Clinical Psychology Midterm 3

Clinical child psychology

A subfield of clinical psychology focused on studying,
assessing, treating, and preventing psychological disorders of
children and adolescents.

the first to point out that young children are not miniature adults

Swiss developmental psychologist Jean Piaget

Developmental psychopathology

- how adaptive and maladaptive patterns of behavior show themselves across childhood and adolescence and how they are influenced by an individual’s developmental stage.
- A research field focused on maladaptive behaviors in childhood
and adolescence and how they are influenced by developmental
stages.

Why, after so many years of neglect, is so much attention now being devoted to child psychopathology?

- research showing that many childhood disorders carry lifelong consequences.
- better able to develop interventions that prevent childhood problems from escalating and extending into adulthood
- media attention devoted to certain high-profile, child-related problems, such as bullying and suicide, and the increased rates at which doctors are prescribing psychotropic medications for children

Attention to the Contexts of Behavior

- children’s behavior is generally more malleable, and more
subject to environmental influence than that of adults, whose behavior patterns have typically been well-established.
- children and adolescents have far less control over these things; sometimes they have no control.
- show more variability than adults do from one context to another.

Processes for Seeking Help

- must depend on parents, teachers, or other significant people in their lives to determine whether they need the help of a mental health professional.
- Sometimes, children are referred to a mental health professional for reasons that have more to do with parental or family problems than with the child’s emotional or behavioral characteristics

Confidentiality

Officially, parents or legal guardians are responsible for young clients, so clinicians’ ethical obligation to maintain confidentiality does not prohibit them from disclosing client information to parents or guardians
- child therapists set ground rules at the outset of treatment where everything the adolescent client discloses will be kept private (even from parents) unless something about the client’s behavior is potentially seriously harmful to the client or someone else.

Special Considerations in Child Assessment

- important to understand a child’s developmental stage when trying to determine if behavior is atypical or not, the majority of clinical assessment instruments are normed
- because the environment influences children’s behaviors so strongly, clinical assessments of children tend to be more comprehensive than those of adults
- children’s emotional and behavioral status depends heavily on
the nature of their family life, will include exploration of the lifestyles, mental health
- questions about the physical environment,

Behavior Rating Scales

are inexpensive, easy to administer, and usually reliable and
valid for their intended purposes
- generally consist of a list of child behavior problems, and generally completed by parents and at least one teacher.
- Behavior rating scales differ in their coverage, with some focusing on specific disorders (e.g., Child Depression Inventory), whereas others cover a wide range of child behavior problems.
- most common is the Achenbach System of Empirically Based Assessment

Clinical interviews for children

- provide a way to collect additional details about the nature and history of a child’s development and problems and to explore other factors in the child’s life that may be contributing to those problems.
- important for correcting any errors in rating scale data.

Structured versus Unstructured Interviews for children

- Unstructured: may be especially helpful for building rapport. Allow clinicians to ask questions that are relevant for diagnosis and treatment, but not related to specific symptoms of disorder. (eg.
find out about differences between what parents and children see as the cause of child’s problematic behavior).
- structured: results of interviews lead directly to a diagnosis in a manner that is relatively reliable and valid. However, can take a long time and may not do much to enhance rapport.
- semistructured: combines the clinical sensitivity and flexibility of the unstructured interview with the higher diagnostic reliability of structured ones.

Intelligence and Achievement Tests

Poor school performance accounts for a large number of child referrals for mental health services, because many children with academic difficulties also have behavior problems.
- to better understand the nature and origins of academic difficulties
- main characteristics measured at all ages include broad
reading, broad mathematics, and written expression.

Projective Tests with children

- the test–retest and interrater reliabilities for these tests are often unacceptably low, or even unknown, especially when used with children
- the tests’ usefulness with children who have difficulty either in answering orally presented questions or providing quantitative data on behavioral rating scales

Behavioral Observation

- Children’s problems usually occur in the home or at school, so observations in these settings give clinicians the opportunity to validate, gain new perspectives on, and resolve discrepancies between reports made by parents and teachers through rating scales and interviews.
- School observation systems focus primarily on classroom behavior, although playground behavior also may be monitored
- most are informal

