Summary Clinical Psychology, Summaries of Clinical Psychology

Download Summary Clinical Psychology and more Summaries Clinical Psychology in PDF only on Docsity! Chapter 1: Clinical Psychology Pages 3-30 What is Clinical Psychology?  Clinical psychologists are individual trained in assessment and diagnosis, intervention or treatment, consultation, research, and the application of ethical and professional principles  Clinical psychologists work with a range of individuals, from infants to the elderly.  They work in a large range of settings, including universities, hospitals, private practice offices…  Little medical training, extensive training in psychotherapy or talk therapy.  Focus on client autonomy and collaboration with patient  Only New Mexico and Louisiana allow trained clinical psychologists to prescribe medication Closely Related Mental Health Professions Psychiatrists  A physician rooted in medicine  Regards psychopathology as an “illness” that is biologically based and its causes can be treated with medicine.  Complete four years of medical school (M.D.), general medical internship, 4-year residency training in psychiatry. o Supervised work in clinical setting or outpatient facility (supervised by experienced psychiatrist) o May thus be better able to identify medical problems for psychological distress.  Blurred lines between clinical psych and psychiatrists.  Specialization is slowly declining—economic impact, competition from other specialties like clinical psych.  Brief quarter-hour sessions of medication management not long psychotherapy sessions.  Prescription privileges are being allocated to other specialties as well and people no longer rely on psychiatrists for advice on medication treatment.  More authoritarian and focus on medication prescription. Counseling Psychologists  Work with moderately maladjusted individuals and use assessment methods, most commonly interviews.  Employed in educational settings, but also employed in hospitals, mental health centers.  Focused on: o Preventative treatment, consultation, development of outreach programs, vocational counseling, short-term therapy.  Counseling psychology is a small field (the file of clinical is bigger with 4x as many graduates from doctoral programs).  Most counseling psychology programs are in the School of Education.  Counseling doctoral program acceptance rates are higher, greater focus on minority/cross- cultural issues.  Only 70 Ph.D. programs are there for counseling psych but there are 360 for clinical psych. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Clinical Social Workers  Work to improve social functioning of individuals, groups, or communities.  In the past social workers focused on external or social factors contributing to patient’s difficulties, while the psychiatrist prescribed medication and the clinical psychologist tested them.  Today social workers are more likely to deal with psychological factors that play a role in individual and family difficulties (more focus on familial factors).  Requires only master’s degree to practice (2 years).  More likely to engage in home visits, workplace visits—active role  The social work field is rapidly growing as a result of them being low-cost alternatives to psychiatrists and psychologists. School Psychologists  Work with students, educators and administrators to promote social and emotional growth of school age children and adolescents.  School psychologists are in high-demand, as they conduct assessment for special educational needs.  Workplace include schools, nurseries, daycare, hospital, clinics…  60 APA programs for doctoral degrees. Health and Rehabilitation Psychologists  May have a doctorate in clinical, but this is not required. This field is new and is rapidly growing.  Through research and practice contribute to the promotion of good health, involved with prevention and treatment of illness. o Ex: design prevention programs to help quit smoking, reduce weight.  Most likely to engage in consultation with different organizations.  Rehabilitation psychologists focus on physical or cognitive disability. o Help with adjustment to physical, social, psychological barriers.  Work at care facilities, medical centers, rehabilitation facilities, hospitals… Psychiatric Nurses  Working alongside psychiatrists and clinical psychologists  They implement the therapeutic recommendations.  Have prescriptive privileges in all but a few states. Others Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 o Acquisition of specific clinical skills  Practicums can be in assessment, therapy, interviewing methods or even in consulting within specific areas/agencies. Research  Competence needs to be developed in computer software, technology and research methods by engaging in research projects.  Different universities place different emphasis on research o Completion of Master’s thesis by the end of second year  A research project/dissertation is required by the end of 4th/5th year that adds new information to the field.  When entering grad school, a student joints a “team of faculty members”—team meets 2/3 hours per week. Qualifying Exam  Preliminary or comprehensive examination, it is three written exams each lasting 4-hours over the span of one-week or 5-day examinations.  Often taken during the 3rd year or students write an in-depth literature review or research grant. The Internship  Provides experience to complete the scientist-practitioner role, required of all clinical programs.  Occurs at the end of graduate training, usually at an independent facility off campus or at university counseling centers or medical schools.  Allows the student to work full-time in a professional setting provides the students with skills that will mirror that of a professional career.  Women are increasingly growing in the field of clinical psych. Training Models  Professional clinical psych programs use the Ph.D. scientist-practitioner model focused on research but the Psy.D. program is an alternative degree more focused on application.  Professional schools award 60% of doctoral degrees for clinical psych.  Combined Program—focuses on core of both knowledge and skills across applied psychology areas—broad skills.  Clinical-Science Model is focused on evidence-based approaches. Clinical Practice  Clinical psychologists are slowly going into private practice and para-professionals & master’s level individuals are being employed more in mental-health settings.  Clinical psychologists need to have a capacity to tolerate ambiguity Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 2: Historical Overview of Clinical Psychology pages 32-58 Historical Roots  Individuals that altered the field of clinical psychology and began viewing mental illness as treatable—Pinel, Tuke, Todd, Dix  The development of clinical psychology slowly expanded in the fields of diagnosis, assessment, intervention, research and professional matters. Diagnosis and Assessment The Beginnings (1850-1899)  James Keen Cattell, a student of William Wundt believed that studying reaction time differences would help to understand intelligence—mental tests.  Witmer founded the current model of treatment by forming the first psychological clinic & a journal called the Psychological Clinic.  Initial emphasis focused on the youth population of children and adolescents who were unable to functionally adapt to society. The Advancement of the Modern Era (1900-1919)  Binet and Simon developed the Binet-Simon Scale—measures intelligence.  Carl Jung developed testing methods around word-associations and 1910 brought the arrival of the Kent-Rosanoff Free Association Test.  WWI brought the screening of individuals entering the military, marking the movement away from children and youth towards adults. Between the Wars (1920-1939)  By the late 1920’s psychologists had individual and group testing tools at their disposal.  The field of intelligence was being expanded with work by Spearman, Thorndike, Thurstone  Wechsler-Bellevue test—first adult intelligence test; created in 1939 and since then modified & adapted.  Rorschach—inkblot tests that attempted to bring people to reveal their real-life experiences by looking at ambiguous stimuli. He published this in his book Psychodiagnostik.  Projective Techniques—Designed to allow a person to respond to ambiguous stimuli, and reveal hidden emotions and internal conflicts projected by the person into the test.  Thematic Appreciation Test (TAT)—Requires an individual to make up stories reflecting activities, thoughts and feelings of the people in the picture. World War II and Beyond (1940-Present)  More complex tests began to develop. Minnesota Multiple Personality Inventory (MMPI)-self-report test, and unique because no interpretation of scores was needed. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Wechsler Intelligence Scale for Children—Alternative to Stanford-Binet scale.  Clinical psychologists were viewed as experts of psychodiagnosis—use of interpretation of test scores as a basis of diagnosis and treatment.  Different approaches—objective nomothetic approach (empirically tested rules) vs. projective idiographic approach (focused more on the individual and interpretations).  Radical Behaviorism: Only overt behavior can be measured and psychological trait measurement is not useful. It brought the era of behavioral assessment—behaviors were understood in the context of the stimuli or situation in which they occurred.  First DSM appeared in 1952, focused mostly on adult psychopathology and post-war symptoms.  Structured Diagnostic Interviews: Standard list of questions that are used as criteria to assess different disorders.  Health care insurers became more interested in managed health because it controlled and reduced costs and required mental health professionals to be more efficient. Interventions The Beginnings (1850-1899)  Jean Charcot focused on interventions for hysteria using hypnosis  Freud and Breuer collaborated on a patient Anna O’s whose treatment was challenging o Psychoanalysis (most influential theoretical and treatment development for clinical psychology) The Advent of the Modern Era (1900-1919)  1900’s—psychoanalytic movement began with Freud’s publication of The Interpretation of Dreams. o Terms like Oedipus complex, ego, id began part of psychological terminology.  