Clinical Psychology Comprehensive Notes

Clinical Psychology: Definition and Scope

Clinical psychology involves research, teaching, and application of methods and principles to understand and alleviate maladjustment, disability, and discomfort.

It encompasses understanding and predicting:

• Intellectual maladjustment
• Emotional maladjustment
• Medical maladjustment
• Psychological maladjustment
• Social maladjustment
• Behavioral maladjustment

Clinical psychologists work with diverse client populations in various settings to solve many problems, adopting a holistic perspective.

Activities of Clinical Psychologists

Based on Norcross et al. (2004), the activities include:

• Treatment/Intervention: 80%
• Assessment/Diagnosis: 64%
• Research: 51%
• Teaching: 49%
• Clinical Supervision: 50%
• Consultation: 47%
• Administration: 53%

Employment Settings

According to Norcross et al. (2004):

• Private practice: 39%
• University settings: 30%
• Hospital settings: 7%
• Outpatient clinics: 6%
• VA medical centers: 3%
• Other: 15%
• None: 0%

Diversity in Clinical Psychology

Clinical psychologists promote diversity by:

• Increasing representation in training and leadership.
• Incorporating diversity factors in assessment and treatment.
• Creating culturally informed resources.
• Including diverse populations in research.

History of Clinical Psychology: Ancient History

• Involves Greeks, Chinese, Romans, and Egyptians.
• Religious models from Deuteronomy and Plato.
• Physiological models from Hippocrates.

Hippocrates’ Four Bodily “Humors”

• Blood: sanguine temperament (courageous, hopeful, playful, carefree).
• Yellow bile: choleric temperament (ambitious, leader-like, restless, easily angered).
• Black bile: melancholic temperament (despondent, quiet, analytical, serious).
• Phlegm: phlegmatic temperament (calm, thoughtful, patient, peaceful).

History: 18th & 19th Centuries

• Philippe Pinel, William Tuke, Eli Todd, and Dorothea Dix advocated “moral treatment”.

History: Beginnings of Assessment

• Sir Francis Galton: "anthropometric lab".
• James McKeen Catell.
• Alfred Binet & Lewis Termin.
• Army Alpha & Army Beta.
• Robert Woodworth.

History: Beginnings of Treatment

• Jean Charcot, Sigmund Freud, Josef Breuer used hypnosis and explored hysteria.
• Advent of Psychoanalysis (Freud).
• World War II influenced treatment approaches.
• Reactions to psychoanalysis led to Behaviorism & Humanism.
• Emphasis on evidence-based treatments.

History: Beginnings of Research

• Wilhelm Wundt: Structuralism.
• William James.

History: The Profession

• Birth of the American Psychological Association (APA).
• Lightner Witmer.
• Professional journals were published.
• Ethical Standards published.
• Growth of APA.

APA Membership

APA membership has grown significantly over the years.

History: The Profession (cont.)

• Split in the field: APA vs. APS.
• Graduate Training: Boulder Conference, Role of the VA hospitals, “Vail Model”, McFall’s Manifesto-Clinical Science.
• Number of programs: APA vs. PCSAS.

Hx of Psychology in Singapore

The Singapore Psychological Society was founded in 1979 to advance psychology as a science and profession.

Mental Health Practitioners

Various practitioners include:

• Clinical Psychology (PhD or PsyD)
• Counseling Psychologists (PhD or PsyD)
• School Psychologists (PhD or EdD)
• Psychiatrists (MD)
• Psychiatric Nurses
• Psychiatric Social Workers (MSW)
• Other Master’s-level Counselors (MA, MS)

Clinical Psychology Training (U.S./Canadian Model)

• Typically 5-6 years total (after undergrad).
• Ph.D or Psy.D. degree.
• Coursework, Practicum experience, Research.
• Qualifying or comprehensive examination.
• Clinical internship (one year).
• Licensure exam(s).

Counseling Psychology

• Work with healthy individuals or those with adjustment problems (PhD degree).
• Often work in counseling centers on university campuses or within communities.
• Address social relationships, career decisions, mild to moderate anxiety, eating disorder risks.
• Measure academic abilities, personality, interests, vocational aptitude.