Understanding and Dealing with Inconsistent Assessment
Information

- informants might have reason to exaggerate or underreport a child’s behavior problems.
- Different informants (including supposedly objective observers) may make different judgments depending on their overall positive or negative bias. Clinicians must consider motivational factors in assessment data rather than simply accepting them at face value
- differing interpretations of the terms used in behavioral rating scales.
- children sometimes do behave differently across situations, such as at home and at school. In these cases, “discrepant” information is not really discrepant, it is descriptive of an inconsistency whose sources a clinician will want to understand

Psychosocial Treatments for Disorders in Children and Adolescents

- psychosocial treatment of children’s disorders is beneficial, showing effect sizes ranging from 0.7 to 0.8.
- Autism Spectrum Disorder (ASD) --> Applied Behavior
Analysis
- Attention-Deficit Hyperactivity Disorder (ADHD) --> Behavioral Classroom, Management Behavioral, Peer Interventions, Behavioral Parent, Training
- Oppositional Defiant Disorder (ODD), Behavioral Parent Training

Activity scheduling

A cognitive behavior therapy method that encourages depressed clients to increase the number of enjoyable activities in their lives

Why do contingency management methods work best for some disorders whereas cognitive/interpersonal methods work best for others?

- children displaying ASD, ADHD, and ODD/CD tend to be younger, less aware of how problematic their behavior is, and less motivated to try to change it. Even if maladaptive cognitions played a part in their problems, these children may not yet be mentally mature enough to address them by talking to a therapist.
- Older children and adolescents who experience depression and anxiety may be far more aware of their distress, more troubled by their symptoms, and better able to work with a therapist to identify and change the thinking patterns that may be contributing to their problems

Pharmacological Interventions

- In the United States, most stimulant medications are approved by the Food and Drug Administration for children ages 6 and older, though some are approved for children as young as age 3.
- criric --> Of particular concern to Breggin is what he sees as the overuse of medication for behaviors that are not necessarily abnormal or that are only abnormal in particular cultures
- Deviancy training: A process through which children in group treatment reward one another’s’ problematic behavior.

Prevention of Childhood Prevention of Childhood Disorders

- Improving parent–child attachment in order to prevent a myriad of emotional/behavioral problems.
- Using a television series to teach parents about positive parenting skills in order to increase children’s compliance and decrease their aggressiveness.
- Using cognitive behavior techniques to decrease the likelihood of anxiety problems in children.
- Educating parents and adolescents about interpersonal skills and cognitive strategies that can head off depression.
- Strengthening communication and parental monitoring in African American families to prevent adolescents from engaging in risky behaviors, such as drinking alcohol, using illicit drugs, and having unprotected sex.
- Large-scale anti-bullying programs that help students learn about the problem, develop more empathy for others, and develop strategies to help victims of bullying.

Diversity and Multiculturalism

- many traditional psychological treatments that were developed mainly for majority populations tend to be
less effective for youth from single-parent homes and disadvantaged and ethnic minority backgrounds
-

Childhod Access to Care

- As many as 25% of children and adolescents who meet criteria for a psychiatric disorder have never had access to outpatient mental health services. This pattern is particularly true for youth from racial/ethnic minority groups and from impoverished backgrounds
- One method is to deliver evidence-based treatment programs in schools

Interdisciplinary Approaches to Research and Practice

- special attention being paid to the many interconnections among biological/genetic, cognitive, social, behavioral, and environmental influences on children
- integrated primary care, offering mental health services in a primary care setting is thought to improve
children’s and adolescents’ access to the mental health services that they need.

Health psychology

A psychological subfield devoted to studying psychological factors influencing health, illness, and coping with illness.

Health psychology in practice

- Today, the top three causes of death—cardiovascular diseases, cancer, and respiratory diseases—are responsible for over 55% of deaths worldwide.
- emotional distress, including that resulting from difficulties in coping with an illness, is a factor in up to 60% of all physician office visits

Stress, Coping, and Health

- Stress: The negative emotional and physiological process associated with people’s efforts to deal with circumstances that disrupt, or threaten to disrupt, their lives.
- The circumstances that cause people to make
adjustments are called stressors.
- Our ability to manage stressors and stress reactions is an important factor in determining how healthy we are and how vulnerable we are to illness.