Healey’s establishment of the child guidance center in Chicago in 1909 reflected a movement towards looking at juvenile offenders and not simply learning problems of children. Between the Wars (1920-1939)  Psychoanalytic therapy was viewed as being the sole right of a medical practitioner but psychologists soon began to use it in their work with children (child guidance clinics).  Adler’s emphasis on family relationships instead of sexuality grew prominent with practitioners.  Play Therapy: Release of anxiety or hostility through expressive play (Freudian Principle based).  Behavior Therapy: Encompassing the works of Watson, Jones, Levy and others it focused on conditioning. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 The 1988 Schism  Many critics felt that the APA was being controlled by practitioners that were using it for their own interests; no longer focused on scientific needs.  Plan to reorganize APA so that it lessened the gap between the clinical wing and academic-scientific wing failed by a 2-1 vote of membership.  American Psychological Society (APS)/Association of Psychological Science—focused on the scientific aspect of psychology. First conference held in June 1988. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 3: Current Issues in Clinical Psychology pages 59-92 Models of Training in Clinical Psychology The Scientific-Practitioner Model  Boulder Model/Scientist-Practioner Model: Attempts to marry science and clinical practice and is the most popular model to this day. Skilled practitioners that could produce own research and learn from others research.  In the past, training was not the focus of the field; clinical psychologists focused on research.  The model sought to aid students in thinking like a scientist in whatever activities they engaged in.  1987—Salt Lake City, Utah: Seeking a model that deemphasized research and placed greater emphasis in clinical skills The Doctorate of Psychology Degree (Psy.D.)  Emphasis on the development of clinical competence, de-emphasis on research competence.  Dissertation is about professional subject and not research contribution.  Increasing experience in therapeutic practice (3rd year divergence)  Differences between Psy.D. and Ph.D. o Great Psy.D. acceptance rate o Lower percent receive full financial assistance o Lower percent of faculty with a cognitive-behavioral orientation o Lower percentage obtain internships at top-facilities o Shorter period to complete degree (5.1 years). Professional Schools  No affiliation with universities and they have their own financial and organizational framework.  Free standing or free for profit schools, mostly offer Psy.D. degrees.  There are 45 professional’s schools and they offer over 60% of the clinical psychology doctorates. Greater proportion of doctorates given by professional schools today.  Rely heavily on student-tuition (so expensive) as not fully-funded and have only part- time faculty.  Very rare that professional schools are APA accredited Clinical Scientist-Model  Scientific and clinical psychology is the only acceptable form of clinical psychology Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Focused on building a science of clinical psychology, by integrating scientific principles into their work.  Academy of Psychological Science (1995)—graduate programs and internships focused on empirical methods of research.  Main goals: o Training—clinical science research + scientific knowledge o Research and Theory—advance clinical science research and theory and integration with other sciences. o Application—broad application to human problems o Dissemination—to foster distribution of knowledge to public in a timely manner. Combined Professional-Scientific Training Programs  Combined specialty in counseling, clinical and school psychology; assumes a share core knowledge based for all three areas.  Graduates however may not develop a specific sub-specialty as an expertise for an area.  Better suited to the future practitioner than the future clinical research scientist. Graduate Programs: Past and Future  1960’s: Shift from university based jobs to private practice work.  Vail Training Conference (1973): Alternative training models to meet the needs of future practitioners. Psy.D. degree and professional school model arose from this conference.  As a result of the excessive number of applicants, many graduate students have been unable to acquire an internship position (25%).  Curriculum will place an emphasis on empirically supported psychological intervention and focal assessment. Professional Regulation Certification  Certification and licensure can vary from state to state; but it is a weak form of regulation in most instances.  People can’t call them “psychologists” unless they have been certified; attempts to protect the public by restricting title use.  Does not prevent anyone from offering psychological services to the public as long as the non-certified people don’t use the same title. Licensing  Stronger than certification, provides the title of “psychologist” but also defines what specific activities are offered for the public.  APA developed a model act for licensure of psychologists. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Level 1—Basic Pharmacology Training: knowledge of medication and substances that may be addictive. Recommended: a course on psychopharmacology.  Level 2—Collaborative Practice: Psychopharmacology consultant with knowledge as well as diagnostic assessment skills. Recommended: coursework and practical exposure.  Level 3—Prescription Privileges: Practice independently and prescribe medication. Recommended: Intensive science based coursework, 2 years of graduate training in psychopharmacology and postdoctoral residency in psychopharmacology.  Only Level 3 individuals are qualified to prescribe.  Additional course requirements would make it longer to complete graduate school; prescription privilege programs may thus only be offered at the post-doctoral level. Technological Innovations Telehealth  Delivery and oversight of health services using telecommunication technologies (ex: websites, email, videoconferencing).  Increased accessibility to services, efficiency, reducing stigma. Ambulatory Assessment  Involves assessing the emotions, behaviors and cognitions of individuals as they are interacting with their environment in real time.  Requires very little retrospection of the client (reflection).  More ecologically valid (ex: tracking mood via phone throughout the day).  Multiple assessments on the same client are possible; multiple forms of ambulatory assessment focusing on different response across domains can also be done. Computer-Assisted Therapy  Clients who don’t have access to mental health professionals for face-to-face time or embarrassment may choose to use this method.  If mental health services are accessible through telephone, internet or videoconferencing it could aid those that have lack of accessibility, inconvenience or fear treatment.  Electronic health records can be maintained and clinicians can view clients Web-based homework’s. Culturally Sensitive Mental Health Services  Given the plurality of U.S. culture, mental health services need to serve ethnically diverse populations.  Clinical psychologists must demonstrate cultural competence—knowledge and appreciation of other cultural groups and the skills to deal with other cultures. o Scientific-mindedness Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 o Dynamic sizing; when to generalize vs. when to individualize o Culture specific expertise; have knowledge of the groups that they work with Ethical Standards  1953: Publication of the Ethical Standards of Psychologists  General principles of ethical standards: o Beneficence and non-maleficence (strive to benefit others and do not harm) o Fidelity and responsibility: professional and scientific responsibility to society o Integrity: strive to accurate, honest and truthful o Justice: all people are entitled to access and to benefit from knowledge generated by psychology o Respect for people’s rights and dignity: enact safeguards and protection measures.  Specific ethical standards underlined under APA membership are enforceable rules, the general principles are not. Rule 1: Competence  Clinicians must only provide services within the boundaries of their training.  Clinicians should not provide treatment for assessment procedures of which they have no knowledge.  Tool kits to ensure competence: performance reviews, case presentation reviews, client outcome data. Privacy and Confidentiality  Respect and protect confidentiality of their patients.  Clinicians should be clear about confidentiality and the conditions under which it can be broken.  Tasaroff Case: A 1976 case in which California Supreme Court deemed that therapist was remiss for not informing all parties of the clients intention to harm his girlfriend.  Being aware that confidentiality may need to be broken in certain instances (e.g. child abuse, potential suicide or murder).  Jaffe vs. Redmond: 1996 Supreme Court case that permits communication between licensed mental health professionals and individual adult patients in psychotherapy. Human Relations  Client-Welfare: The best interests of the client and as such this condones relations of a sexual nature, relationships, sexual harassment.  Most common ethical dilemma for psychologists—confidentiality (breach of potential risk due to abuse or other reasons). Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 5—Diagnosis and Classification of Psychological Problems What is Abnormal Behavior?  Psychopathologist: Scientist that studies the cause of mental disorders and the factors that influence its development.  Hard to define abnormal behavior—a. no single descriptive feature is shared by all abnormal behavior, no one criteria are sufficient to define abnormal behavior and b. there is no discrete boundary between abnormal and normal behavior. Definition 1 of Abnormal Psychology: Statistical Infrequency or Violation of Social Norms  Person whose behavior is deviant or non-conforming is likely to be noted as “abnormal”.  Statistical infrequency—difference from the norm in a very low IQ score (ex: score of 64)  Violation of social norms—dressing different from typical girls or women Definition 1: Advantages of the Statistical Infrequency or Violation of Social Norms Definition 1. Cutoff Points: Has cutoff marks that are quantitative (a low score can be compared to the cutoff point). Ex: Used to compare psychological test-scores (above the cutoff is clinically significant). 