Comprehensive Guide to Clinical Psychology: Attributes, History, and Ethics

Attributes of Clinical Psychologists

- Personal

- Legal

- Ethical

- Educational

- Competence

Personal

compassion, integrity, interested in people, good communication skills, empathy, intellectual/scientific curiosity, scientific thinking

Legal

licensed by state in which you practice

Ethical

follow enforceable standards of the ethics code

Educational

doctoral degree from APA-accredited program, completion of 1-year internship, 1-year postdoctoral fellowship (or equivalent supervised clinical experience)

Competence

Pass the EPPP, state licensing exam, jurisprudence exam, other exams for areas of specialty (e.g., Neuropsychology)

Types of counseling

- Counseling

- School Psychology

- Psychiatry

- Social Work

Counseling Psychology

Psychotherapy, career counseling, or other forms of counseling related to life changes or developmental problems

School Psychology

Testing the cognitive abilities of children and adolescents, diagnosing academic problems, and setting up programs to improve student achievement

Psychiatry

Medical specialty, psychotherapy as well as medication for the treatment of psychological disorders

Social Work

Employ various psychotherapy techniques but also focus on how social and situational variables affect their clients' functioning

Miscellaneous

Psychiatric nurses, pastoral counselors, paraprofessionals, psychological assistants, psychiatric aides, psychology technicians

What is evidence-based practice

-Patient values and preferences

- Clinical experience

- Best research evidence

Steps of scientific thinking

- What am I being asked to believe

- What kind of evidence is available to support the claim

- Are there alternative ways to interpret the evidence, including those that my biases and preconceptions might have kept me from seeing?

- What additional evidence would help evaluate the alternatives

- What conclusions are most reasonable given the kind of evidence available?

- Boulder (scientific-practice) Model

- Developed during the very first clinical psychology training conference at UC-Boulder in 1949

- Recommends completion of a Ph.D. in psychology, with an emphasis in training to conduct clinical research

- Refined at The University of Delaware in 2011 to emphasize application of research to clinicians

- Vail (Practitioner-Scholar) Model

- Developed at the National Conference on Levels and Patterns of Professional Training in Psychology in 1973 at Vail, CO

- Recommends completion of Psy.D. in psychology, with emphasis on preparation for clinical service delivery

Clinical science model

everything (including service delivery) should be science-based

Healthcare affecting clinical psychologists

- Mental health parity

- managed care

- prescribing privileges

- delivery models

Timeline

- 1859- Darwin's origin of species

- 1879-1st formal research lab

- 1883- First classification of mental disorders

- 1892- APA established

- 1896- 1st Clinical psychologist

- 1896- Binet's mental tests, first version of Freud's theory

Johannes Müller and Hermann Helmholtz-

Neural basis for vision and hearing, converting physical energy to mental experience

Ernst Weber and Gustav Fechner

Formulas documenting change in mental experiences

Wilhelm Wundt

founded the first laboratory for the study of psychology

- Emphasized empiricism, similar to "hard" sciences

- Considered the father of modern psychology

Lightner Witmer

-The first Clinical Psychologist

-rained by Wundt in 1892, established the first psychology clinic

Franz Gall

- most famous early individual differences researcher for developing phrenology

-Individual differences and mental testing

Individual differences and mental testing

James Cattell

developed the first standardized test battery

Alfred Binet

Developed a battery to identify children with intellectual disabilities

Robert Yerkes

Developed the Army Alpha and Beta to test the intelligence of recruits for the U.S. Army before WWI

- Developed during this period:

- Word Association test (Carl Jung)

-Rorschach inkblot test

- Goodenough Draw-A-Man test

- Thematic Apperception Test

- Wechsler-Bellevue intelligence scale (basis for most intelligence tests today)

Emergence of Medical Model

- Early Belief was based on evil spirits, demon possession, or other supernatural forces

- Hippocrates- attributes mental disorder to humoral imbalance (blood, black bile, yellow bile, and phlegm)

- Unpopular during the Middle Ages due to the influence of the church

Emergence of Psychotherapy

- Most psychologists were skeptical about expanding the field to include psychotherapy.

- Translation of Freud's psychoanalytic theories into English helped popularize psychotherapy

Psychoanalytic Theory (Freud)

- Began at the start of the 20th century

- Emphasizes struggle between unconscious forces for control of human behavior (id, ego, superego)

- Intensification of conflict among conscious forces leads to the use of defense mechanisms; failure of defense mechanisms leads to psychopathology

- Goal: to make the unconscious conscious (e.g., dream analysis, free association, transference and countertransference)

-Psychodynamic approach flows from this movement, still emphasizes the unconscious but is more practical

Humanistic Theory

- Began in 1930s

- A view of behavior as controlled by the decisions that people make about their lives based on their perception of the world

- Emphasized innate drive for self-actualization

- Psychopathology develops when growth potential is blocked by distorted perceptions of reality or lack of emotional awareness

