Exam 1: Intro to Clinical Psych

Scientist-Practitioner Model: also known as the Boulder model; balances practices and science.

• Must know clinical and research methods 

• A lot of people have been unhappy with/ this training because they were doing more clinical work rather than research

Scholar-Practitioner Model: focuses on delivering psychological services 

• This led to the development of the PsyD 

• Today around ½ of the doctoral degrees awarded are PsyDs 

Psy D. v.s. Ph.D.

• Ph.D: stronger emphasis on research 

• smaller class sizes

• More full-time faculty

• Higher admissions

PsyD: stronger emphasis on delivering therapy;

• Free sending & independent schools; lower admission standards

• Offer less funding to students; larger class size; Lower rates of success w/ getting into APA predoctoral internship (needed to complete the doctoral program) 

Clinical Scientist Model: emphasis on empirically supported treatments and scientific training (even more than the scientist-practitioner model).

• Richard McFall: in 1991 he published the “Manifesto for a Science of Clinical Psychology”

• Clinical Psych Programs are very competitive about 17% of applicants get in v.s. PsyD about 40%-50% of applicants get in.

• Try to get a high GPA (around 3.5 or higher)

• try to get to know your professors! leads to stronger letters of recommendations

• Research experience; High GRE scores 

• Clinically relevant experience 

• GRE: Graduate Record Examination 

• Personal Statement needs to include goals, why you’re applying to that specific program & career aspirations.

• Get people to revise your statement 

Graduate Training:

• Comprehensive Exams 

• Clinical Training: Practicum training; Required one-year-long pre-doctoral internship 

• Graduate from an APA-accredited program…a one-year long-predoctoral internship is required (for PHD & PsyD) 

Research Training:

• Grad students work closely with faculty mentors to develop an are of research 

• Many (not all) PhD programs require their students to complete a master’s thesis

• All PhD programs require their students to complete a doctoral dissertation 

• Students must defend their dissertation to a committee of faculty members to demonstrate their knowledge.

Predoctoral Internship:

• All clinical psych programs end in a 1 year internship. 

• Full year of supervised clinical experience in an applied setting.

• Program should be accredited by the APA. If not…that could impact your licensing a clinical psychologist

• Must complete b4 the doctoral degree is awarded. Application processes have many similarities to applying to grad programs.

• ”Match” process

Post-Doctoral Training:

• Clinical: most states require 1-2 years of postdoctoral training for licensure.

• Research: at academic institutions; typically funded by faculty grants 

• Getting Licensed: requirements vary in each state; need to pass the national licensure exam ( the examination for professional practice in psych). Also a state specific exam!

Continuing Education: staying updated w/ new findings in psych

Activities and Work Settings:

• Research + Teaching 

• About 50% of clinical psychologists pend @ least part of their time teaching

•  Supervision: a specialized type of teaching for grad students 

• Take many forms: direct observations, reviewing audio or video taped sessions 

• Potential Ethical Issues

• It can also be difficult to evaluate the performance of. supervisee

• Psychotherapy: most predominantly engaged in activity 

• Assessment: second most common activity

• Consultation: formal; ex: a school hire…this is where you’ll evaluate students w/ behavioral problems or to work w/ teachers to find effective interventions 

• Informal: consultations often take place informally between colleagues. Administration 

Distinguishing Clinical Psychology from Related Professions:

• Psychiatry: attend school and re licensed physicians, spend less time w/ psychotherapy, mostly prescribe meds (psychotropic medicine)

• Counseling Psych: differences are shrinking(compared to clinical psych) tend to everyday problems of life. Ex: big life transitions like break ups, moving, death, etc.

• School Psych: psychological testing to diagnose learning disabilities, ADHD, developmental delays, a lot of consultations. Master degree.

• Professional Counselor: Masters degree, focus on psychotherapy (not assessment or research). Takes 2-3 years to complete.

• Social Work: alleviate the person’s problems, protecting them from their environment & putting them in a better one. Help individuals combat homelessness, helping children find homes, etc. Clinical training takes about 1 yer. helps people w/ food stamps disability, etc.