2. Intuitive Appeal: Behaviors that we consider abnormal would be judged as abnormal by others. Definition 1: Problems of the Statistical Infrequency or Violation of Social Norms Definition 1. Choice of Cutoff Point: Conformity criteria are limited as it is difficult to establish cutoff points. Very few guidelines on how to form cutoff points. Shouldn’t categorize every abnormality as deviant. 2. The Number of Deviations: How many deviant behaviors are needed to earn the label “deviant”? 3. Cultural and Developmental Relativity: What is classified as deviant for one group, is not deviant for another. Also some behaviors that are appropriate at one developmental stage may be inappropriate at another (focus on comparison to same-age peers and not all-peers). a. Reducing cultural practices to the extreme (i.e. subcultures) is too much. Definition 2 of Abnormal Psychology: Subjective Distress  Subjective feelings and sense of well-being of the individual (ex: feeling happy, sad, troubled…). Definition 2: Advantages and Problems of Subjective Distress Definition  Individuals are aware of their emotional experiences and can express them; harder for children.  Labeling someone as maladjusted only works if their behavior is specified and their behavioral manifestations are stated.  How much subjective distress is needed to be defined as “abnormal”? Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Categories Versus Dimensions—Is present vs. absent appropriate or is a dimensional model better?  Based on symptoms a patient is placed within a category.  Easy to confuse categorization with explanation  Abnormal behavior is not different from normal behavior but it falls along a dimension (degree).  Category implies an all-or-nothing approach (present vs. absent) instead of using a dimension. Bases of Categorization—Should there be multiple ways to make a diagnosis? Does this create too much heterogeneity within the diagnostic category?  Diagnostic measures may be complicated requiring the clinician to know a wide variety of techniques.  Membership in any one area is most likely going to be heterogeneous because there is multiple basis for diagnosis. Pragmatics of Categorization—How do we decide if a condition is included in the diagnostic manual?  Homosexuality was dropped from the DSM and regarded as a lifestyle (dropping from DSM was done through a psychiatric membership vote).  DSM is crafted by committees. Members are from different backgrounds and constituencies. Description—Are diagnostic category features properly described? Are diagnostic criteria specific and objective?  DSM-IV provides detailed information for Axis I and II. Also provides information about each diagnosis including age of onset, course, prevalence, complications, family patterns…these features enhance reliability and validity. Reliability—Are diagnostic judgements reliable & can different clinicians agree on a diagnosis?  Refers to the consistency of diagnosis across raters; DSM III—specific criteria attempted to increase reliability of diagnosis.  Developed structured diagnostic interviews that push clinicians to use specific DSM criteria; this had led to greater reliability.  Even with structured interviews, reliability is not guaranteed (e.g. generalized anxiety disorder). Validity—Can we make meaningful predictions based on our knowledge of an individual’s diagnosis?  If clinicians fail to agree on proper classification of patients then it can’t be demonstrated that the classification system has meaningful correlates or has validity.  Establishing validity of a diagnostic criteria involves 5 steps (Robbins & Guze): o Clinical description and features beyond the disorders symptoms (ex: demographic). o Laboratory studies—identify meaningful correlates of the diagnosis (ex: psych tests) o Delimitation from other disorders—homogeneity among clinicians o Follow-up studies—assess test-retest validity of diagnosis o Family studies—determine if the disorder runs in the family. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Bias—Are DSM features biased due to gender, race, SES background? Are clinicians biased in their interpretations or application of the diagnostic criteria?  The DSM system would be called into question if the same cluster of behaviors resulted in a diagnosis for one individual but not for another.  Two areas of most bias—sex bias and race bias  DSM has been regarded as a male centered system that overestimates pathology in females.  For some diagnosis biological/cultural factors may influence which gender is diagnosed more (ex: antisocial personality disorder is more common in men).  Clinicians may however be biased in the way they apply the diagnosis; but it does not indicate sex bias within the diagnostic criteria.  Culture may influence diagnosis & treatment factors, “culture bound syndromes” (ex: koro, voodoo death) and if a patient decides to seek treatment or not. Coverage—Does the DSM criteria apply to people that present with psychological or psychiatric treatment? Is the DSM too narrow or too broad in coverage?  DSM-IV-TR has very descriptive and detailed diagnosis, but some feel that it may be too broad. o Ex: childhood developmental disorders (i.e. dyslexia…) being labelled as mental disorder  Other diagnosis: “premenstrual dysphoric disorder”—may be used against women. Additional Concerns  Mental disorders use terms like disorder, symptom, condition, and suffers from make it seem like the person has a disease.  Diagnosis can be stigmatizing to the labeled individual and it is also why people do not seek treatment.  Observers see the label not the person (ex: can damage relations, employment opportunity). The Diathesis-Stress Model  Diathesis: Vulnerability or predisposition to develop a disorder (can be biological or psychological). o Necessary but not sufficient for a disorder; added component is stress.  Stress can be environmental (ex: abuse), biological (ex: poor nutrition), interpersonal (ex: bad marriage) or psychological (ex: bad family environment).  Diathesis can influence perception of stress (one event can be more stressful for someone than another).  Diathesis also influences person’s own life course and choice experiences.  Both Diathesis + Stress is needed disorder o High diathesis and high-moderate stress level greater likelihood of disorder. Value of Classification  Categorization allow us to generalize and predict  DSM has been accused of being used more by clinical research than clinical practice. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 6: The Assessment Interview pages 160-188 Assessment in Clinical Psychology  1960’s and 1970’s—Decline in assessment measures and focus more on therapy.  Clinical Assessment: Evaluation of an individual or family’s strengths and weaknesses, conceptualization of the problem and prescription for alleviating it.  Our capacity to understand a problem is based on our skill to diagnose it (diagnose before treatment).  Referral Question: Take into consideration what question was asked by the referral source and what the referral source is seeking. (e.g. from parent, teacher, psychologist). What Influences How the Clinician Addresses the Referral Question?  The type of information asked is often based on the clinician’s theoretical approach (ex: psychodynamic clinician may ask about childhood experiences but a behavioral clinician may ask about daily life).  Assessment Interview: Most basic and serviceable data gathering tools. It has a wide range of application and adaptability, but this again depends on the clinician’s skills. General Characteristics of Interview An Interaction  Interaction between at least 2 people in which each person contributes to the process and influences the other’s response.  Involves face-to-face interaction but the conversation is based on a specific set of goals in mind.  One characteristic that interviews have that conversation does not—the interexchange is not based on personal satisfaction or prestige (used to gather data and information). Interviews Versus Tests  More purposeful but less formalized than standardized psychological tests.  Psychological tests—collection of data under standardized conditions using structured procedures.  Interviews can use an individualized approach and are more flexible. The Art of Interviewing  Except for diagnostic interviews have a degree of freedom to their structure.  Clinician slowly learns to respond to patients cues over time. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 The Clinician’s Values and Background  Clinicians must examine their own assumptions before making judgements about others; some misconceptions may essentially be a part of the other person’s culture.  Gender differences or different frame-of-references can sometimes elicit the same response of disconnect from the patient. The Patients and Clinicians Frame of Reference  Being sensitive to the patient’s initial perceptions and expectations in necessary to establish rapport.  The clinician needs to be prepared and should know everything there is to know about that patient before the first meeting. o The clinicians should also be clear about the purpose of the interview, and clear about the nature of what is required if it is for a referral. Varieties of Interviews  Interviews first differ in terms of purpose, and second in terms of whether it is unstructured (clinical interview) or structured.  Unstructured Interview: Clinicians are allowed to ask any questions that come to mind in any order.  Structured Interview: Verbatim set of standardized questions in a specific sequence. The Intake-Admission Interview  Helps determine why the patient has come to the hospital or clinic and judge whether the facilities resources will meet the patients’ needs and expectations.  Conducted by a psychiatric social worker.  Can be done face to face or via phone.  Informs patients of clinicians fees, policies, procedures. The Case-History Interview  A complete personal and social history is taken—concrete facts and dates and a patient’s feelings about them.  Broad history and context in which the patient and problem can be placed.  Gathering historical-developmental context so that diagnostic significance and implications can be determined.  Can also use outside sources (e.g. parents, teachers, peers). Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 The Mental Status Examination Interview  Conducted to assess cognitive, emotional and behavioral problems.  