Selye’s General Adaptation Syndrome (GAS)

- A pattern of physiological reactions to stressors that includes stages of alarm, resistance, and exhaustion.
- The GAS begins with an alarm reaction, which is often called the fight-or-flight response because it helps us combat or escape stressors. The reaction releases “stress hormones,” like cortisol
- If stressor persists, or if new ones occur in quick succession, the alarm stage is followed by the stage of resistance, during which less dramatic but more
continuous biochemical efforts to cope with stress can have harmful consequences. For example, prolonged release of stress hormones can create chronic high blood pressure, damage muscle tissue, and inhibit the body’s ability to heal
- stage of exhaustion appears when various organ systems begin to malfunction or break down. People experience physical symptoms like fatigue, weight loss, heart disease
CRITIQUE --> the model does not allow for individual differences in the experience of stress

Barbara Dohrenwend's four-stage model of how stressors and stress reactions contribute to psychological disorders

- stressful life events occur,
- a set of physical and psychological stress reactions.
- stress reactions are mediated by environmental and
psychological factors that either amplify or reduce their intensity
- the interaction of particular stressors, particular people, and particular circumstances results in physical
and/or psychological problems that may be mild and temporary (some anxiety, a headache) or severe and persistent (anxiety or mood disorder)

Stress and the Immune System

- prolonged stress can cause the suppression of the immune system
- although stressors—especially prolonged stressors—can suppress immune function, short bouts of stress can actually enhance activity in some portions of the
immune system
- Developmental Aspects of Stress --> childhood stress can have long-delayed effects.

Measuring Stressors

- Schedule of Recent Experiences (SRE). It contains a list of 42 events, respondents identify the events that have
happened to them during the past months, and give
each event a weight based on the amount of adjustment needed to deal with it.
- even though people who are exposed to significant stressors are more likely overall to become ill than are those exposed to fewer stressors, most people who experience stressors do not become ill.

three particularly important vulnerability or resilience factors

adaptive coping strategies, stress-hardy personality characteristics, and social support.

Adaptive Coping Strategies

- coping --> People’s cognitive, emotional, and behavioral efforts at modifying, tolerating, or eliminating stressors
- Problem-focused coping was favored for stressors related to work, while emotion-focused coping was used more often when the stressors involved health.
- Men tended to use problem-focused coping more often than women in certain situations, but men and women did not differ in their use of emotion-focused coping

Stress-Hardy Personality Characteristics

a variety of personality and cognitive characteristics, including optimism, resilience, faith and hope, curiosity, subjective well-being, and adaptive defense mechanisms, all of which can contribute to adaptive coping
- positive emotional states may play a health-protective role.
- Optimism can often lead to self-deception and less careful cognitive processing, but without a certain amount of optimism, people may be more vulnerable to stressors

Social Support

- The experience and perception of being cared for and part of a network of communication and mutual obligation.
- It provides relationships in which emotional support, feedback, guidance, assistance, and values are exchanged.
- The first is the stress-buffering pathway, whereby the experience of stress is lessened as a consequence of the support provided.
- The second is the direct effects pathway, where the experience of stress is directly impacted by changing the actual stressor
- relationship between stress and illness is weaker among individuals who perceive high levels of social
support in their lives
- people’s perception of social support can strengthen their belief that others care for and value them; it may also enhance their self-esteem and increase feelings of confidence about handling stress in the future.

DOWNSIDES
- having a dense social support network entails
increasing one’s exposure to communicable diseases.
- Social ties can also create conflicts if others’ helping efforts leave the recipient feeling guilty, overly indebted, or dependent

Psychological Factors in Cardiovascular Disease

- the most health risky aspect of the Type A pattern is hostility, a trait characterized by suspiciousness, resentment, frequent anger, antagonism, and distrust of others
- hostility: A pattern of suspiciousness, resentment, frequent anger, antagonism, and distrust.

Cardiovascular Diseases prevention

- programs aimed at eliminating smoking and other harmful habits, and at promoting regular exercise, low-fat diets, and other healthy habits
- Community-based and internet-based interventions are also being tried, with some showing success in assisting individuals with behavior change

Pain prevention

- single most common physical symptom and is the most common reason that people visit a healthcare professional, so pain management is an important objective in health psychologists’ interventions
- help patients to perceive less pain, to cope with the psychological distress associated with chronic pain, to decrease impairment of day-to-day functioning, and to develop strategies for more effectively living with chronic pain

Cancer prevention

Their goal is to promote an improved quality of life for cancer patients by helping them to:
(a) understand and confront the disease more actively;
(b) cope more effectively with disease-related stressors
(c) develop emotionally supportive relationships in which they can disclose their fears and other emotions.