Assessment Diagnostic:

• 1800’s Europe labeling systems began to take place.

• Neurosis: individual that suffers from mental health symptoms but still in touch w/ reality 

• Psychosis: broken from reality 

• Emil Krapen: (1855-1926) published the firstt textbook on psychiatry; considered the “father of descriptive psychiatry.” Dementia predecessor of schizophrenia; exogenous + endogenous disorders

• The first DSM was published in 1952

• DSM-II published in 1968 (no major changes)

• DSM-III published in 1980 worked w/ significant change provided specific diagnostic criteria 

• The DSM has been revised several times (currently on DSM-5) but no change has been as significant as the DSM-III

• Rapid expansion of the disorders in DSM

• number of disorders represented in the 1st DSM increased by 300% from one of the most recent ones, DSM-4 (1994)

Assessment of Intelligence:

Alfred Binet: 1857-1911; helped children w/ learning disabilities. Established to help public school students w/ class placements & to identify any learning disabilities 

In 1939 David Wechsler: Created the intelligence test for adults. Wechsler-Bellevue test.

• Has been revised several time; now known as the Wechsler Adult Intelligence Scale (WAIS)

• He also created tests for different ages: Wechsler Intelligence Scale for Children (WISC). Wechsler Preschool & Primary Scale of Intelligence (WPPSI)

Assessment of Personality:

• Projective Personality Test: a personality test in which people project their personality characteristics win responses to ambiguous or vague stimuli 

• Influenced by psychodynamic theory  

• Projective Assessment of personality: hermann Rorschach (1884-1922), Inkblot Test (Rorschach ink-blot Method)

• Thematic Apperception Test (TAT): developed @ Harvard by Henry Murray & aas published in 1938 

• Objective Personality Tests: more scientifically sound; scoring & interpretation is more straightforward. Typically self-directed…paper and pencil instruments 

• Minnesota Multiphasic Personality Inventory: (MMPI; Hathaway & McKinley) Published in 1943. Validity scales assessed random responding, and intentionally misleading responses. 

• Clinical psychologists: have also developed more specialized

• assessments

• Ex: The Beck Depression Inventory (BDI)

• Psychotherapy

• -1930s: most clinical psych workers worked in an

• academic settings.

• -1940's, 1950's: psychotherapy began playing a larger role

• Influence of War on Clinical Psych

• -Intelligence tests were used in WWI

• WWI created a demand for more clinical psychologists w/ soldiers coming home w/ "shell shock" (PTSD)

• B4 WWI, very few graduate programs offered training in clinical psych.

* Led to accreditation programs + requested formalized therapy.

• Psychodynamic Approach: rurally dominated; challenged as time passed, different approaches were developed.

• Behavioral Approach: popular in the 1950's, and 1960's, emphasized empirical method; measure problems&

• progress in observable, quantifiable terms

• Humanistic Approach ("client-centered"): popular in 1960's; relationship, personal growth.

• Cognitive Therapy: currently very popular; emphasis on logical thinking.

• Criticism of projective assessments beginning in 1950's

• An extensive review of projective techniques concluded

• Standards for normative data

• Psychological tests now need to ensure that normative data comes from a representative sample (ex: ensure there's diversity in your sample)

Additional Growth

• The trend to push specialization

• Increase clinical psych training programs

• Psychologists in APA are clinical psychologists who are more dominated by clinical interests.

• Moral Treatment Movement: significant efforts were made to reform mental health treatment.

• William Take: 1732-1822 founded the York Retreat in England

• Philippe Pinel: 1745-1826 worked to reform mental health care in France

• Also encouraged record-keeping

• Eli Todd: 1762-1832 advocated for the humane treatment of the mentally in the U. S.

• Opened the retreat in Hartford, Connecticut in 1824.

• Dorothea Dix: 1802-1887 her efforts resulted in the establishment of more than 3 state institutions for the mentally ill in the U. S.