Very unreliable because they are unstructured in nature.  One of the primary modes of assessment for a variety of mental health issues. The Crisis Interview  Hotline interviews for people fearful of abusing their children or abusing drugs.  Rules of interviewing are blurred but the basics remain.  Purpose is to meet the problem as it occurs and provide immediate resource of relief. The Diagnostic Interview  Evaluation against DSM-IV criteria; historically it used a free form unstructured interview.  Structured diagnostic interviews: Standard set of questions and follow up questions in a specific sequence. Allows for greater inter-rater reliability.  Very few clinicians used these structured interviews in daily life (only 15%). Reliability and Validity of Interviews  Interrater Reliability: Level of agreement between two raters who evaluate the same patient. Quantified using the kappa coefficient or the intraclass correlation coefficient.  Kappa Coefficient: To determine how reliable rater judge the presence or absence of a feature of a diagnosis. Between .75 and 1.00 *best inter-rater agreement level.  Validity concerns how well an interview measures what it intends to measure.  Predictive validity: Scores from a measure, correlated (“predicted”) future events relevant to that construct. Reliability  Structured interviews are more reliable than unstructured (reduce information and criterion variance)  Information Variance: Variation in the questions that clinicians ask, observations made and the method integrating that information.  Criterion Variance: Variation in the scoring threshold among clinicians. Clear cut scoring criteria is better.  DSM-III and structured interviews to assess DSM criteria made diagnostic interviews more reliable.  Test-Retest Reliability: Consistency of scores or diagnosis across time (retaken). o Goes down over longer time periods—years or months. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Validity  Content Validity: Measures comprehensiveness in assessing the variable of interest (does it measure all areas of the construct of interest).  Criterion-Related Validity: Ability of a measure to predict (correlate with) scores on other relevant measures.  Concurrent Validity: Type of criterion-related validity. Extent to which interview scores correlate with scores on other relevant measures given at the same time.  Predictive Validity: Type of criterion-related validity. Extent to which interview scores correlate with scores on other relevant measures, at some point in the future.  Discriminant Validity: Extent to which interview scores do not correlate with measures that are not theoretically related to the construct being measured. E.g. no reason phobia of spiders should relate to intelligence.  Construct Validity: Extent to which interview scores demonstrates all aspects of validity. Suggestions for Improving Reliability and Validity  Use a structured interview, or consider developing one.  Interview skills that are essential: establish rapport, being a good communicator, listener, knowing when to remain silent and ask questions, observe verbal and non-verbal cues.  Be aware of patients motives and expectations for the interview.  Be aware of your own (clinicians) expectations, biases and cultural values. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Sternberg’s Triarchic Theory of Intelligence  People function on the basis of three aspects of intelligence: componential, experiential and contextual.  Emphasis on planning responses and monitoring them and de-emphasis on speed & accuracy.  Componential: Analytical thinking (good test-taker)  Experiential: Creative thinking (combine separate elements of experience  Contextual: “street smart”—practical, can play the game and manipulate the environment. Today’s Focus—More on Spearman + Thurstone Contributions  Focus is largely still on a single IQ or Spearman’s g.  Current intelligence tests are made up of subtest scores (Thurstone factors). The IQ: It’s Meaning and It’s Correlates—The Intelligence Quotient (IQ) Ratio IQ  Mental Age (MA): Index of mental performance (X items passed)  Chronological Age (CA): Individual’s given age  IQ: Used to overcome differences cause by CA and MA to express deviance  IQ= MA/CA x 100  IQ measurement is not one of equal-interval measurement and we can’t add & subtract (so IQ of 100 is not twice IQ of 50). Deviation IQ  Ratio IQ is limited and not fully applicable to older age groups.  Compares an individual’s performance on IQ test with his/her same age peers .  Same IQ has a different meaning for different ages (ex: same IQ for 22 year vs. 80 year old). Correlates of the IQ: School Success, Occupational Status and Success, Demographic Group Differences  School o General IQ shows success in school and specific tests measure what area. o IQ scores + grades correlation—.50  Occupation o Based on educational level acquired (income, race, prestige…) o IQ also good predictors of job performance  Demographic Group o Differences between sexes for specific abilities; males on spatial and quantitative ability and females on verbal ability. o Hispanic & African Americans have lower IQ scores than North or European Americans. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Heredity and Stability of Intelligence  Intelligence is influenced by genetic factors (behavioral genetics)  Similarity in intelligence is a result of the amount of genetic material shared (monozygotic more similar than dizygotic twins or siblings).  IQ variance associated with genetics varies from 30% to 80%.  Environment plays a role—biological relatives raised together are more similar.  Heritability of intelligence is not stable; 20% in infancy and 60% in young adults, 80% in old age. Stability of IQ Scores and the Flynn Effect  IQ Scores tend to be less stable for children and more stable for adults and more influenced at a younger age for children than for adults (i.e. environment).  Flynn Effect: From 1972 onwards Americans IQ scores on average have increased 3 points each decade. The Clinical Assessment of Intelligence Scale 1: The Stanford-Binet Scales Stanford-Binet 1972 revised test kit version followed a fourth revision in 1986 and the most recent revision in 2003—Stanford-Binet Fifth Edition (SB-5) Description:  Hierarchical Model of Intelligence; 5 factors that tap non-verbal & verbal abilities. 1. Fluid Reasoning: Ability to solve new problems. Measured by sub-tests a. Quantitative Reasoning, Visual-Spatial Processing, Working Memory and Knowledge  Each sub-test is made up of items of varying difficulty (age 2-adulthood)  Multistage Testing: Two routing subtests the Object-Series Matrices and Vocabulary subtest o Routing: Examinee’s performance on these two sub-tests determine which item to start with for each remaining subtest. Standardization and Reliability and Validity:  Included 4,800 participants aged 2-96 years old; participants were tested using various areas.  SB-5 administered to individuals with disability, mental retardation to ensure utility of scores.  Comparing Stanford-Binet to other scales like Wechsler Scales; the scale has strong validity. The Clinical Assessment of Intelligence Scale 2: The Wechsler Scales  Wechsler-Bellevue Intelligence Scale; developed to correct flaws in Stanford-Binet Scale.  Test was designed for adults and items were groups into subtests not according to age level.  Used a deviation IQ concept; intelligence is normally distributed, compare with same-age peers. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 The WAIS-IV Description:  1955—Wechsler-Adult Intelligence Scale (WAIS); revised version 1981 (WAIS-R).  1997—(WAIS-III); and most recent version 2008 (WAIS-IV)  Inclusion of reversal items in the subtests introduced first in WAIS-III o Two examinee’s both begin with the same base items then based on performance subsequent items are presented in reverse sequence until a perfect score on two consecutive items is obtained.  WAIS-IV—provided Index scores in addition to the Full Scale IQ Scores. Obtaining the Full Scale IQ Score and Index Scores + Standardization:  Raw scores converted to standardized scores for a given age group.  Full IQ Score and Index score—adding scale scores of each subtest and converting sums to IQ equivalents. Reliability and Validity  Scores from previous WAIS-III and WISC-IV are strongly correlated with WAIS-IV scores (good).  Over relying on global IQ scores can thus be misleading (Full Scale IQ) The Wechsler Intelligence Scale for Children (WISC-IV)—Description and Standardization  1949—WIC; multiple revisions since then and the latest version WISC-IV was published in 2003.  Used to test children age 6-16 years old; has 10 core and 5 sub-tests. A reduced version of WAIS.  Individual subtests define 4 major indices and make up the Full Scale IQ (*see pg. 212). o Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PCI), Working Memory Index (WCI), The Processing Speed Index (PSI) The Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III)  1967—WPPSCI developed; a revised version since then and the latest WPPSI-III in 2002.  Similar to the WISC-IV but targeted towards youth; so children below the age of 6.  Only 3 indices—Full Scale IQ, Verbal IQ and Performance IQ; addition of PSI for age 4+; but also has several subset scales specific for children only. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 2 Construct Validity Approach  Scales are developed to measure specific constructs from a theory (personality). Validation is obtained when the scale measures the theoretical construct.  The most desirable and labor-intensive approach Description of MMPI  Uses the Keying Approach; Hathaway & McKinley wanted to identify psychiatric diagnoses of individuals. Originally designed for ages 16+, but was also used with younger individuals.  Given to both clinical and non-clinical population.  550 items that were answered T/F or “can’t say”. Only items that differentiated clinical from non-clinical individuals (ex: depressed individuals vs. non-clinical individuals) were included. Description of MMPI-2  MMPI originally overemphasized the U.S. population and lacked diversity; this was changed.  Language was changed to be modern, & 154 new items were added bringing total to 704 items.  Lower age range—can be used with at least 13 year olds or those with 8th grade education level.  