HIV/AIDS prevention

- programs designed to reduce the unprotected sexual contact and needle sharing
- major goal of AIDS prevention programs in these countries is to empower women to learn about HIV transmission, take greater control of their sexual lives, obtain protective devices such as female condoms or vaginal microbicides, and become less economically dependent on men and therefore less subject to coerced or commercialized sex

Improving Adherence to Medical Treatment

- Maintaining behavior change remains one of the most vexing problems in health psychology.
- compliance or adherence--> the extent to which patients adhere to medical advice and treatment regimens
- Nonadherence tends to be especially common in treatments that are complicated, unpleasant, and
involve substantial lifestyle changes and long-term consequences

Causes of Nonadherence

- miscommunication between physicians and patients makes instructions confusing to follow or forget what they were told.
- Adherence may also be reduced by the sheer complexity, inconvenience, or discomfort associated
with some kinds of treatment
- patients do not have a good system for reminding themselves about what to do and when to do it.

the health belief model

patients’ adherence to treatment depends on factors such as:
(a) how susceptible to a given illness they perceive themselves to be and how severe the consequences of the illness are thought to be;
(b) how effective and feasible versus how costly and difficult the prescribed treatment is;
(c) the influence of internal cues (physical symptoms) plus external cues (e.g., advice from friends) in triggering health behaviors; and
(d) demographic and personality variables that modify the influences of the other factors

Interventions to Improve Adherence

(a) educating patients about the importance of adherence so that they will take a more active role in maintaining their own health;
(b) modifying treatment plans to make adherence easier; and
(c) using behavioral and cognitive behavioral techniques such as self-monitoring, reminder cues, and other tools to increase patients’ ability to adhere.

Requirements for Mental Health Experts in the Legal System

1. expert testifies when the judge believes that the expert’s scientific, technical, or other specialized knowledge will help the trier of fact (typically jurors) to understand the evidence or to determine a fact at issue.
2. testimony must be based on sufficient facts or data.
3. expert’s testimony must be based on reliable and accepted principles and methods within the expert’s field. In the legal field the term “reliable” means “based in sound science.”
4. The principles and methods used or referred to by the expert must be applicable to the facts or data in the case.

--> experts are not allowed to offer an opinion on whether a defendant is competent to stand trial or was sane at the time of an offense or any other opinion that goes to the ultimate issue before the court.

reducing the overly adversarial nature of all kinds of scientific and technical
expert testimony by;

(a) limiting the number of experts each side may introduce to testify about a given topic;
(b) requiring that the experts be chosen from an approved panel of individuals reputed to be objective and highly competent; and
(c) allowing testimony only from experts who have been appointed by a judge, not those hired by opposing attorneys

Methods for Studying Psychological
Treatments

- Gordon Paul’s “ultimate question” about psychotherapy research: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?"

list of outcome research goals
--> Determine the efficacy of a specific treatment, that is the extent to which treatment works in large-scale studies run under controlled conditions.
--> Compare the relative effectiveness of different treatments, that is, determine the extent to which a treatment is useful in the real world of clinical service delivery.
--> Determine the specific components of treatment that are responsible for particular changes.
come about?”

Basic Designs of Psychotherapy-Outcome Research: Past and
Present

- Statistically significant --> Describes a difference that would rarely be seen, even after many replications of a study, if there really was no difference.
- Clinically significant--> Describes improvement that is large enough that clients feel and act more like people without a disorder.

Experiment

A method for discovering the causes of specific events by manipulating one or more independent variables, then looking for changes in one or more dependent variables.

Independent variable

A factor that researchers manipulate in an experiment.

Dependent variable

In an experiment, a factor in which changes are to be observed.

Within-subjects design

Research in which changes are observed and analyzed as clients receive one or more forms of treatment.
--> they can help to establish whether a given treatment works for one or a few clients, but they usually cannot tell us how well they would work for other clients with similar problems.
--> more commonly used in therapy-outcome research.