School Psychologists

• Work in school settings (PhD degree).
• Work with students, educators, parents, school administrators.
• Promote intellectual, social, emotional well-being.
• Conduct assessments (giftedness, intellectual/learning disabilities, or ADHD).
• Develop learning programs, behavior modification programs.

Health Service Psychology

Comparison:

Psychiatrists

• MD degree.
• Licensed physicians; diagnose, assess, treat, study mental health problems and disorders.
• Attribute biological causes (and brain abnormalities) to mental health problems.
• Use medical approaches for treating patients, including medication and electrical or magnetic stimulation.

Psychiatric Nurse Practitioner

• Usually a master's in nursing.
• Specialize in treating psychiatric patients.
• Diagnose, create, and implement treatment plans.
• Skills overlap with clinical psychologists and psychiatrists.
• Work in research, teaching, administration.
• Can prescribe meds in many U.S. states.

Social Workers

• MSW degree typically.
• Provide psychological treatment to individuals and groups.
• Focus on familial and sociocultural factors underlying psychopathology.
• Often work for public agencies, mental health teams, private practice.
• Lower-cost alternative to psychiatrists and psychologists.

Licensed Professional Counselor

• Usually MA degree.
• Trained to work with individuals, groups.
• Work in private practice, community mental health centers, rehab facilities, correctional facilities, and school, college, university counseling centers.
• More LPCs than any other professional in the mental health workforce.

Marriage and Family Therapists

• Usually a master's degree.
• Attend to marital/couples’ conflict, parent-child conflict, substance abuse, sexual dysfunction, grief, dementia, depression, anxiety, schizophrenia.
• Focus is on individual’s behavior in relationships.

Unregulated Terms

“Psychotherapist,” “Life Coach,” and Other Unregulated Terms

• “Therapist,” “psychotherapist,” and “life coach” are unregulated titles.
• Do not require documentation, licensing, or continuing education.
• Unregulated services are not the same as professional and paraprofessional services.
• Buyer beware!

Other Kinds of HSP Psychologists

• Health psychology: Often clinical psychologists working in medical settings.
• Neuropsychology: Often clinical psychologists with specialized training in assessing brain-behavior relations.
• Forensic psychology: Often clinical psychologists working in the legal system or prisons, etc.
• Clinical child psychology: Working with kiddos and adolescents specifically.

Other Kinds of Psychologists (Without Training to Practice)

• Developmental psychologists: Change of psychological processes over the life span.
• Social psychologists: Individual and group interactions.
• Cognitive psychologists: Mental processes.
• Behavioral neuroscientists: Biology of behavior.
• Quantitative psychologists: Statistical procedures.

Clinical Psychology Training (in the U.S./Canadian Model)

• Typically 5-6 years total (after undergrad).
• Ph.D or Psy.D. degree.
• Coursework, Practicum experience, Research.
• Qualifying or comprehensive examination.
• Clinical internship (one year).
• Licensure exam(s).

Models of Clinical Psychology Training

Practice, Research, Training.

The Scientist-Practitioner Model (The Boulder Model)

• Conference in Boulder, Colorado, in 1949.
• Training in university departments
• Competence in psychological assessment and treatment
• Training as researchers.
• Required to complete a clinical internship.
• Earns Doctor of Philosophy (PhD)

The Practitioner-Scholar Model (The Vail Model)

• Alternative to Boulder model.
• Emphasizes more practice, less science.
• Led to Doctor of psychology (PsyD).
• More therapeutic experience and assessment
• Less rigorous doctoral dissertation.

Emergence of HSP Professional Schools

• High tuitions, large faculty–student ratios
• Acceptance rate 41% to PsyD, 15% to PhD programs
• PsyD faculty have less expertise in evidence-based psychological interventions
• PsyD students accrue more student loan debt
• PsyD students less likely to match to clinical internships
• PsyD students less likely to successfully pass national licensing exam

The Argosy Disaster and Professional Schools of Psychology

• Argosy University: a system of 22 for-profit career colleges.
• Housed one of the largest PsyD programs in the United States.
• Argosy used student aid $to pay payroll and debt rather than give the$ to students.
• Gov’t shut down the aid; Argosy went bankrupt and shut down.
• For-profit schools’ flaws exposed in Argosy fail