Versions in multiple languages are available & an adolescent version MMPI-A is also available. Validity Scales  As MMPI & MMPI-2 as self-report measures they are susceptible to distortion due to attitudes.  To detect “faking-bad” behavior the MMPI & MMPI-2 incorporates 4 validity scales: o Cannot Say Scale—items left unanswered o F(Infrequency) Scale—tendency to exaggerate one’s problems/ symptoms o L (Lie) Scale—attempts to present oneself favorably o K (Defensiveness) Scale—attempts to present oneself favorably  “Added” MMPI-2: o Fb (Back-page Infrequency) Scale—tendency to exaggerate one’s problem’s/symptoms o VRIN (Variable Response Inconsistency) Scale—random responding or T/F to most items o TRIN (True Response Inconsistency) Scale—random responding or T/F to most items Short Forms and Interpretation Through Patterns (Profile Analysis)  Shortened versions of the MMPI & MMPI-2; but loss of interpretation is present and intense scrutiny should be present in terms of whether these and reliable and valid measures.  MMPI—interpretation on elevated scale scores (ex: high Sc score schizophrenia).  MMPI-2—interpretation of “pattern or profile” test scores Interpretation Through Content and Supplementary Scales  Shift from clinical use of MMPI & MMPI-2—away from use of differential psychiatric diagnosis based on a single score to a more sophisticated profile analysis of scale scores.  MMPI-2: Content scales have been developed (ex: identify health concerns, identity fears…)  Supplementary Scales: 450 MMPI scales ranging from Dominance to Success in Basketball! MMPI-2 there are 20 supplementary scales (ex: Anxiety, Strength, Social Responsibility). Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 3 A Summary Evaluation of the MMPI and MMPI-2 Screening and The Question of Personality Traits  MMPI-2 useful for information about mental disorder diagnosis in terms of severity and hypothesis generator.  Not useful for a screening specific disorders (ex: depression) as very long + time intensive.  Atheoretical: MMPI measures symptoms of psychopathology. Not useful for understanding general personality traits and situational determinants. Reliability and Validity of MMPI-2  Lacks internal consistency but do show good test-retest reliability.  Strong validity with external correlates—emotional states, stress reactivity.  2 aspects of validity for MMPI-2 (Butcher et al., 1995)—incremental validity & cut-off scores. o Incremental Validity: If a scale’s score provides information about a person’s personality features, behavior or psychopathology that is not provided by other measures  All psychological tests including MMPI-2 lack incremental validity. o Cut-off scores validity: Varies on the nature of the sample population (which patients have or don’t have the disorder).  MMPI-2 cut off T score of 65+ may or may not be appropriate. Personnel Selection and Bias  Empirical Criterion Keying approach limits usage of MMPI-2 to those that understand it.  May not be appropriate to use MMPI-2 to screen candidates for employment hiring (invasion of privacy into religious beliefs, sexual orientation).  MMPI original—may be biased against ethnic groups. Test Bias means that different predictions are made for two groups even when they receive the same score. Concerns about the MMPI-2  The normative sample is too education; individuals without college degrees not represented.  Criteria for inclusion of “normal respondents” is confusing.  Those who are administered both versions of the MMPI show different results on each version.  Scores on MMPI-2 are lower than the MMPI  Internal consistency of the MMPI-2 Scale is low Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 4 The Revised NEO-Personality Inventory (NEO-PI-R) Description  Self-report personality inventory that is made up of the Five-Factor Model (FFM)  OCEAN (Openness to Experience, Consciousness, Extraversion, Agreeableness, Neuroticism). o There are 6 subscales/facet scales for each FFM  The 240 items are rated on a scale (strongly disagree, disagree, neural, agree, strongly agree)  Original Version (Costa & McCrae) looked at only Neuroticism, Extraversion and Openness.  Half of the items are reverse scored—lower scores are more indicative of a trait. Norms and Reliability & Stability, Factor Structure  U.S. Census for distribution of age and racial groups as well as college students.  Excellent internal consistency and test-retest reliability (for periods as long as 6 years later).  Factor analysis have supported the NEO-PI-R five-factor-model structure. Clinical Applications, Alternative Forms of the NEO-PI-R  Axis II (Personality Problems), application to the NEO-PI-R makes sense.  The NEO-PI-R and related FFM can be used for clinical assessment related to Axis I & II disorders.  60 question NEO Five Factor Inventory (NEO-FFI); but has no facet scales. There is also Form R. Limitations of the NEO-PI-R  Lack of validity scales, has no items to assess response patterns and test taking approach.  May not be good for clinical diagnosis because it was based of a “normal” personality Nature of Projective Tests  Projective techniques: First developed by Rorschach in 1921, uses inkblots as a method of differential diagnosis for psychopathology. Characterized as a person’s modes of behavior by observing their behavior in response to a situation that does not elicit a particular response.  Characteristics include: 1. Examinees are forced to impose their own structure and reveal something of themselves when responding to ambiguous stimuli 2. Stimulus material is unstructured (supposed to be ambiguous without a clear answer). 3. Method is indirect—examinees are not aware of the purpose of the test. 4. There is freedom in response—allows a range of responses 5. Response interpretation deals with more variables—allows for interpretation along multiple dimensions. Standardization of Projective Tests, Reliability and Validity  If they were standardized it would allow for communication & checks against biases.  Other’s ague that project tests can’t be standardized because each person is unique.  Test-retest reliability may change with participants over time, but even split-half reliability is difficult to demonstrate in projective tests.  Validity needs to ask specific questions: Does the TAT predict aggression in situation A? Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 7 Use and Abuse of Testing: Protections, The Question of Privacy  Clinicians should use only assessments that lie within their competence (only then can they acquire tests).  The examinee or individual has a right to full explanation of how their responses & results will be used. Informed consent must thus be obtained.  Must only be given tests relevant to the evaluation and reason for test must be provided. Use and Abuse of Testing: The Question of Confidentiality & The Question of Discrimination  There are cases in which confidential matters must be disclosed (i.e. Tarasoff case). If the person is going to harm themselves or others, then information can’t be privileged.  Tests might discriminate against minorities (only include White-middle class populations) or include only certain population members (ex: TAT only white members in cards) Use and Abuse of Testing: Test Bias  This is a validity issue (i.e. criterion or performance varies significantly across groups). That it is more accurate for one group than another. o Using traits characteristic for one group (ex: men) but not the other group (ex: women).  Differences in mean scores does not mean bias, and bias can be overcome. The Use and Abuse of Testing: Computer-Based Assessment  Used to standardize tests, interpret responses, cut costs, increase clients attention.  Internet based psychological testing may lack qualities of traditional testing—less reliable, valid, lack of control over testing situation, technological issues, cultural differences in test interpretation.  Computer Based Test Interpretation (CBTI’s): Generate quick responses and processing complex scores, but they must result in inaccurate interpretations of results.  CBTI’s must be clinically useful (should aid in clinical understanding and treatment), valid (accurate interpretations) and reliable (interpretations should be similar for similar scores). Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 9: Behavioral Assessment pages 255-282 The Behavioral Tradition Sample vs. Sign  Behavioral Assessment: Assessment that focuses on the interaction between situations and behaviors for the purposes of creating behavioral change.  Focus on how well assessment device samples the behaviors and situations  Sample orientation: Parallels how a person behaves in a situation; as in a test.  Sign orientation: Inference about performance is indicative of some other characteristic.  Traditional research has used a sign as opposed to sample orientation. But behavioral research sample approach is used. Functional Analysis  Exact analysis is made of the stimuli that precede a behavior and the consequences that occur from it.  Behaviors are learnt and maintained as a result of consequences that follow them. Identify stimulus that occurs beforehand and determine reinforcements that follow, to elicit change.  Behaviors that are monitored must be recorded in observable, measurable terms.  Antecedent Conditions: Stimulus conditions that lead up to the behavior of interest.  Consequent Events: Outcomes or events that follow the behavior of interest o E.g. lack of attention (stimulus) taking pencil from another child (behavior) attention (consequence).  Organismic Variables: Physical, physiological or cognitive factors of the individual that are important to determine the client’s problem.  SORC Model—Used to conceptualize a client’s problem o S—Stimulus or antecedent conditions that bring on a problem o O—organic variables related to the problem o R—response or problematic behavior o C—consequences of the problematic behavior Behavioral Assessment as an Ongoing Process  Behavioral assessment is an ongoing process that occurs before, during and after treatment.  Diagnostic formulations—potential targets for intervention  Patients context or environment—social support, physical environment, evaluation of skills.  Initial understand of client’s behaviors, resources will lead to a treatment plan. