PSYC 401: Midterm 1

what is clinical psychology?

• scientific discipline with many areas of application

• field of practice that deals with human functioning, problems and their solutions, promotion of physical, mental, social well-being

• unique combination of research and clinical practice

• varied training experiences and areas of expertise

types of knowledge

• empirical: from scientific method

• religious: spiritually based

• apriori: from philosophers

• research

APA clinical psychology definition

psychological specialty that provides continuing and comprehensive mental and behavioural health care for individuals and families, consultation to agencies and communities, training/education/supervision, and research-based practice

EACLIPT (EU’s APA) Beliefs

• clin psyc is more than psychotherapy - research and clin practice together

• combine many different countries into one union - movement towards similarity

• expanding into medicine and healthcare

• trained as a clinician and researcher instead of just research

clinical activities

• assessment: diagnose and formulate treatment to person - detailed

• treatment: therapy

• consultation: instruction on group interaction, business strategy

• research and teaching activities

types of research

• nomethetic: variable centred, measuring a group of people on a number of variables - most research

• idiographic: person centred, detailed understanding of an individual (case studies, qualitative data)

scientist-practitioner training model (Boulder, PhD [1949])

• equal weight to science and practice - work in academia or clinical practice

• PhD as required degree

• training within university

• most dominant model for clin psyc training

practitioner training (Vail, PsyD [1973])

• training for practice like law, dentistry, medicine training

• focus on training practitioners

clinical science training model (McFall, 1991)

• to produce competent clinical scientists

• all applied clinical work to be evidence-based

• psychological services not to be administered until benefits are validated and negatives are ruled out empirically

core competencies of clinical psychology

1. access/apply current scientific knowledge and skills appropriately and habitually

2. contribute to knowledge

3. critically evaluate own interventions and outcomes

4. practice vigilance about sociocultural variables influencing science

5. subject work to scrutiny

Norcross and Karpiak (2022) clinical psych demography study

• majority are straight, white men

• women in clin psyc has been gradually increasing since 1960

• 90% of 2022 sample were white

• majority work in private practice and practice psychotherapy

• most have never published anything

• high job satisfaction

• integrated/eclectic and psychodynamic are most popular theoretical perspectives

myths in clinical psychology

• Freud’s sexual abuse, hysteria theories

• that psychoanalysis or psychoanalytic psychotherapy is dead or not empirically sound

• that there is sound evidence only for CBT

• that none of early psychodynamic theories are in use today

divisions in APA

54 (experimental, developmental, personality, social, etc.

• clin psych = 39: “…professionals who identify themselves as having a major commitment to the study, practice and development of psychoanalysis and. psychoanalytic psychotherapy”

20th century psychoanalysis revised

• unconscious memory → implicit memory

• primary process though → spreading activation

• object representation → person schema

• repression → cognitive avoidance

• preconscious processing → preattentive processing

• parapraxis → retrieval error

• reptition compulsion → nuclear script

• ego → central executive

• ego defence → defensive attribtuion

what do orientations or paradigms determine

• how we approach understanding behaviour

• viewpoints we adopt

• data we perceive and utilize

• theoretical models we develop

• research questions

• methods used

ancient greek perspectives

• empiricists: focus on observable signs, symptoms, syndromes

• theorists: focus on theoretical or putative underlying causes - can’t see them

philosophical issues in abnormal behaviour paradigms

• insurance company approach to treatment (only one type of treatment for each psychiatric diagnosis)

• importance of context (each case of disorder will stem from different combo of things)

Kraeplin (empirical) vs. Freud (theoretical)

• biological, disease processes, causes like viruses vs. psychological, underlying dynamics of person, personality, and environment

• DSM 1-4 and beyond vs. psychoanalytic concepts, psychodynamic diagnostic manual