Clinical Science Model

The Clinical-Scientist Model

• Popularity of Vail model and PsyD disturbed science-minded clinical psychologists
• Many practitioners used ineffective treatments not supported by research or clinical studies
• Many relied on unreliable and invalid assessment techniques, questioning positive outcomes

Clinical Science Model

• Legitimacy of science in training and in practice of clinical psychologists.
• Academy of Psychological Clinical Science was formed; affiliated with Association for Psychological Science (APS).
• Clinical-scientist model of training involves instruction in empirical methods of research with clinical work.
• Separate accreditation now exists for clinical science programs (PCSAS). Look for it.

Summary of training models

• Scientist-practitioner (Boulder) model: integrates science and practice; practice prioritized
• Practitioner-scholar (Vail) model: emphasizes practice over science; builds clinical skills, de-emphasizes scientific basis
• Clinical scientist model: rigorous training in empirical research methods; integrates scientific principles into clinical practice, changes in health care, education

*A New Wrinkle?

APA developing procedures and accreditation standards for Master’s level practice in CLINICAL PSYCHOLOGY. Impact and NY recognition are questioned.

Clinical Psychology around the World

• United Kingdom: terminal degree is D.Clin.Psych., a three-year degree after undergraduate and applied experience.
• Singapore: Only Master’s degree required; not regulated by Singapore government.

Clinical Psychology in Singapore

• Practice not regulated by the Singapore government.
• Singapore Psychological Society provides a registration service.
• Requirements: applied Master’s or Doctoral psych degree accredited by a national accrediting body, 1000 supervised practicum hours.

Current Issues in the Field

• Professional Regulation
• Impact of Managed Care
• Prescription Privileges
• Technological Innovations

Professional Regulation

Clinical psychologists require a license to practice:

• ~2000 hours of postdoctoral fellowship supervised clinical experience
• Exams: Examination of Professional Practice in Psychology (EPPP) and a state, province, or territory-specific jurisprudence exam.

Why is licensing important?

Licensing regulates the practice of psychology and protects the public and the field of psychology.

Board Certification

Board certification documents expertise within a specific specialty area in psychology. The American Board of Professional Psychology (ABPP) offers certification involving verification of credentials, handling of clinical cases, and oral examination.

Managed Health Care

Managed care (e.g., HMO/PPO) involves "Essential Paradigm Shifts" regarding the number, frequency, and role of sessions, place of change, when therapy ends, and use of community resources. The Mental Health Parity Act of 1996/2008 addresses these issues.

Prescription Privileges

This involves psychologists prescribing medication, which is debated. Status varies.

Technological Innovations / Telehealth

Overview includes ambulatory assessment (ecological momentary assessment, electronically activated recorders, physiological measurements), computerized assessment, and computer-assisted therapy (AI!).

Professional Ethics

Main concern involves history, principles vs. standards, and enforcement.

General Ethical Principles (2002)

• Principle A: Beneficence & Nonmaleficence
• Principle B: Fidelity & Responsibility
• Principle C: Integrity
• Principle D: Justice
• Principle E: Respect for People’s Rights & Dignity

Ethical Scenario A

A scenario involving child abuse reporting and confidentiality concerns is presented, questioning whether to report the abuse despite the mother's wishes.

Competence

Clinical psychologists must:

• Practice within their competence.
• Represent their training accurately.
• Be sensitive to personal attributes of clients.
• Not allow personal problems to interfere with treatments.
• Receive informed consent for services.
• Adhere to ethical standards’ guidelines.

Privacy and Confidentiality

Confidentiality is chief to client-psychologist relationship. Clinical psychologists can act against wishes of client when someone may be at harm/risk, a client has been harmed, a client may attempt fatal harm to self, or the client is a minor.

Privacy and Confidentiality: Harm to Others

The Tarasoff case set a precedent for a “duty to warn.” Uncertainty exists in “imminent” time frames and vague ideations of homicide/suicide.

Privacy and Confidentiality: Others Harming a Client

Law requires reporting client abuse, but this can be challenging when clients may not want to be reported or the perpetrator is present. Clients may feel betrayed.