• Lightner Witmer: (1867-1956) before Witmer, psych was an academic discipline only focused on research not on the application,

• Opened the first psychological clinic in 1896, primarily treated children w/learning difficulties

• Witmer was the first to propose the profession of clinical psych formally

Psychiatrists and clinical psychologists are different…Psychiatrists can prescribe medication

Several states have granted psychologists prescription privileges to their clients

Why is this helpful…

* This may be due to a shortage of psychiatrists—> underserved populations could benefit 

* Clinical psychologists are more expert than primary care physicians (50-80% of prescriptions are written for medication 

* Other non-physicians already have prescription privileges…why not extend that to clinical psychologists. (Professions that have prescription privileges: dentists, podiatrists, advanced practice nurses, optometrists, etc.)

* Convenience for the client 

* Professional autonomy. They’re able to treat their clients on their own

* Professional identification. Would further differentiate clinical psych from other mental health professionals

* Evolution of the profession. May progress the field

* Revenue of the profession. Could offset salary decreases

Arguments against Prescription Privileges:

* Training Issues. What kind of education should clinical psych receive b4 prescribing? How in-depth should it be, and when should it occur?

* Threats Psychotherapy: the way psychologists understand and interact with their clients may change from behavioral, cognitive, and emotional processes to symptom reduction via meds

* Identity confusion/ Client confusion 

* Potential influence of the pharmaceutical industry. What if drug companies push clinical psychologists to give their clients medication? Pharmaceutical companies pressuring psychologists to give their clients more meds to

Overexpansion of Mental Disorders:

* DSM range has expanded drastically 

* Authors of the DSM review research and solicit feedback from professionals b4 including any new disorders/changing any existing disorders

*  Concern about pathologizing (deeming time as a mental disorder) normal behaviors. Ex: Anxiety

New Disorders and Definitions of Old Disorders:

* What might lead to overexpansion? Introducing new disorders that capture experiences once considered “normal.” Ex: premenstrual dysphoric disorder, binge-eating disorder, prolonged grief disorder

*  “Lowering the bar” or diagnosing existing disorders (so that the criteria for a disorder might apply to more people. Ex: changing the ag to diagnosis ADHD must be present from 7 to 12 

* Potential Consequences: People might receive treatment for things they don’t actually need

Overexpansion: Influence of the Pharmaceutical Industry?

* Some professionals attribute overexpansion to the pharmaceutical industry

* 69% had financial ties to major pharmaceutical companies…as a result, DSM-5 did place some limitations on involvement in terms of the amount a company stock could be owned. ( the amount of payment they receive from companies)

*    Professionals that have financial ties with pharmaceutical companies are more likely to prescribe their patient's medications than professionals that aren’t 

Influence of Tech:

* Covid had an impact with the increase of tech to deliver therapy 

* Tech delivery services from 7% pre-pandemic to 85% during COVID

* Pandemic increased the # of people seeking psychological services

* Telepsychology—> the use of tech including the internet, videoconferencing

(zoom) smartphones, and text-based services in the application of clinical psych. 

* Apps, email, texts, and VR help clients immerse themselves in situations where they experience anxieties. Helps manage their fears. Exposure therapy + practice good coping mechanisms. Typically used for people with phobias, PTSD, and anxiety disorders. 

* Potential to help underserved populations

* Research for tech psych has been favorable   

Rise of Multiculturalism in Clinical Psych:

* Diversity is increasing within the US in numerous ways

* Individuals seeking mental health services are coming from a wider variety of cultural backgrounds   

* Culture shapes the way the client understands the problems for which they’re going through and seeking help for 

Recent Efforts to Emphasize Issues of Culture:

* Increase of specialized journals and books 

* Emergence of APA divisions. Ex: Society for the Psychology of Sexual Orientation and Gender Diversity (Division 44): Society for the Study of Culture, Ethnicity and Race (Division 45)

* APA has ethical could that make professionals uphold cultural sensitivity and competence 

* Principe E: Respect of People’s Rights and Dignity

* Psychologists need to be aware of and respect different cultures, individuals, and role difference    

* Standard 2.01 Boundaries of Competence 

* Standard 3.01 Unfair Discrimination   

* APA accreditation standards for graduate programs. “Cultural and Individual Differences and Diversity” is one of 8 domains that a program must address 