Between-subjects designs

Research in which different groups of clients are compared after receiving differing treatments or control conditions.
--> Nonspecific effect- Elements of a therapy program other than the specific procedures used in a treatment.
--> allow manipulation of several independent variables
simultaneously rather than sequentially
--> tend to be expensive.
--> usually takes many clients and a large staff to recruit, organize, and treat groups of the size necessary for powerful statistical analyses of results

External validity

The degree to which the results of a particular study are likely to apply to other clients and treatment situations.

Internal validity

The degree to which the design of an experiment includes enough control over potentially misleading influences that researchers can draw accurate conclusions about the causes of their results.

Randomized Controlled Trials

- generally considered the “gold standard” by which treatments are evaluated and consequently adopted into clinical practice
- results tend to have higher internal and external validity.

Results of Research on Individual Treatments

(a) about 90% of clients felt better after treatment,
(b) there was no difference in the improvement of clients who had psychotherapy alone or psychotherapy plus medication,
(c) none of the approaches to psychotherapy was rated more highly than the others, and
(d) greater improvements were associated with treatment by psychologists, psychiatrists, and social workers compared with family physicians or marriage counselors

Box Score Reviews

A summary of outcome research which counts the number of studies that are judged to give positive and negative results.

Meta-Analytic Studies

A statistical technique for standardizing and summarizing the outcomes of many therapy studies.
- these analyses have confirmed the conclusion that psychological treatment is an effective intervention for a wide variety of psychological disorders, and that its overall effectiveness is medium to large in magnitude.

Effect size

The average difference in outcome between treated and untreated groups across the studies in a meta-analysis.

Dodo Bird Verdict

All approaches to psychotherapy, they say, are equally effective, probably because of beneficial, but nonspecific, factors.

Empirically Supported and Evidence-Based Treatments

empirically supported treatments (ESTs).
- Well-established/efficacious and specific
- Probably/possibly efficacious
- Promising

Evidence-Based Practice

combines research on specific treatments with research on the impact of client and therapist characteristics, the nature of the therapeutic relationship, and knowledge based on clinicians’ professional experiences and expertise
- many studies used to evaluate the efficacy of various
treatments have not included enough members of racial and ethnic minority groups. As a result, we do not know if treatment will work on diverse client.

Therapist Variables

- two therapist variables found to be demonstrably effective were higher levels of empathy and encouraging
feedback from clients.
- showing positive regard for the client, sharing the client’s therapy goals, and having a sense of collaborating with the client.

Client Variables

1. Clients who, from the beginning, are open to treatment, more willing to disclose their thoughts and feelings, and less resistant tend to have better outcomes.
2. Clients who have strong expectations that the treatment will be successful tend to have better outcomes than those who do not expect success

Relationship Variables

- better relationships between therapists and clients of all ages are associated with better treatment outcomes

Findings on Group Therapy

- group therapy can be an effective form of treatment, especially when there is strong group cohesion and a strong therapeutic alliance

Findings on Couples Therapy

- almost all forms of couples therapy appear to produce significant improvements in the couples’ relationship satisfaction and psychological adjustment
- some evidence that two of the key short-term factors in successful couples therapy are communication training and the development of problem-solving skills

Findings on Family Therapy

- Families who complete a course of therapy together usually show significant improvements in communication patterns and in the behavior of the family member whose problems prompted therapy in the first place
- Behavioral and structural family therapies have received the strongest empirical support.
- most of the strongest family therapy procedures include behavioral and psychoeducational components.

Findings on Self-Help Resources and Self-Help Groups

- There has been somewhat more research on using self-help books and websites. It suggests that some of these resources can be effective for treating mild depression, eating disorders, gambling, anxiety, and mild alcohol abuse
- the effectiveness of self-help materials can vary substantially

Findings on the Combination of Psychotherapy and Medication

studies have found that psychotherapy—particularly behavioral and CBT—can result in benefits that are greater and more enduring than drug treatments for anxiety disorders, depression, OCD, PTSD, and other
problems in adults and children
- combining medication and psychotherapy seems especially valuable for some disorders and for clients who do not respond to either treatment alone.