- Goal: to "unblock" growth potential by correcting perceptions or facilitating emotional awareness

Behavioral Theory (B.F. Skinner, E.L Thorndike)

- Began in the 1950s

- Based on the assumption that human behavior is determined mainly by what a person has learned in life, especially through rewards and punishment and observation

- Emphasized principles of classical and operant conditioning

- Psychopathology results from maladaptive learning

- Goal: to learn more adaptive behavior through conditioning (e.g., Little Albert experiments, Mary Cover Jones, and exposure therapy)

Cognitive Theory (Julian Rotter, Aaron Beck)

- Also began in the mid-1950

- A view that focuses on and attempts to alter for the better clients' maladaptive self-statements, expectations, assumptions, and other problematic mental processes

- How people think influences what they believe about themselves, the world, and others, and therefore, their behavior

- Psychopathology results from distorted perceptions of reality that influence unhelpful behaviors

- Goal: to change maladaptive thought patterns and develop healthier ways of thinking

Cognitive-Behavioral theory (Albert Ellis, Judith Beck)

- Began in the 1960s and the 1970s

- A view that focuses on learning as the main influence on behavior and the thoughts that accompany it: its treatment methods seek to change the way clients think, as well as behave

- Blend of behavioral and cognitive approaches

- Goal: to modify both unhelpful cognitions and behaviors

Social System Approach

- A view which highlights the clients' roles in various social networks and the resulting need to use assessment and treatment methods that take into account the social and cultural forces operating within those networks

- Emphasizes the position of clients within larger social and cultural contexts

- Not a specific type of therapy

- Should be incorporated into every clinician's practice

Biological Approach

- Behavior and mental processes are significantly shaped by biological processes

- Typically used in pure form by researchers examining biological influences on psychological disorder or disease states (e.G., Alzheimer's)

- Best used in biopsychosocial model

Contemporary Issues

- Transdiagnostic approaches

- Science-practice gap

- mental Hospitals

- Changing landscape of therapy

- Diagnosis

How should clinical psychologists be trained?

- Shakow Report (1947)

- Written by David Shakow and the APA's Committee on Training in Clinical Psychology

- Three primary recommendations

-Clinical psychologists must be trained first and foremost as psychologists

- Salt Lake City Conference

- Established standard courses for accredited clinical psychology programs

- Required courses in research methods: statistics:ethics:assessment:history of psychology: biological, social, and cognitive-affective bases of behavior: and individual differences

- Delaware Conference (2011)

- Convened due to concerns about training in intervention development, basic psychopathology mechanisms, efficacy and effectiveness in research, and the disseminating/implementing recent scientific findings

- Mostly aspirational, rather than prescriptive

- Traning Models

Certification and Licensure

- Research

Clinical scientist model

- Middle

Scientist- practitioner model

- Practice

Practitioner scholar model

Professional regulation

Standards of competence that must be met in order to be authorized to practice

Certification

Professional regulation through laws that limit the title Psychologist to people who have met certain requirements specified in the law

Licensure

- Professional regulation through laws that define the services a psychologist is authorized to offer

Research Ethics

- Belmont Report was published in 1976

- 3 main principles

- Respect for person

Beneficence

Justice

- Research with human subjects must go through an institutional review board (IRB)

Ethics Code

- Preamble and five General Principles

-Enforceable standards in 10 areas

- Ethics Enforcement

APA Ethics Code

- Resolving ethical issues

- Competence

- Human Relations

- Privacy and confidentiality

- Advertising and other public statements

-Record keeping and fees

-Education and training

-Research publication

- Assessment

- Therapy

Ethics code- General Principles

- Beneficence and nonmaleficence

- Fidelity and Responsibility

- Integrity

- Justice

- Respect for people's rights and dignity

Malpractice and legal consequences

Need 4 elements for a successful malpractice suit:

- Professional relationship between client and clinician

- Negligence on the part of the clinician in treating the client (e.g., reasonable clinician in similar circumstance rule of thumb)

- Client suffered harm

- Clinician's negligence caused the harm to the client

- Only 2% of psychologists will be sued for malpractice during their career

Independent Practice

-freedom of choice laws

-Mental Health parity

-Managed care programs

- Private practice models (solo vs. group vs. mixed model)

- Prescription Privileges

- Multicultural Competence

An awareness of the existence and impact of sociocultural differences that helps clinicians be more effective when working with diverse client populations

Cultural Humility

The ability to maintain an interpersonal stance that is other-oriented in relation to aspects of cultural identity that are most important to the person

Culturally adapted treatments

evidence-based treatments that have been systematically modified to make them more compatible with clients' cultural practices, beliefs, and values

Future Issues

- Training

- Psychotherapy integration

- Interdisciplinary science/practice

- Positive psychology, posttraumatic growth

- Spirituality

- Telehealth - most recent version is from 2013...