* DSM changes in light of multiculturalism

* General guidance to help w/cultural competence. Ex: suggests aspects of culture to assess clients   

Glossary listing of cultural concepts of distress

Includes 9 terms that represent psychological problems observed in groups in various parts of the world 

* Taijin Kyofusho—> a condition in which a person anxiously avoids interpersonal situations because they believe that their appearance, actions, or odor will offend other people 

* Revisions of prominent assessment methods. Ex: Minnesota Multiphasic Personality Inventory (MMPI) was revised and became the MMPI-2

Knowledge of Diverse Cultures:

* Need to be familiar with the client’s culture; this is an ongoing process

-Learning about one's own culture

* Everyone’s viewpoint is unique, everyone has had unique experiences

* Realize that difference between people are not deficiencies 

* Discus discomfort 

Cultural Humility—> an attitude about diversity centered on the recognition of the limits of your own knowledge and an openness to learning about the identities and experience of other people      

Culture—> small groups within a society that my not fully constitute cultural groups but whose members may nonetheless posses typical and culturally meaningful characteristics

* Ex: a psychologist working in a prison setting, working w/ military personnel

* It’s important to keep in 

* Adolescents are identified as a subculture 

* Be aware of microaggressions—>comments or actions made in a cross-cultural context that convey prejudicial, negative or stereotypical beliefs. May express or suggest dominance or superiority    

-Cultural adaptation of treatments w/ empirical evidence…we can’t assume that because a treatment works for one group it would work with other clients wit the same background  

* Ex: guided imagery scripts

* The DSM changes in the light of multiculturalism…helps with cultural competence

American Psychological Association Code of Ethics:

* professionals are obligated to behave ethically

* Ethics will be touched on at various points during the course 

* APA published its first code of ethics in 1953

Theres 2 distinct sections  :

* General Principles

-Aspirational—> broaer descriptions of ethical behavior 

* Ethical Standards

-Enforceable—>rules of conduct. Psychologists can be found guilty of an ethical violation if they break these rules

APA General Ethical Principles:

A. Beneficence and Nonmaleficence: “psychologists strive to benefit those w/ whom they work & take care do n harm”

B. Fidelity & Responsibility: “Psychologists establish relationships of trust w/ those whom they work”

C. Integrity: “Psychologists seek to promote accuracy, honesty, & truthfulness in the processes, procedures and services being conducted by psychologists”

D. Justice: “all persons to access and benefit from the contributions of psych 

E. Respect for People’s Right and Dignity: clients are able to decline services/treatment at any point 

Psych Ethical Beliefs:

* Some behaviors are considered blatantly unethical by by the majority of respondents 

* Some behaviors are considered unquestionably ethical

* Most other behaviors (covered in the ethical code) fall into a gray area   

Confidentiality:

Standard 4.01: “Psychologists have  a primary obligation and take reasonable precautions to protect confidential info

However, some situations require clinical psychologists to break confidentiality…

Tarasoff and the Duty to Warn:

August 1969– a student @ the University of California @ Berkley (Prosenjit Poddar)

* Become romantically interested in another student (Tatiana Tarasoff) sought therapy and shared that he wanted to kill Tatiana.

* His psychologist broke confidence; police got involved, and the student never returned to therapy

* October 1969–Poddar killed Tarasoff (stabbed and shot her); Tarasoff’s parents sued the psychologist and others involved in the case for wrongful death

Court found the psychologist liable: known as the Tarasoff v. Regents of the University of California (1974)

Duty to Warn:    

Duty to Warn: also known as the duty to protect. Began after the Tarasoff case; st of legal precedent for psychologists. Duty to warn people toward whom their client makes credible, serious threats.

* “The protective privilege ends where the public peril begins”

Professionals could potentially save lives 

* There are some potential difficulties w/ practical applications

Confidentiality With Children and Adolescents:

* Confidentiality is often more of a challenge w/ minors; Concerns about privacy from caregivers.