• symptom as entity vs. psychodynamics

• descriptive nosology vs. causal nosology

symptoms as focus perspective

• group of symptoms or observable behaviours seen as cause of difficulties

• focus of treatment is on eradicating symptoms

• behaviour school orientation, ICD, DSM

• variant embraced by insurance

underlying cause as focus perspective

• problems, symptoms, signs caused by underlying processes

• assessment and treatment focused on underlying causes of behaviour

• orientation of psychodynamic, cognitive behavioural in past, and PDM

classification of psychiatric disorder

• important for clinical work and research

• one of the first steps to understanding phenomenon

• info made more accessible, meaningful, less cumbersome

historical disease classification

• pre-history likely divided into normal vs. abnormal

• Hippocrates’s 4 humours (black bile = depression, yellow bile = anxiety, phlegm = sluggishness, blood = mania)

• ancient Greece empiricists (treatments to findings) and theorists (remedies through hypothetical-deductive reasoning)

philosophical classification issues

• nature of psychopathology, normalcy, belief in paradigm

• differences in perspectives (Kraepelins vs. Freudians)

classification purposes

• description and need to identify

• communication

• research

• treatment

  • correct diagnosis = correct treatment (although some diagnoses have no treatmenr

• insurance

• theory development

• epidemiological info

diagnosis

assigning a diagnostic category

• structural interview → diagnosis

formulation

attempt to explain genesis, maintenance, and process related info for treatment

• assessment → formulation

classification systems

• DSM, ICD focus on assigning diagnoses to set of problems

• PDM, OPD focus on developing formulation in relation to stated problems

how to classify?

1. divide disorders into mutually exclusive (distinct) and collectively exhaustive (all disorders classified) subclasses

2. subclasses defined by necessary and sufficient conditions

   • characteristics necessary for classification

   • set of sufficient conditions belonging to a subclass

• should be reliable (get the same result each time, agreement with others)

• should be valid (classification speaks on true world, disorders that exist)

DSM

categorical approach to defining abnormality, descriptive diagnostic tool based on described elements and criteria to diagnose them

• first published in 1952 and V was published in 2013, over 400 disorders, developed by the APA, most common in US

• descriptive features based on observable things

• individuals must meet a minimum number of symptoms to be diagnosed

what does the DSM provide info on?

• diagnostic features

• associated features and disorders

• associated lab findings

• age-related, culture-related and gender-related features

• conditions that still require further research

pros of the DSM

• reliability has improved over previous editions

• provides info on research and reliable and valid info

• axis IV and V are good at attempting to take many factors into account

cons of the DSM

• labelling and stigma still an issue

• biological tests not used

• some patients diagnosed inappropriately

• doesn’t lead to differential treatment ideas for the most part

• subjective

• non-transparent revision process

• lack of empirical support for diagnoses

ICD manual

international classification of diseases - used in hospital settings internationally

• developed by WHO

• diagnostic info and causes of death

• includes classification of mental and behavioural disorders

• descriptive classification scheme

PDM

psychodynamic diagnostic manual - not intended to compete with DSM, provides more levels of description than DSM

• develops a thorough/comprehensive diagnostic picture of the whole person

• describes/categorizes elements not found in DSM

• developed from psychoanalysis, object relations

• “taxonomy of people”

• symptom patterns are expressions of how patients cope with experience

• understanding biological and psychological origins of mental health

PDM diagnostic framework

• describes the whole person - surface and deeper levels, emotional and social functioning (including personality patterns, social/emotional capabilities, unique mental profiles, personal experiences of individuals)

• based on current neuroscience, treatment outcome studies

• healthy → neurotic → borderline → psychotic

PDM rationale

• human behaviour is complex

• DSM simplifies behaviour too much

• want to direct focus on full range of affect, thought, behaviour in context of individual’s own unique history - function and etiology

• see disorders as result of some process

• prevent diagnoses made from narrow observations instead if naturally occurring patterns

• efficient for diagnosing concurrent conditions

• demonstrated long term efficacy

PDM axes

P: personality patterns and disorders (interaction with the world)

M: mental functioning (info processing, self-regulation, relationships, self-confidence, emotional expression, learning, coping, sense of morality) → moving towards adding more categories