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Treatment includes collaboration between therapist and client and feedback will lead to adjustment of treatment. Behavioral Interviews Behavioral interview allows therapist to assess the client’s “hope” for end results.  Ultimate Outcomes: Happiness, life satisfaction, making the world better.  Behavioral Interviews: Clinician attempts to make sense of the problem and of the variables that seem to maintain the problem.  Basic goal is to identify the problem behaviors, situational factors that maintain those behaviors and consequences that result from the problem. Naturalistic Observation  Observing individuals in their natural environment, will enable a clinician to better understand the problem.  Observation in a natural environment has limitations and is easier for children than adults who may be outpatients.  Clinicians need to ensure that clients are not observed without their knowledge or that family members are not drawn into the observation net—do not compromise privacy.  Due to the cumbersome nature of it, clinicians prefer to use traditional assessment.  Examples: o Home Observation (Family mealtime routines) o School Observation (school classroom, playground). Rate frequency, duration and intensity. o Hospital Observation (mental retardation; open environments)  Unfiltered observation not contaminated by extraneous variables. Controlled Observation or Analogue Behavioral Observation  Clinicians can exert certain amount of control over the events being observed, may be better in situations where behavior does not occur very often on its own.  The environment is “designed” for the clinician to observe the behavior occurring.  Situational Tests: Place individuals in situations similar to real life and observe how people behave. Controlled Performance Techniques  Assessment procedure in which the clinician palces individuals in a controlled performance situation and collects data on their reaction, performance and behavior.  Approaches include: o Behavioral Avoidance Tasks (Total number of steps/tasks completed) o Fear Arousal Accompanying Responses (Total fear or distress ratings) Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Cognitive-Behavioral Assessment  Cognitions relate to the development of pathological situation, its maintenance and changes.  Notion that client’s thoughts play a vital role in behavior.  Cognitive Functional Approach: Functional analysis of the client’s thinking process must be made to plan an intervention strategy. What underlying cognitions are aiding with lack of performance, and under what circumstances?  E.g.-think out loud, verbalize thoughts. Strengths and Weaknesses of Behavioral Assessments  Behavioral assessors specify the behaviors targeted for intervention, treatments are provided before, after and during treatment and on this basis are modified as such.  Behavioral assessment like natural observation is time intensive and expensive.  Behavioral assessors now widely use DSM criteria to diagnose disorders. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 11—Psychological Interventions (Pg. 311-340) Intervention Defined  Psychological Intervention: A method of inducing change in a person’s behavior, thoughts or feelings. Intervention in the context of a professional relationship (client-patient).  In referring to treatment the terms intervention and psychotherapy have been used interchangeably.  Woolberg (1967): symptoms and treatment, promoting positive growth (type of medical def.)  Rotter (1971) and Frank (1982) pose different definitions using terms like—interaction between a healer and sufferer, reliving of distress & disability, personal growth. Does Psychotherapy Help?  Need to address both the efficacy of a treatment and the effectiveness of a treatment.  Efficacy Studies: Average person receiving treatment is demonstrated to be less dysfunctional than the person not receiving treatment. o Take place in a research lab/university clinic (focus on internal validity)  Effectiveness Studies: Focus on external validity and the representativeness of the treatment in the “real-world”. May not include control groups or random assignment; focus is on whether a client receiving treatment as it is typically administered reports significant relief/benefits. Evidence Based Treatment and Evidence Based Practice  Focus on whether clinical evidence-based treatments (psychotherapy vs. no treatment) are more effective than other therapies.  Evidence-Based Treatment (EBT): Refers to treatments/interventions that have produced significant changes in clients/patients in controlled trials. o Treatment vs. control group (comes solely from controlled clinical trials)  Evidence-Based Practice (EBP): Broader practice that includes treatment informed by various sources.  Society of Clinical Psychology (sub-division of the APA) developed specific criteria to evaluation different approaches to therapy/intervention treatments.  Referred to as “evidence-based treatments” these criteria addresses whether certain therapy mechanisms may be useful in reducing mental health symptoms. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Features Common to Many Therapies  Supportive factors—positive relationship, trust lay the groundwork for change in person’s beliefs & attitudes (learning factors)  lead to behavioral change (action factors—mastery, risk taking. Relationship/Therapeutic Alliance & The Expert Role - Client-therapist relationship is important for successful psychotherapy (accepting, non- judgmental, insightful and professional) - Therapists are also expected to be competent as a result of training, knowledge and experience. Building Competency/Mastery - Help the client be a more competent human, greater satisfaction. Therapist may work with client to help them learn new things or alter their faulty ways of thinking. - It can be a learning experience; develop feelings of self-efficacy in the individual. - Mastery—confident, expect to do well and feel good about themselves; will function better. Non-Specific Factors - Faith, Hope or expectations for increased competence; individuals come to therapy believing that it will help promote mental health. - The expectations of the client are vital to the therapy process. Nature of Specific Therapeutic Variables The Patient or Client The Degree of the Patient’s Distress  Therapists generalization is that people that need therapy the least are ones that will benefit most from it.  Research data on this has been inconsistent—greater individual distress greater improvement, vice-versa and curvilinear (of finding poorer outcomes). Intelligence  Communicating with a patient about past experiences, insight & introspection requires some level of intelligence.  Behavioral therapy has been successfully used with individuals with different intelligence levels. Age  Young adults are viewed as being better for therapy than older adults (more flexible)  Considering the specific characteristics of the patient and not age alone is important. Motivation  In Psychotherapy most of the work occurs outside therapy though homework and between therapy sessions. Need to engage in anxiety provoking “new behaviors” (i.e. Albert Ellis)  Psychotherapy is a voluntary process & can’t be forced on a patient  Varied findings on how to best assess client motivation. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Therapists need to recognize that not all individuals are ready to make change; the action stage is where administered treatment is most likely to have an effect.  As certain processes match certain stages, therapists should only use interventions specific to that stage. Issues in Psychotherapy Research  Hans Eysenck attacked the efficacy of psychotherapy, but many have criticized his work for its validity as he did not match participants in the treatment vs. control groups.  Studies that seek to understand the efficacy of psychotherapy use an experimental design with a control group and a treatment/experimental group.  Waiting List Control Group: Treatment is delayed until after study is completed  Attention Only Control Group: Patient meets regularly with a therapist, but there is no treatment o Matched on age, race, gender, severity of symptoms (factors that could influence outcome)  Patient Functioning: Symptoms of psychopathology Research Considerations 1. What is the sample? —ex: voluntary or coerced patients, were the therapist’s behaviors or psychoanalysts 2. What relevant variables were controlled? Ex: --control vs. treatment group variables. 3. What were the outcome measures? —were outcomes measured identically for all patients or were they tailored? Was a single measure used or were there multiple measures? 4. What was the overall nature of the study? (experiments, case studies, correlational studies…) Comparative Studies Studies comparing efficacy techniques and not only looking at outcomes. The Temple University Study  The study comparing 90 outpatients with neurotic symptoms concluded that patients that received Behavior Therapy (BT) did the best in the long-term  Those who obtained Psychoanalytic therapy (PT) improved equally as well as the BT Group; but those in the BT Group showed slightly more improvement; flexibility & versatility of Behavioral therapy. Meta-Analysis  A method of research that complies all studies relevant to a topic or question and combines the results statistically.  Effect size: The size of the treatment effect Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Process Research  Refers to research that investigates the specific events that occur in the course of the interaction between therapist & patient. (Rogerians)  Some therapy processes have been shown to relate to treatment outcome.  Therapy investigators either looked at process research or outcome research.  Process therapy researchers felt that the process that was used during therapy related to the outcome that occurred (film/tape therapy sessions).  Factors that influence relationship between therapeutic process and outcome o Client-therapist communication o Therapist competence and adhere to treatment protocol o Therapist use of guidance and advice not related to outcome Recent Trends Focus of Psychotherapy Research  Specific factors (motivation, SES) that are related to higher efficacy and effectiveness  What aspects of specific therapy mechanisms (e.g. CBT therapy) are most important for the therapy outcome.  Focus on types of therapies that work for each specific diagnosis. Practice Guidelines  Clinical psychologists are being held accountable for the services they provide by insurance companies.  