Concerns and Compromises in Therapy Research

- any conclusions drawn from the results of any outcome study must be tempered by awareness
of the compromises in research design and methods that were made in an effort to strike a reasonable balance between internal and external validity.
- if the researcher maximizes external validity by researching clients in community treatment settings who may have a broader range of problems, the lack of experimental control may compromise internal
validity.
- factors such as flexibility in training strategies and technologies will be crucial in the future dissemination and implementation of evidence-based practices

The MCC theory implied three ideas:

(1) there are a set of competencies that predict therapy outcomes, which can be clearly articulated and then acquired by trainees;
(2) one can reliably differentiate therapists who are competent from those who are not; and
(3) the competencies are characteristic of the therapist across clients

Trends That Informed the MCO Framework

Rather, it compliments existing models of psychotherapy (e.g., cognitive-behavioral therapy, interpersonal, psychodynamic, or systems). Additionally, the MCO framework articulates a “way of being” in session for therapists (e.g., cultural humility), a way of
identifying and responding to therapeutic cultural markers in sessions (e.g., cultural opportunities), and a way of understanding the self in these moments (e.g., cultural comfort).
- Moreover, the MCO framework challenges therapists to fully examine their motivation to have an “orientation” that guides their lived experiences around cultural dynamics.

the MCO framework detailed three
constructs

- First, culturally humble therapists strive to take advantage of cultural opportunities that arise in session.
- Second, culturally humble therapists strive to develop
cultural comfort for engaging various cultural identities of clients. We elaborate on each of these three pillars of the MCO framework.

Ten nuggets of wisdom for counselors old and new

1) For many new counselors the responsibility of diagnosis can be daunting. Many of my students chide me as I refer to the “patterns of behavior” a client manifests versus a specific diagnosis. Yalom further challenges that all behavior is purposive and serves the host. Therefore, discovering how these patterns or symptoms serve the client may provide insight into deeper meaning.
2) Cultivate meaning: the cultivation of understanding is key for a client’s wellness. Therefore, I am inclined to assess what meaning the client ascribes to a particular symptom or patterns of symptoms.
3) Model honesty: To be honest, one experiences risk of rejection, and betrayal. Yet vulnerability can offer great rewards in relationship. As clinicians, we ask our clients to be truthful, and we often negatively refer to those who withhold information as “resistant.”
4) Healer and healed are in courtship. Yalom poignantly reminds us that the secret to the therapeutic alliance is the unconscious dance that occurs between the healer and the healed.
5) Isolation exists only in isolation once shared, it evaporates.
6) Choose your fate, love your fate. We make choices in our life that contribute to our experiences
7) Take time to chimney sweep. It adds to clarity of mind and peace of body.
8) Be more generous to your own humanity
9) Die at the right time: shunning of distractions of the past and concerns for the future. It requires us to be fully present in the moment
10) We are people, not pathologies

Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study

- first group consisted of dyads with a positive relational outcome
- Positive relational development occurred when these emotions were successfully accommodated and replaced with a growing sense of safety with the therapist.
- the second group consisted of dyads with a troubled or frail relational outcome.
- During the initial phase of therapy, clients described feeling overwhelmed by fear and shame. Relationship became troubled when the client experienced an increase in shame and/or fear during the first sessions. When forming a therapeutic relationship, it is vital that the client experience the therapist as genuine and skilled, and that the therapist is able to engage and connect deeply with the client on a person-to-person level.

Togetherness in the Working Phase: Experiencing a Deep Connection and Mutual Engagement

- for clients, togetherness was rooted in perceiving the therapist as genuinely caring for them.
- All clients described their therapist as warm, welcoming, caring and accommodating, which in turn repaired an initial sense of inequality in their
relationship.
- feeling deeply understood, acknowledged and accepted as a person was the safest route out of feelings of shame and unworthiness

two phases in which a therapeutic relationship emerges

(1) the relational processes that occur when a person encounters another person (real relationship), and
(2) the relational processes that occur when the dyad takes on a therapeutic mission (the working alliance).
- A strong therapeutic relationship can be seen as a successful consolidation of both.