S: manifest symptoms and concerns (DSM categories, personal experience of difficulties) → moving towards more heterogeneity of symptom presentation and their developmental pathways

healthy personality

• identity: self and others as complex/stable

• object relations: satisfying relationships

• affect tolerance: experience full range of age-expected feelings

• affect regulation: regulate impulses, emotions, coping

• moral sensibility

• reality testing: know what’s real/fake

• ego strength: respond to stress resourcefully

neurotic personality

• anxiety-based

• no distortions in reality

• recognizers their problems

• no great personality disorganization

borderline

in-between neurotic and psychotic

psychotic

• gross distortions in reality

• some personality disorganization

• does not recognize problem

what are ethics

• group of principles that inform how people should act in a given situation or towards each other

• ethics can be used as a decision-making tool

• spectrum of jus behaviour: minimal → aspirational

ethics vs. morality

ethics = set of standard set by an external source (CPA) for a group of individuals to adhere to

morality = your own internal set of standards, beliefs, values of right and wrong

don’t always align

why care about ethical and legal issues in clinical psychology?

• ensures care is standardized

• protect patients/clients

• protect yourself

who are psychologists responsible for?

• clients/patients

• students

• supervisees/research assistants

• research participants

• employers, colleagues

• profession at large

• society

three guiding bodies

1. code of ethics (aspirational/core values, CPA and APA ethics)

2. professional standards (prescriptive for profession, college of psychologists in BC)

3. legal standards (prescriptive for society, legal statutes and case law)

CPA objectives

• improve health and welfare of Canadians

• promote excellence in psychological research, education, practice

• promote advancement, development, dissemination, application of psychological knowledge

• provide high-quality services to members

features of CPA code of ethics

• empirically derived - sample of psychologists offering how they would respond to an ethical issue, responses categorized into groups by ethical principle

• differential weighing of 4 principles

• introduced concept of social contract (expect all members to behave ethically)

• includes minimal and aspirational standards

4 principles of CPA ethics

I: respect for dignity of persons and peoples - non-discrimination, informed consent, confidentiality, privacy

II: responsible caring - competence, self-care, maximize benefit/minimize harm

III: integrity of relationships - accuracy, honesty, avoidance of conflicts or deception

IV: responsibility to society - development of knowledge, respect for society

confidentiality

a professional standard of conduct to not disclose info about a client except under certain conditions

• psychologist-client relationship expected to be private

• privacy: right to choose info being shared

• privilege: right to refuse disclosing info to legal system

limits to confidentiality

• court order - subpoena therapists when client is charged

• harm or risk of harm to a child - Child, Family, and Community Service Act (report to Ministry of Children and Family Development)

• unsafe to drive - Motor Vehicle Act (repot to Superintendent of Motor Vehicles)

• risk of harm to self or others - Adult Guardianship Act, Case Law

infants act

explains legal position of children under age of 19

• Mature Minor Consent: ensure child understands need for treatment, what treatment entails, risks and benefits (typically children above 12)

duty to protect

clin psychologists’ duty to protect clients and others from foreseeable harm

• Tarasoff v. Regents of the University of California (1976)

• Smith v. Jones (1999) - extension of Tarasoff

Tarasoff v. Regents of the University of California (1976)

Prosenjit Poddar, a UC Berkeley student, told his therapist Dr. Moore that he intended to kill Tatiana Tarasoff. Dr. Moore notified his supervisor and campus police, but Poddar was released after appearing rational. Poddar killed Tarasoff two months later and Tarasoff's parents sued the university and several employees, including Dr. Moore and the police officers

• Tarasoff I: Duty to Warn - therapists should always warn when there is a threat

• Tarasoff II: Duty to Protect - protections ends where public peril begins

Smith v. Jones (1999)

strengthen Tarasoff II

• risk to clearly identifiable person or group of persons

• risk to serious bodily harm, death, psychological harm

• imminent danger

ethical dilemma

professional situation in which one or more ethical principles or laws are in conflict

10-step Ethical Decision Making Model

1. who are the people potentially affected by the decision?