- Dissemination of mental health information

- international outreach

Intake

- Procedures designed to establish the nature of clinical problems

- Normally at the start

- Asking basic info like education and symptoms

- 1/2 of clients after the first intake normally don't come back

Mental status examination (MSE)

- A planned sequence of questions designed to assess a client's mental functioning

- planned series of questions

- To see what someone is struggling with

- What you are looking for: appearance, appearance behavior, speech, mood

Problem-referral

A procedure designed to answer a specific referral question

Orientation

a procedure designed to acquaint clients with upcoming assessment, treatment, or research procedures

Crisis

A procedure designed to provide support, collect assessment data, and offer help to troubled clients, all in a very short time

Debriefing

A procedure designed to provide clients with info and assess their understanding of a just-completed event

Nondirective

relies on open-ended questions, allows client to speak with minimal interruptions

Structured

Least flexible, highly standardized, must repeat questions word for word, includes decision trees and skip logic

Client Variance

Difference in how clients respond to the same questions asked by different providers

Information Variance

Difference in how clinicians ask questions or make observations

Criterion Variance

Different is how clinicians apply standards or judgment to the same set of client responses

Section 4: Ethical Standards

- Maintaining confidentiality

- Discussing the limits of confidentiality

- Recording

- Minimizing intrusions on privacy

- Disclosures

- consultations

- Use of confidential information for didactic or other purposes

Stage 1: beginning

- Important considerations

- Setting considerations

Setting

- Rapport-building

- Frame-setting: establishing norms and expectations for the session

- Opportunity to establish partnership

Stage 2: middle

- Important consideration

- Appropriate balance of directive and nondirective techniques

- Reflective listening

- Summarizing

- Behavioral observation

Stage 3: Closing

- Important considerations

- Signal the end of the session

- Reinforce client's effort

- Reflect their emotions

- Assess for client questions

- Ask for feedback

Reliability

Do clients give the same information each time they are interviewed? Do clients draw the same conclusions from the same client data?

- Test-retest

- interrater

Validity

Do interviews provide the information they are supposed to provide?

- Convergent

- discriminant

- criterion

Supplement self-report data

clients may not be able to accurately recall their behavior over the past month or purposely misrepresent info

Ecological Validity

Can occur in real-world settings to provide information on how clients typically behave

Situational Determinants of behavior

What triggers, reinforces, or punishes client behaviors in various contexts?

Naturalistic

- Watching behavior as it occurs in its natural context

- Ethnography

- Self-monitoring

- Unobstructive/ corroborating

Controlled

- Watching clients in specially constructed situations designed to elicit behaviors of clinical interest

- Performance measures

- role-play

- Physiological measurement

- virtual reality

- Behavioral Avoidance tests

Behavioral Observations

- General appearance and behavior

- Manner toward examiner

- Psychomotor

- Speech

- Thought form and content

- Mood and affect

- Inferred cognitive function

- Insight and judgment

What is Clinical assessment

The collection and synthesis of information to reach a clinical judgement about people and their problems

Referral source

The person or agency requesting the psychological assessment.

Referral question

The trigger that shapes the clinician's choice of assessment instruments and the interpretation and communication of results

General steps of assessment

1. Receive and clarify the referral questions

2. Plan data collection procedures

3. Collect assessment

4. Process data and form conclusion

5. Communicate assessment results

Types of Assessment information

Observation

interviews

test

Historical records

Purpose of Assessments

- Clarification

- Planning treatment

- Predict Prognosis

-Predict performance

Clarification

- What is their diagnosis?

- Why are they having these problems?

Planning treatment-

- Which treatment(s) work for this diagnosis?

- How well is the treatment working?

Predict Prognosis

- How well will treatment work for this client?

- How much is the client likely to improve over time

Predict performance

How well will this employee perform in this job setting

- Validity (how accurate is something)

Standardization

We have to look at reliability and validity for the patient population

Fidelity vs. Bandwidth dilemma

The time I have with the patient (bandwidth) vs. how deep can you get with the client ( Fidelity).

Positive Predictive Power

How good an assessment is at identifying someone who actually has a given diagnosis

Negative Predictive Power

How good an assessment is at identifying someone who does not have a given diagnosis

Base rate

Frequency with which a given diagnosis actually occurs in any given groups of people

Communicating Assessment Results

Level 1: Information Client already knows and is likely to agree with

Level 2: Info client may not know but may help explain phenomena client has noticed

Level 3: Information that may be confusing or threatening to client and with which they may disagree

What makes a good assessment report

Clarity for all readers

Relevance to goals

Incremental validity: "the ability of the assessment report to add something important to what is already known about a client"

- Incremental validity: "the ability of the assessment report to add something important to what is already known about a client

A psychological Test

a systematic procedure for observing and describing a person's behavior in a standard situation