Professional Training

- it was not until the late 1940s that clinical psychology found a unique opportunity to establish its identity, expand and elevate its status. During World War II, there was a need for mental health professionals who could work with combat veterans and their families

recommendations in the Shakow report for formulating a clinical training program

1. A clinical psychologist should be trained first and foremost as a psychological scientist, not just as a clinician.
2. Clinical training should be as rigorous as the training for nonclinical areas of psychology.
3. Preparation of the clinical psychologist should be broad and directed toward assessment, research, and therapy.
- greatest impact of the Shakow report was to prescribe the mix of scientific and professional preparation that has typified most clinical training programs ever since.
- This recipe for training—described as the scientist–professional model

The Boulder Conference

- That committee (now called the Commission on Accreditation) published training standards that clinical training programs have to meet in order to be accredited.
- focuses instead on ensuring that accredited training programs are capable of graduating psychologists whose competencies will enable them to provide high-quality health-care services

The Vail Conference

- conferees officially recognized practice-oriented training as an acceptable model that defined their mission as preparing graduate students to deliver clinical services (Psy.D. degree)
- most controversial recommendations was that people trained at the master’s level should be considered
professional psychologists. The M.A. proposal was short-lived.

Clinical Psychology Training Today

- the scientist–practitioner model has proven to be a tough competitor and is still reflected in more clinical psychology training programs than any other model
- Many faculty in these research-oriented clinical programs became increasingly concerned by a lack of rigor in the APA accreditation system’s standards for what constitutes scientific clinical research.
- They were also concerned that the long list of requirements that students must fulfill for a program to maintain APA accreditation made it difficult for students to dedicate as much time to research as would be desirable

Professional Schools and the Doctor of Psychology (Psy.D.) Degree

- creation of graduate programs with differing philosophies about how to train clinicians
- The Psy.D. programs offered provide training that
concentrates on the skills necessary for delivering a range of assessment, intervention, and consultation services.
- troubling features with freestanding Psy.D. programs - higher acceptance rates and lower admission criteria reflect their status as profit-making organizations, so easier for mismanagement of funds
- slightly less likely than those of Ph.D. programs to be
accepted into APA-accredited internship programs
- tend to score lower than Ph.D. program graduates do on the EPPP
- less likely to qualify for a specialty diploma from the American Board of Professional Psychology

Clinical Psychology Training Models

- Clinical scientist model, grew out of the Academy of
Psychological Clinical Science approach and places emphasis on scientific research. Most commonly followed in university settings.
--> want clinical psychology to develop as a research specialty focused on investigating the origins, assessment, and treatment of psychopathology

- The scientist–practitioner model, which follows the Boulder conference recommendations and provides equal emphasis on research and application to practice. Common in traditional university Ph.D. programs and some professional schools.

- The practitioner–scholar model, follows the Vail conference recommendations and stress human-services delivery while placing proportionately less emphasis on scientific training. Most commonly seen in professional schools and many Psy.D. programs
--> want the field to develop as an applied profession
devoted to clinical service

Evaluating Clinical Psychology Training

the key elements in training are teaching graduate students how to:
(a) evaluate and choose assessment and treatment methods on the basis of high quality research evidence; and
(b) directly evaluate the effectiveness of the treatment
being provided to each client. Outcome monitoring at the individual client level is especially important when there is minimal applicable research evidence

The Internship Imbalance

- require students to complete a full-time, 1-year
clinical internship that is APA-approved
- internship imbalance as the numbers of graduate students in clinical psychology has grown and the number of internship slots shrank due to funding problems

Professional Regulation

establishing standards of competence that must be met in order to be authorized to practice.

Certification and Licensure

- most important type of regulations are state laws that establish requirements for the practice of psychology and/or restrict the use of the term psychologist to people with certain qualifications
- 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 that a psychologist is authorized to offer.
- Certification laws dictate who can be called a psychologist, while licensing laws dictate both the title and the services that psychologists may offer.
- psychologists are required to keep their license or
certification up to date by paying a periodic renewal fee and by documenting their involvement in continuing education (CE)

state boards of psychology perform two major functions:

- determining the standards for admission to the profession and administering procedures for selecting and examining candidates, and
- regulating professional practice and conducting disciplinary proceedings involving alleged violators of professional standards

American Board of Professional
Psychology (ABPP) Certification

- licensure signifies a minimal level of competence (and is required before seeking a diploma), diplomate status is an endorsement of professional expertise
- Depending on the specialty area, multiple years of
experience are a prerequisite to even take the ABPP examination, which is conducted by a group of diplomates who observe the candidate dealing directly with clinical situations

Ethical Standards of the American Psychological Association

Legally enforceable statements about what constitutes ethical and unethical behavior by psychologists in ten specific domains.