2. what are the relevant ethical issues/laws? Which ethical values/laws are in conflict?

3. How do personal biases, stresses or self interest affect my choice of action?

4. what are my possible plans of action?

5. What are the likely short-term and long-term risks and benefits of each possible action?

6. What is your best choice of action?

7. Act on your first-choice decision and assume responsibility for consequences

8. carefully evaluate outcomes of your chosen course of action

9. continue to accept responsibility, consider an alternative action if needed and correct any foreseeable consequences

10. taking steps to prevent similar problems in the future

what are the training requirements for clinical psychologists?

• must be registered with a provincial psychological regulatory organization

• has to have a Master’s degree in Psychology

• has completed specialized training from a clinical psych program in a graduate school

how does one access clinical psychologists?

usually found in public institutions or private practice

clinical psychologists protecting the public

• must accept code of ethics established by their provincial regulatory organization

• info about whether a specific individual is a registered psychologist can be obtained by calling provincial regulatory association

counselling psychologists

similar to clinical psychologists but are more likely to become service providers at master’s degree level

• less likely to work with populations that have psychoses or severe personality disorder

psychiatrists

physicians certified in treating mental illness using a biologically based approach to mental disorders

• 4 year residency, training for psychotherapy, prescribing medication

professional social workers

case management, medical social work, counselling, human services management, social welfare policy analysis, community organizing, advocacy, teaching

unconscious mental life (Shedler, 2022)

not just that we do not fully known our own minds, but there are things we seem not to want to know

• cognitive scientists use the word implicit

• goal of psychoanalytic treatment is to expand freedom and choice by helping people become more mindful of their experiences, not to uncover repressed memories

• most psychiatric struggles served as adaptive coping mechanisms to life difficulties

the mind in conflict in therapy (Shedler, 2022)

humans can be two or more minds about things - we often have complex and often contradictory feelings and motivations

• common with anger

• ex. bulimia: binge eating to fill an inner void vs. purging to feel in control

• system 1 and 2 thinking

viewing the present through the lens of past experience in therapy (Shedler, 2022)

we quickly learn certain templates or scripts about how the world works

• impossible not to perceive/interpret events through lenses of past experience

• goal of psychoanalytic psychotherapy is to loosen bonds of past experience to create new life possibilities

transference during therapy (Shedler, 2022)

activation of preexisting expectations, templates, scripts, fears, and desires in context of the therapy relationship with the patient viewing the therapist through lenses of early important relationships

• schemas become active in therapy, transfer them to therapist - let them happen and use them to understand the patient

• therapist becomes a magnet for unresolved desires and fears

defence during therapy

anything person does that serves to distract attention from something unsettling or dissonant can be said to serve a defensive function

• tend to avoid, deny, minimize something that is dissonant with our habitual ways of thinking

• we are quick to attribute an undesirable trait in ourselves to someone else (projection) or to circumstances outside our control (externalization)

• therapy helps us recognize ways we disavow aspects of our experience with the goal of helping us claim what is ours - resistance comes from within

psychological causation during therapy

contextualizing “random” symptoms (not consciously accessible)

• therapy helps us recognize connections that exist between thoughts, feelings, actions, events

• overdetermination, multiple functions

• allow patients to say whatever comes to mind (free association)

defining psychological problems

• statistical or normative approach: if behaviour conforms to norms of particular society or social group

• subjective interpretation: if own behaviour is abnormal/in need of changing (often leads to therapy)

• judgements of maladaptive functioning: expert deems if behaviour is abnormal

issues with defining psychological problems

• what is defined as abnormal may not represent formal psychological disorders - may be problems with living instead (relationships, achievement, physical)

• abnormal behaviour viewed as entirely negative/pathological when the behaviour may be intertwined with person’s personality

• judgements of abnormality are subjective, depends on cultural context

signs

problem/abnormality that can be observed by a clinician but not necessarily by the patient

symptom

abnormality/complaint perceived by a patient- subjective manifestations

syndrome

group of signs/symptoms that reflect a specific health-related condition

mental disorder

no agreed definition - implies existence of a clinically recognizable set of signs, symptoms, behaviours that often produce distress and interference with personal function

what processes are affected by psychological problems?