Privacy and Confidentiality: Clients’ Self-Harm

The Baker Act allows individuals at “imminent risk” to be held against their will between 48 and 72 hours.

Privacy and Confidentiality: Working with Youth

Confidentiality is not offered to minor clients; parents can request all details, and therapists must disclose life-threatening issues.

Ethical Scenario B

A scenario questions if a psychologist dating a patient's niece is ethical.

Ethics in Relating with Clients

Psychologists should decline working with clients when there is a dual relationship, therapy no longer helps, treatment is inconsistent with diagnoses, clients decide therapy is no longer required, or charging for unnecessary services.

Consenting Professional relationship

Clients begin with obtaining informed consent, informing clients about the treatment/assessment process, addressing their fears, reviewing a consent form, and answering client questions.

Research Ethics

Clinical psychologists must adhere to these ethical standards when conducting research: informed consent, confidential data, extreme care if using deception, debriefing, no data fabrication, and avoid plagiarism.

Research Methods in Clinical Psychology

Epidemiological Research, Correlational Methods, Experimental Methods.

Epidemiological Research

Definition involves incidence and prevalence.

Correlational Research

To observe and measure the relationship between two variables. The Pearson correlation coefficient ($r$) is used.

The downsides includes third Variable Problem, Where $x$ may influence $y$; alternatively, a third variable $z$ may influence them both.

Correlation Matrix

A table showing correlations between multiple variables.

Factor Analysis

A correlational technique designed to reduce the size of a large matrix down to “factors” or dimensions. Used for theory and scale development.

Advanced Correlational Techniques

Confirmatory Factor Analysis, Structural Equation Modeling, Latent Trait Modeling / Item Response Theory, Latent Class Analysis / Taxometrics, Latent Growth Curve Modeling.

Experimental Research

Used to study cause-effect. Independent Variable, Dependent Variable, Random Assignment. Advantages & Disadvantages.

Psychological Measurement (Psychometrics) & Clinical Assessment

Basic Psychometric & Statistical Concepts

Normal Distribution, Mean/Median/Mode, Standard Deviation, Skewness.

Test “Norms”

Raw scores are meaningless without norms, such as the mean ($M$) and standard deviation ($SD$).

Test Scaling

To aid interpretations, test scores are generally scaled to a common metric.

The following formula can be used: $Scaled = \frac{RawScore - NormMean}{NormSD} \times scaledSD + scaledM$

Reliability

Definition and Types: Test-Retest / Temporal Stability, Interrater / Interjudge, Internal Consistency.

Interrater Reliability

Cohen’s Kappa statistic can be used to measure interrater reliability.

Internal Consistency Reliability

Definition and Ways to assess includes Split-half, Cronbach’s coefficient alpha, McDonald’s omega.

Reliability Recap

Why should we care about reliability?

Unreliability decreases test validity and our confidence that observed scores reflect “true” scores.

Standard Error of Measurement

How is it operationalized

If $SD$=15 & Reliability=.90, then $SEM$=4.7
If $SD$=15 & Reliability=.60, then $SEM$=9.5
If $SD$=15 & Reliability=.30, then $SEM$=12.5
If $SD$=15 & Reliability=.00, then $SEM$=15.0

$SEM = SD<em>{test} \sqrt{1 - reliability</em>{test}}$

Validity

Validity comprised of many “aspects” …

• Definition
• Face Validity
• Content Validity Relevance and representativeness
• Criterion-related Validity Concurrent vs. predictive validity

Construct Validity

“Construct”, Convergent Validity, Discriminant Validity, Nomological Net (Cronbach & Meehl, 1955) Construct = Theory, Construct Validation = Theory testing.

Methods of Psychological Test Construction

Content Validation Approach, Empirical Criterion Keying Approach, Factor Analytic Approach, Construct Validation Approach.

Content Validation Approach

Items selection with the following two questions:

• Do items appear to measure the construct?
• Are they representative?

Empirical Criterion Keying

• Item selection based on discrimination between normal vs. criterion groups.
• Item content is less important.

Factor Analytic Approach

• Item selection based on intercorrelations and factor analysis.
• Looking for underlying dimensions.

Construct Validation Approach

• Combines previous three approaches.
• Scales are developed to measure specific construct from a theory.