- Principle A: Beneficence and Nonmaleficence. psychologists should “do no harm.”
- Principle B: Fidelity and Responsibility. Must be trustworthy and uphold the highest ethical
standards in professional relationships.
- Principle C: Integrity. Remain accurate, honest, and truthful in their professional work.
- Principle D: Justice. Treat all individuals, but especially clients, fairly and justly.
- Principle E: Respect for People’s Rights and Dignity. Treat individuals with the utmost respect for their dignity and individual freedoms.

Dealing with Ethical Violations

- when psychologists behave in an ethically questionable manner, they are subject to censure by local, state, and national organizations whose task it is to deal with violations of ethical practice.
- Those who believe that a psychologist has been involved in wrongdoing can file a formal complaint with the APA and/or the state psychology board.

Regulation Through State Laws

- Duty to Warn: A therapist’s obligation or option to notify potential victims about potentially dangerous clients.

Regulation Through Malpractice Litigation
Four elements must be established in order to prove a claim of professional malpractice:
1. A special professional relationship (i.e., service in exchange for a fee) existed between the client/plaintiff and the clinician/defendant.
2. The clinician was negligent in treating the client. Negligence involves a violation of the standard of care, defined as the treatment that a reasonable practitioner facing circumstances similar to those of the plaintiff’s case would be expected to give.
3. The client suffered harm.
4. The clinician’s negligence caused the harm suffered by the client

The Economics of Mental Health Care

- won battles over licensure by the 1950s, and psychology was recognized as an independent profession in the 1970s and 1980s
- By 1983, 40 states covering 90% of the U.S. population had passed freedom-of-choice legislation so that licensed psychologists were reimbursable providers of mental health services
- In 1996, the Mental Health Parity Act law prevented insurance companies from providing lesser coverage for mental health

Independent Practice

- Solo practice—The clinician owns the entire practice and responsible for renting, decorating, purchasing assessment instruments, advertising, billing, etc.
- Group practice—Two or more clinicians offer services
together, usually sharing the costs of the office, office staff, equipment, etc. Hire associates, who either work for a fixed salary or who receive a percentage of the
income they generate from their clients
- Mixed-model practice—Two or more clinicians work together, as in a group practice, but they are legally and financially independent. Clinician may rent space in another office.

Prescription Privileges

- Efforts to allow specially trained clinical psychologists to prescribe psychotropic medication for their clients.
- Advocates
--> 98% of psychologists have referred a client to a psychiatrist for psychotropic medication;
--> 75% of them make such referrals on a monthly basis; and approximately 1/3 clients is taking medication
--> concerned about clients’ inability to gain access to psychiatrists and qualified primary care physicians

- Against
--> worried that existing training for this activity is far less extensive than it is in other health professions and thus might be inadequate to assure
client safety
- recent proposals for training psychologists to prescribe have dropped the prerequisite coursework in the biological and physical sciences that had been identified as necessary by the APA’s Ad Hoc Task Force
--> prescription privileges would lead to an
increasingly intense focus on the medical and biomedical aspects of behavior

Professional Multicultural Competence

- The percentage of clinicians who are women
and/or members of racial and ethnic minority groups has increased dramatically
- sometimes appropriate to alter certain assessment and treatment methods to make them more effective for clients from particular racial/ethnic minority groups
- culturally adapted treatments are more effective than standard treatments for ethnically diverse clients

The Future of Clinical Psychology - Training

- Controversy will likely continue over the question of how clinical psychologists should be trained.

The Future of Clinical Psychology
- Psychotherapy Integration

- The process of combining elements of various clinical psychology theories in a systematic manner
- A number of other integrative therapies are gaining
popularity, including integrative problem-centered therapy, cognitive-affective-relational-behavior therapy
- integration can be a good idea when done in an evidence based way eg--> clinicians can select assessment and treatment methods and apply them to particular clients based on the clinician’s understanding of the research evidence that supports various change principles
- the predominant theme in psychotherapy integration is to find evidence-based practices that can be applied to specific clients at specific times