• emotions and emotion regulation (anxiety, depression, anger as predominant emotions, poor emotional regulation, blunted or flat affect)

• thoughts and intellectual functioning (cognitive dysfunction, rumination, poor cognitive processing)

• perceptions (hallucinations)

• interpersonal processes (poor relationships and representations of others/oneself)

• poor regulatory/coping behaviour

• developmental issues

• damaging environment

current conceptualizations

ICD, DSM, PDM - descriptive classifications from observable signs and etiological or causal components

• PDM starts with personality when assessing psychopathology, DSM/ICD starts with the syndrome

categories of behavioural disorders in DSM

1. organic mental disorders (dementia, delirium)

2. mental disorders due to substance use (dependence syndrome)

3. schizo/delusional disorders

4. mood disorders

5. neurotic/stress-related disorders (anxiety)

6. syndromes associated with physiological disturbances (eating disorders, sleep disorders)

7. disorders of adult personality (personality and sexual disorders)

8. mental retardation

9. disorders of psychological development

10. behavioural and emotional disorders with onset in childhood

DSM axes

I: clinical disorders

II: personality disorders, mental deficits

III: general medical conditions

IV: psychosocial and environment

V: global assessment of functioning

PDM focus

• healthy and disordered personality

• profiles of mental functioning - relationships, expression, understanding of emotions, coping, self-awareness, morals

• subjective experience of symptoms

responding to cultural differences within the DSM?

outline for cultural formulation - assessment of cultural identity of individual, cultural conceptualizations of distress, psychosocial stressors and cultural features of vulnerability and resiliency, cultural features of relationship between clinician and client

• assessment using cultural formulation interview

most frequent complaints against psychologists

1. inappropriate assessment procedures

2. lack of professional competence - boundary violations

3. client relationships - like violating confidentiality

APA code of ethics general principles

• beneficence and nonmaleficence

• fidelity and responsibility

• integrity

• justice

• respect for people’s rights and dignity

APA ethical standard

• resolving ethical issues

• competence

• human relations

• privacy and confidentiality

• advertising and public statements

• record keeping and fees

• education and training

• research and publication

• assessment

• therapy

membership in the CPA have to

1. adhere to CPA code in all psychologist activities

2. apply the code conscientiously to new areas of activity

3. engage in ongoing development and maintenance of ethical knowledge

4. discuss ethical issues with colleagues

5. bring attention to ethical issues that require further attention

6. bring concerns about unethical actions directly to psychologist

7. bring concerns about serious unethical actions to person/body best suited to investigate

8. consider seriously other concerns about one’s own unethical actions

9. not be malicious about ethical reporting

10. cooperate with Association concerned with ethical conduct

critical inquiry studies

research that uses critical thinking to analyze structures, policies, activities, and/or social impact of an institution, organization or other social entity

vulnerable individuals

dignity, well-being, best interests are easily violated due to their cognitive/emotional characteristics, level of voluntary consent, interests compete with interests of more powerful individuals, high risk of harm

respect for dignity of persons and peoples ethical standards

• general respect

• general rights

• non-discrimination

• fair treatment/due process

• informed consent

• freedom of consent

• protections for vulnerable individuals and groups

• privacy

• confidentiality

• extended responsibility (amongst other professionals)

responsible for caring ethical standards

• general caring

• competence and self-knowledge

• risk/benefit analysis

• maximize benefit

• minimize harm

• offset/correct harm

• care of animals

• extended responsibility

integrity in relationships ethical standards

• accuracy/honesty

• objectivity/lack of bias

• straightforwardness/openness

• avoidance of incomplete disclosure and deception

• avoidance of conflict of interest

• reliance on the discipline

• extended responsibility

responsibility to society ethical standards

• development of knowledge

• beneficial activities

• respect for society

• development of society

• extended responsibility