* Clinical psychologists will sometimes openly discuss this dilemma w/ clients and their parents 

* Reach an informal agreement regarding confidentiality 

Disclosing Vs. Not disclosing can be complicated   

Child Abuse: every state has laws requiring mental health professionals to break confidentiality to report known or suspected child abuse.

* Can require difficult judgment calls…tricky issues like a client not wanting to disclose the identity of the potential abuser; disclosing abuse from parents/guardians.

Informed Consent:

* Informed Consent: the ethically mandated process of informing a person about proposed activities (ex: as a therapy client or research participant) and obtaining the individual’s voluntary consent before proceeding with/ the activities 

* Likely, you have all had to consent to being in a research study

* Also needed in assessment, therapy 

* Gives the individual the right to gather info or refuse   

Purpose of Informed Consent:

* Research: study, procedures, length of time required, risk or adverse effects, incentives to participate, right to decline.

* Assessment: Nature and purpose of the assessment, any relevant fees, the involvement of other parties, and limits of confidentiality 

* Therapy: nature and the anticipated course of therapy, fees, involvement of 3rd parties, and limitations of confidentiality

-Lastly, provide an opportunity for clients to ask questions 

Boundaries and Multiple Relationships:

Ethical Standard 3.05a (APA) states that a multiple relationship occurs when a psychologist is in a professional role w/ a person and:

1. At the same time is in another role w/ the same person

2. At the same time is in a relationship w/ a person closely associated w/ or related to the person whom the psychologist has a professional relationship 

3. Promise to enter into another relationship in the future w/ the person or person closely associated w/ or related to the person 

Sexual Multiple Relationships: one of the most damaging (ex: the psychologist becomes a sexual partner of the client)

* The APA states that “Psychologists do not engage in sexual intimacies w/ curretn therapy clients/patients” Standard 10.05

Nonsexual Multiple Relationships: friendship, business relationships, affiliations through religious activities, etc. 

Not every multiple relationship is unethical…

“A psychologist refrains from entering into multiple relationships if the multiple relationships could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.  Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.” (Ethical Standard 3.05a)

Overall having multiple relationships with a client can be a slippery slope…many times major violations are preceded by a “slow process of boundary erosion”

* Other common examples of gray areas:

Hugging, accepting gifts, sharing food or drinks, self-disclosing one’s thoughts and feelings, borrowing or lending objects

Competence:

 Competence: sufficient capability, skills, experience, and expertise to complete particular professional tasks adequately.

* Psychologists should be providing services, teaching, and conducting research w/ populations and in areas within the boundaries of their competence 

* Having a degree or licensure doesn’t automatically make a psychologist competent for all activities. Ex: training w/ adults—competent to work w/ children?

Psychologists also have to make an effort to remain competent past the initial 

training/experiences. Continuing education.

A psychologist’s problems might also interfere with/ their work

* Must take appropriate measures to address those issues if not then it’s possible those problems could linger into their jobs

Burnout: state of exhaustion that relates to engaging in continually emotionally demanding work.

* 1/3 of clinical psychologists experience burnout (study population of 500)

Burnout:

Approximately 2/3 of clinical psychologists report experiencing mental health difficulties themselves (Tay et al., 2018)

* Many mental health professionals seek therapy themselves during their careers

* Can impact their careers

-Reach out for support or seek self-care

Self-care: deliberate efforts by clinical psychologists to maintain or enhance their well-being to enable themselves to provide high-quality professional services.  

Contemporary Ethical Issues:

* Managed care and ethics: a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by Mangang company

* Managed care companies can put clinical psychologists in a position of divided loyalty

-Psychologists also often face pressure to give a DSM diagnosis of some kind 

-Unethical, can constitute insurance fraud

* Tech and ethics 

* make sure that the technology used is secure

* Social media? 

Ethics in Small Communities:

Living in a rural or small town

* Can be an issue in larger cities (often communities exist defined by ethnicity, religion, sexual orientation, etc)

The issue of multiple relationships is likely the most difficult in these settings 

What if you are a clinical psychologist living in a small town?

* May not be able to refer our client to another professional 

* It’s likely helpful to educate the client about multiple relationships from the beginning