologists.
2. Mental Health Units in General Hospitals for short-term in-patient treatment, interdisciplinary actions, tasks and support for other specialties in the hospital.
3. Rehabilitation units or Chronic-treatment Units.
4. Intermediate structures, such as day-hospitals or therapeutic communities.
5. All of this constitutes an integrated network in a given region (Comunidad Autonoma)

Let us mention some Programs in which clinical psychologists carry out their day-by-day tasks in the public network of Mental Health:

Integrated public services are provided at the Primary Health Care level. Support and coordination of professionals of this level is extremely important. Thus, clinical psychologists have taken over more duties to overcome the traditional separation between comprehension (and subsequent treatment of general health problems) and what is known as mental health problems. They also contribute by teaching psychological and interpersonal skills to other professionals at this level, in order to help them manage health problems, patients' changes in habits, and in general, health promotion in the community as well as in small groups and in individuals.

This continuous work helps this first level of care to detect psychopathological cases and to organize a follow-up, while at the same time easing and improving referral procedures.

Therefore, activities in this area include general health promotion and education activities; report-writing activities; carrying out interdisciplinary expertise and participating at various levels in specific programs of Primary Care Teams, in coordination with them.

The above mentioned activities of Primary Health Care are, in general, the most highly recognized since they imply activities of psychological assessment, psychotherapeutic activities or psychological treatments in their multiple orientations and areas (individual, family, groups, institutional). The soundness of the above-mentioned procedures, however, has forced clinical psychologists to improve a number of skills. This includes: defining the appropriate treatment methods, deciding the proper time period for each activity, linking psychological treatment to other actions of a different nature and/or to other community facilities (educational centres, social services, etc.), complementing other professionals from the same team but of different disciplines, being versatile with regard to where the patients are seen (at the patient's home, at schools, in social centres, in mental health centres). All this calls for considerable cognitive and instrumental adjustment.

On the other hand, there are at least two large age groups differentiated from the general adult population which demand specialized interventions: the infantile-juvenile group and the elderly population. These groups call for programs and/or specific care units. Thus, primarily with the infantile-juvenile population, clinical psychologists (together with other professionals) are developing care programs for these populations, covering actions such as: Health Promotion and Education, Prevention and Therapeutic Assistance, support for and coordination with other regional health services (Primary Care and hospitals: especially Maternity and Paediatrician Services), educational centres, and social and legal services.

However, Spanish clinical psychologists are taking into account certain aspects that were, up till now, considered irrelevant, such as: decision-making criteria and modalities of hospitalization, the establishment of criteria and explicit protocols about such things as the action in severe clinical situations for the child and/or family, the right moment for programmed, but not urgent, surgery, or the possibility of joint mother-and-child hospitalization (Consejeria de Salud de la Comunidad Autonoma de Madrid, 1990). All these aspects are now considered relevant.

The main objective of these programs is to enable the subjects to whom the series of activities is directed to acquire the necessary skills to become reintegrated in their environments (as much as possible) or to join new ones, with as much autonomy as they can manage. On the other hand, these programs attempt to modify people's attitudes towards mental illness.

In order to guarantee sufficient support for this population, the existence of intermediate structures plus coordination with and support for the social services are absolutely necessary.

Lastly, we wish to point out briefly the work being carried out in general hospitals, where there is a great variety of activity and posts for clinical psychologists.

There are Hospitalization Programs at the regional level that are coordinated with similar programs at the local level, where out-patients received psychological treatment. These units provide intensive care, ensuring that hospitalization lasts only for that period of time necessary to establish the conditions for out-patient treatment. That is, hospitalization should become a link in a more global therapeutic framework of intervention. This requires establishing common criteria between at least two sub-teams of the same territory, regarding hospitalization, its objectives, agreements, time and type of case-admission in the Out-Patient Care Program.

On the other hand, we cannot fail to mention the labour and research associated with other hospital services, mostly involving oncology, psychosomatic disorders, pain, pre and post-surgery psychoprophylaxis, chronic illness (diabetes, asthma, haemophilia) and so on. All of these share aspects of interdisciplinary and specific work with increasingly acknowledged results.

Therefore, Clinical Psychology is well on its way and should not falter. It has been very successful, but we must also emphasize some of the urgent problems of Clinical Psychology in Spain. Let us have a look at some of them:

• - Mental Health is a significant sphere of intervention, but not the only one.
• - An adequate post-graduate training must be achieved, linked to the intervention field and recognizing it formally as a health specialty.
• - Continuous training and up-grading of Clinical Psychologists must be emphasized and operationally articulated in order to avoid biases.
• - There is a clear need to contrast the usefulness of current interventions with the daily heterogeneous demands made on Clinical Psychologists.
• - There is a need for establishing lines of research to avoid the existence of single case studies. Besides, these lines of research should be associated with contrasted social needs in the population or in the health system.
• - There is a training need for client contact skills and for acquiring new competencies to help patients to deal with the problem areas of their lives (Olabarría and Escudero, 1990).

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The present status is that different frameworks coexist, sometimes "peacefully", sometimes in intense rivalry. From our point of view, the coexistence of a large spectrum of theories and approaches enriches the design of learning experiences for students and practitioners.

In this way, a collective effort is being made, among professionals from applied and research areas, to adjust to the inevitable evolution of Clinical Psychology by transforming it into a psycho-technological discipline.

Having emphasized how much progress has been made due to incorporating Clinical Psychology into public services, we should not leave out private practice-level developments. Unfortunately this sector is more difficult to quantify and more complex to analyze because we do not have sufficient data to let us carry out realistic estimates. According to a study carried out by Avila (1989), in the region of Madrid, 82% of clinical psychologists were freelance or self-employed consultants. This proportion has decreased to 76% in the last few years. This is probably due to the incorporation of clinical psychologists into the public health network. Thus clinical psychologists' private activity still by far exceeds their public activities. The fact that this profession is not yet incorporated to a great extent within the framework of the public health system may be a contributing factor to this state of affairs.

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                           JOSÉ RAMÓN CORREAS GONZALEZ
                      
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              LAST UPDATED Sunday 6 de August de 1995 - - 

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