Several professional organizations have developed practice guidelines that recommend specific forms of treatment/intervention for specific psychological problems. Manualized Treatment  Treatment manuals were originally developed to ensure standardized treatment across patients.  Manualized treatment has been criticized for undermining clinical judgement, treatment not being tailored to patients with comorbid conditions.  Manualized treatment is more focused and, easier to teach and supervise and more focused from the patient’s perspective and are far more appealing to managed care companies. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 12—Psychotherapy: The Psychodynamic Perspective (Pg. 343-366) Psychoanalysis: The Beginnings  Focus is on unconscious motives and conflicts in the search for roots of behavior.  Freud was influenced by Jean Charcot (famous work on hysterics), and his use of hypnosis. The Case of Anna O.  Josef Bruer’s work with Anna O’s, patient with severe hysteria led Freud to develop his initial theories on catharsis, transference and moral anxiety.  Freud over time asked patients to simply talk about whatever came to their minds; this method led to the development of a concept known as free association. The Freudian View: A Brief Review  Psychic Determinism: Everything we do has meaning and purpose and is goal-directed.  To account for different aspects of behavior Freud also assumed the existence of unconscious motivation. o A person understands motivation for healthy behavior; the causes of disturbed behavior are unconscious; so to treat these they need to be made conscious. The Instincts  Life energy is provided by the life instincts/Eros and the death instinct/Thanatos.  Life instincts: All positive aspects of behavior—thirst, sex, hunger, creative aspects (ex: music)  Death instincts: Self-destructive behavior; Freud believed all behavior was instinctual. Personality Structures—The Id, Ego and Superego (Iceberg)  Id: Deep inaccessible part of the personality. Instinctual gratification urges that need to be immediately met (access is gained via dreams & neurotic behavior; has no value, logic or ethics). o Pleasure Principle: One seeks to obtain pleasure and avoid pain. Discharge tension. Uses the primary process (ex: dreaming)  Ego: Organized, rational system that uses perception, learning and memory to gain satisfaction. o Reality Principle: Attempts to delay gratification of the Id until a suitable mode & object are identified. Uses secondary process (ex: learning, memory, planning). o The Ego balances the demands of the Id and the Superego (provide satisfaction/prevent from being killed).  Superego: Develops during childhood from the Ego. Ideas and values of society as conveyed by parents as well as rewards and punishments. Its goal is to block extreme impulses of the Id o Oedipus Complex—Child’s sexual attraction to the parent of the opposite sex. o Ego Ideal—Reward (pride + worth)/Conscience—Punishment (guilt +worthlessness) Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Transference  When a patient reacts to a therapist as if they were some important figure that is part of the patient’s childhood.  The conflicts that were present during childhood are voiced in therapy and transference provides the therapist with important clues. o Encourage transference—sitting on the couch, away from therapist, no advice given.  Transference can be both positive and negative—ex: direct admiration, love, anger, comments about the therapy room, attack on the therapist.  Both positive and negative transference are forms of resistance. Interpretation  The method by which the therapist reveals patient’s unconscious thoughts or feelings.  Allows patients to view their thoughts, feelings. This is a slow repetitive process.  Interpretations are limited to important life areas that relate directly to patient’s problem.  It should be offered when it arouses enough anxiety in the patient for serious consideration but not when too much anxiety is present or else the patient may reject it.  Small doses of interpretation over time are best. Psychoanalytic Alternatives  Psychoanalytic theory was also influenced by Alfred Adler, Carl Jung & other neo-Freudians.  The neurotic symptoms were now seen as being rooted not only in sexual or aggressive urges but it was now being associated with the fear of being alone/adult insecurity.  How interpretation occurred and by whom was different (family, spouse, friends…) Ego Analysis  Origination from traditional psychoanalysis, this theory held that there was an overemphasis on unconscious and instinctual determinants that occurred at the expense of the ego process.  Conflict-free functions of the ego—memory, learning, perception; apart from mediating demands between the Id & the real world.  Focus on contemporary problems in living than examination of the past. Contemporary Psychodynamic Psychotherapy  Those who no longer practice the Freudian techniques are said to practice “psychoanalytically oriented” therapy or psychodynamic psychotherapy.  May involve only one or two vs. five sessions in one week, short-term treatment or can be open-ended.  Greater flexibility has been introduced. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Interpersonal Psychotherapy: An Empirically Supported Treatment (Form of Psychodynamic)  Interpersonal Psychotherapy (IPT): Brief, insight oriented approach mainly used for depressive disorders.  Involves through assessment of depressive symptoms, targeted intervention and reducing symptoms by improving relations with others. Does Psychodynamic Psychotherapy Work?  Support for psychodynamic psychotherapy work with children and adolescents is not promising. The findings for adults are slightly more supportive.  For those studies showing support criticisms include: poor quality meta-analysis studies, poor methods and the failure to specify the effects of psychodynamic therapy for a disorder.  There is slight support for psychodynamic therapy for major depressive disorder, panic disorder, bipolar disorder and substance abuse & dependence. Interpretation and Insight  Psychotherapeutic treatment and psychoanalysis use of insight into solving problems is its greatest asset but can also cause problems (ex: too much examination of the past).  Learning specifics behind their problems may help in the short-term but a failure to emphasize alternative ways of behaving may be a shortcoming of psychoanalysis.  Psychoanalysis assumes that insight behavioral change; but others have argued that it is behavioral change insight. Curative Factors  Positive outcomes in psychodynamic psychotherapy depend of client-therapist alliance in terms of quality & strength.  Therapeutic alliance: Refers to patient’s affective bond to the therapist. o Allows for self-examination by the patient and allows for interpretation. The Lack of Emphasis on Behavior  Psychoanalysis engages in interpretation but fails to deal with behavior.  A therapist that engages in interpretation but also guides the patient in learning situations will be more effective than one who relies solely on insight.  This may be linked to rise of behavioral therapist; psychoanalysis does not focus on behavior. The Economics of Psychotherapy  The fact that psychoanalysis (reconstruction of the personality) takes anywhere from 3-5 years means that it is expensive, and so only those in need for psychotherapy are likely to go in for it (not poor, uneducated minorities).  Psychoanalysis is viewed as being limited as it can only help some, but it has proved to be helpful for those who can afford it.  Brief psychodynamic psychotherapy treatments with manuals have shown to be more effective than those without manuals. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Chapter 13—Psychotherapy: Phenomenological & Humanistic-Existential Perspectives (Pg. 370-388) Client-Centered Therapy (CARL ROGERS) Origins  1930’s—Psychoanalysis was dominant in both theory and practice; focus was being kept on theories that had a close association with treatment.  Carl Rogers resided in New York and was heavily exposed to psychoanalytic thinking.  Influenced by the ideologies of Otto Rank and Jessie Taft.  Rogers adopted therapeutic notions of permissiveness, acceptance, and the refusal to give advice. The Phenomenological World  Teaches that behavior is totally determined by the phenomenal field of the person.  Phenomenal Field: Everything that is experienced by a person at any given point in time.  To understand a patient, one must know what the world is like for them.  Phenomenal Self: The part of the phenomenal field that the person experiences as the “I”. o Adjustment issues occur when the phenomenal self is threatened. Theoretical Propositions of Client-Centered Therapy  Individuals exist in a world of experience of which they are the center.  The person is the best source of information about the self (as they are most aware of their own world).  Relied largely on non-judgmental atmosphere, verbal self-reports rather than inferences or observations; focus on the inner world as reported by the person.  Self-Actualization: Human tendency to maintain and enhance experience of the self. Behavior is a goal-directed for an organism to satisfy its needs.  Self: A crucial concept, that refers to the awareness of one’s being and functioning. o Based on interaction with environment and the evaluation of others.  The self-structure is revised to assimilate experiences that are inconsistent with the self.  Growth Potential: A capacity for competence that all individuals have. Goal of client-centered therapy is to release this capacity self-actualization tendencies. Core Features of Client-Centered Therapy Three core therapist characteristics: accurate and empathetic understanding, unconditional positive regard and genuineness or congruence. Empathy  Patient needs to feel that they are understood so the therapist has to convey a sensitivity to the needs, feelings and circumstances of the patient.  Empathy does require some level of detachment in the part of the therapist. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Existential Therapy  Rejects Freud’s views and instead views people as searching for meaning.  There is a focus on restoring meaning of life and increased spiritual awakening.  Basic human nature characteristic: search for meaning (imagination, symbolization & judgement). This search occurs within a social context/interaction with people.  Decision making and personality (i.e. what one is & what one might become) is also a part of it. The Goals and Techniques of Existential Therapy  To help the individual reach a point at which awareness and decision making can be exercised responsibly.  Does not emphasize techniques; emphasis is on understanding and experiencing the client as a unique essence.  Therapist may ask clients questions that force them to examine the failings in their life or to search for meaning in life. A Form of Existential Therapy: Logotherapy  Developed by Viktor Frankl; technique encourages clients to find meaning in what appears to be callous, uncaring and meaningless world.  He developed this therapy of meaning based on his experiences in a Nazi concentration camp.  When agonizing over the meaning of life; Frankl believes that Logotherapy should be the therapy of choice. Client’s own responsibility & obligation to the future.  Paradoxical Intention: Client is told to perform the behavior or response that is the object of anxiety/concern.  De-Reflection: Therapist instructs the client to ignore a troublesome behavior or symptom. Gestalt Therapy Emphasis is on present experience and immediate awareness of emotions and actions. Movement of Heterogeneity  Frederick (Fritz) Pearls whose education was grounded in psychoanalysis is regarded as the founder of Gestalt Therapy.  Gestalt therapists do not agree and at times; the goal of therapy is to express an individual’s own sense of uniqueness and their interpretation of life. Basic Notions of Gestalt Therapy  Conceptualizes the person as an absolute whole, not disjointed.  NO! —Individual developing an awareness of themselves. The focus is on the NOW.  Therapist facilitates client’s awareness and how inner potential is being deflected from expression (in-the-moment basis). Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103  Focus on current awareness not recovery of memories or repressed impulses. The Now and Nonverbal Behavior  Reality is now, behavior is now, and experience is now. It all occurs in the now; seeking answers in the past is dealing with that which no longer exists.  Anxiety is the gap between the now and the later.  Therapist does not interpret patient’s feelings but asks them to focus on their present emotions.  The therapist pays close attention to non-verbal behavior (ex: using the patient’s stiffness) Dreams  Psychoanalyst asks the patient to associate various elements of the dream while the Gestalt therapist asks the patient to relive the dream in the now.  Patient confronts the dream directly (deal with conflicting parts of the self). Topdog-Underdog and Defenses  Patient asked to take part in a conversation when opposing parts of the self are in conflict.  (Topdog—superego “should’s” of the personality) and (Underdog—id “primitive, evasive, disrupts efforts of the Topdog”). Goal is to integrate both parts of the self.  Gestalt therapy aims to expose the defenses and games behind which client’s hide. Responsibility and Rules  Gestalt therapy focuses on getting the client to accept responsibility for their own actions and feelings. Can’t blame feelings on something else or someone else.  Pillars of Gestalt therapy—Awareness, experience, now & responsibility  Rules o Communication in the present tense (no past or future focus) o Communication is between equals (one talks with, not at) o Use of “I” language not “it” language—client takes responsibility o Client’s focus is on immediate experience “feelings of this moment” o No gossip talk or talking about someone else o Questions are discouraged Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Moral Precepts or Rules to Live by for Gestalt Therapy 1. Live Now (be concerned with the present not past or future) 2. Live here (concerned with what is present not absent) 3. Stop imagining (experience only that what is real) 4. Stop unnecessary thinking (experiencing only the senses) 5. Express directly (do not explain, judge or manipulate) 6. Be aware of pleasant and unpleasant 7. Reject all “shoulds” and “oughts” that are not your own 8. Take full responsibility for your actions, thoughts and feelings. 9. Surrender to being yourself. Concluding Remarks  Gestalt therapists vehemently opposed to the idea of research.  Clients were mostly young, well educated people whose problems were mainly alienation and estrangement. Emotion Focused Therapy  Also termed process-experiential therapy (PET); this integrates client-centered and Gestalt therapy.  Emotions are adaptive and give out life experience its value, meaning and direction.  Dysfunction is the result of an impairment in being able to integrate experiences into a coherent self. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Nutritional Deficiencies and Toxic Disorders  Malnutrition can lead to neurological and psychological deficits  Metals, toxins, gases, some plants can be absorbed through the skin toxic consequences or brain damage o Delirium: Disruption of the consciousness Chronic Alcohol Abuse  Can lead to tolerance and dependence on the substance; changes in neurotransmitter sensitivity or shrinkage of brain tissue.  Deficits of Limbic system—memory formation, emotional regulation & sensory integration.  Diencephalon: Region near center of the brain that includes the bodies of the hypothalamus. o Shrinkage or lesions in these areas.  Atrophy of the cerebral cortex & damage to the cerebellum Consequences and Symptoms of Neurological Damage  Impaired orientation—difficulty recalling name, day of week, surroundings  Impaired memory—difficulty recalling loved ones, memories, filling in gaps, learning issues  Impaired intellectual functions—difficulty with comprehension, speech production, general knowledge  Impaired judgement—difficulty with decisions  Shallow and Labile Affect—laughing/weeping easily and switching emotions inappropriately  Loss of emotional and Mental Resilience—can function in daily life but difficulty functioning under stress (ex: fatigue, mental demands), emotional reactions.  Frontal Lobe Syndrome: Personality deficits—ex: poor impulse control, planning issues, temper tantrums. Brain-Behavior Relationships  Important to determine where in the brain the injury occurs, same-size lesions in different brain regions will produce different behavior deficits.  Brain damage can lead to deficits in visual perception, auditory perception, voluntary motor coordination, memory and other brain regions.  Clinicians are called to determine level of intellectual deterioration—involves comparison to previous levels of functioning. o Decline due to psychosocial factors (ex: motivation, emotional issues) or brain injury. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Methods of Neuropsychological Assessment Major Approaches  Standard Battery Approach/Fixed Battery Approach: Evaluates patients for all basic neuropsychological abilities. o Very expensive, possibility of patient becoming fatigued, not tailored/inflexible  Process/Flexible Approach or Hypothesis-Testing Approach: Assessment is tailored to the individual patient and the neuropsychologist chooses specific tests. o Can be very useful but can also lead to the clinician choosing the wrong test. Interpretation of Neuropsychological Test Results  Interpretation in the context of normative data (ex: patient score below average mean score).  Various methods also include Difference Scores for impairment, Pathognomonic signs of brain damage (failing to draw the left side of a picture), Pattern Analysis & statistical formulas.  Cutoff scores or absolute scores shoved the most accuracy. Neurodiagnostic Procedures  Neurodiagnostic Procedures: CAT scans, fMRI’s, spinal taps and other procedures for detecting the presence and location of brain damage. Variation in expense, sensitivity, risk for patients.  SPECT & fMRIs assess blood flow changes in the brain; are useful for assessing brain function. Testing Areas of Cognitive Functioning Intellectual Functioning  Include WAIS-IV and modified versions of it (ex: adding additional subtests).  WAIS-R-NI—most information provided for person’s cognitive strategies; WAIS-IV most used subtest is the Information, Comprehension and Vocabulary subtests. o Can be used as baseline—least affected by trauma Abstract Reasoning  Patients with brain damage approach abstract tasks in a concrete manner.  Similarities subtests of WAIS-IV and Wisconsin Card Sorting Test (WCST) Memory and Visual-Perceptual Processing  Wechsler Memory Scale (WMS/WMS-IV is most recent)  Performance is assessed with 5 index scores—Auditory, Visual, Visual Working, Immediate and Delayed Memory.  Discrepancy between scores—contrast scores.  Benton-Visual Retention Test—test of memory for designs  Rey-Osterrieth Complex Figure Test—assesses visual-spatial memory (draw a picture from memory & then draw it again after a certain period of time).  Needed for activities like reading a map, parallel parking; use of certain WAIS-IV subtests. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103 Language Functioning  Brain damage impacts the production or comprehension of language—repeating words, sentence, difficulties with articulation.  Language comprehension can be assessed using the Receptive Speech Scale. Test Batteries The Halstead-Reitan Battery  Most widely used test-battery, and is made up of several measures (ex: Category Test)  These tests can be supplemented by the MMPI-2 and the WAIS-IV  Provides information about the localization of lesions and if they appear to be gradual or of sudden onset.  This test is very time consuming—takes 6 hours to administer; but highly valid & reliable. The Luria-Nebraska Battery  Alternative to Halsterad-Reitan, 269 tasks of 11 subtests. Viewed as reliable & valid.  High agreement with results found on the Halstead-Reitan Battery.  Main advantage is unlike the Halstead-Reitan it only takes 2.5 hours to administer Variables That Affect Performance on Neuropsychological Tests  Includes biological sex, age and educational level.  Variables like motivational variables (cooperation, level of arousal).  Malingering: A motivational variable; refers to faking on psychological tests. It’s difficult to detect even for the most knowledgeable clinician. Downloaded by Recruitment Jakarta2 (jakarta2recruitment@gmail.com) lOMoARcPSD|6265103