Chapter 5: Ethical and Professional Issues in Clinical Psychology

American Psychological Association Code of Ethics

• First published in 1953, with nine subsequent revisions

• Applies to all specialties, but especially relevant to clinical psychologists

• Divided into aspirational (general principles) and enforceable (ethical standards)

• Models for ethical decision making, such as Celia Fisher's model

• Psychologists' ethical beliefs based on surveys and studies

Confidentiality

• Confidentiality specifically mentioned in general principles and ethical standards

• Tarasoff case and the duty to warn and protect

• Challenges faced by clinical psychologists in interpreting and applying duty to warn

• Dilemmas when the client is a child or adolescent and how much to reveal to parents

Informed Consent

• Informed consent is required during research, assessment, and therapy

• Facilitates an educated decision-making process

Boundaries and Multiple Relationships

• Multiple relationships can be problematic

• Ethical standard 3.05a defines sexual and nonsexual multiple relationships

• Criteria for impropriety in multiple relationships: impairment in the psychologist and exploitation or harm to the client

Competence

• Competence includes being a competent psychologist, boundaries of competence, and remaining competent

• Personal problems and burnout can affect competence

Ethics in Clinical Assessment

• Ethical considerations in test selection, test security, and test data

Ethics in Clinical Research

• Ethical obligations in conducting research

• Efficacy of psychotherapy and the ethical dilemma of participants who don't receive treatment

Contemporary Ethical Issues

• Managed care and the position of divided loyalty

• Ethical issues related to technology, such as psychological tests on the internet and online therapy practices

• Ethics in small communities and ways to overcome ethical issues

Chapter 6: Conducting Research in Clinical Psychology

Why Do Clinical Psychologists Do Research?

• To gain knowledge about psychological disorders and establish a foundation for the field

How Do Clinical Psychologists Do Research?

• Research on treatment outcomes to determine the effectiveness of therapies

• Distinguishing between statistical significance and clinical significance

• Research on assessment methods to evaluate and improve them

• Research on diagnostic issues, such as validity, reliability, and relationships between disorders

• Research on professional issues, including activities, beliefs, and practices

• Research on teaching and training issues, such as training philosophies and specialized training

Conclusion

• Clinical psychologists engage in research to gain knowledge about psychological disorders, evaluate treatment outcomes, improve assessment methods, explore diagnostic issues, examine professional issues, and address teaching and training concerns. Ethical considerations, such as confidentiality, informed consent, boundaries, and competence, are essential throughout the research process.

Page 34: How Do Clinical Psychologists Do Research?

• The experimental method is used in clinical psychology research.

• The method involves observation of events, development of hypotheses, empirical testing of the hypotheses, and alteration of hypotheses based on results.

Page 35: The Experimental Method

• The development of hypotheses in the experimental method includes independent and dependent variables.

• Randomized clinical trials (RCTs) are used to maximize internal validity.

• RCTs are criticized for producing results that may not translate to the real world.

Page 36: Quasi-Experiments

• Quasi-experimental designs are used when constraints limit the testing of certain hypotheses.

• Quasi-experimental designs are less scientifically sound than experimental designs.

Page 37: Between-Group Versus Within-Group Designs

• Between-group designs involve an experimental group and a control group.

• Within-group designs involve comparisons of participants in a single condition at various points in time.

Page 38: Analogue Designs

• Analogue designs involve an approximation of the target client or situation.

• Analogue designs use participants whose characteristics resemble those of the target population, or ask participants to imagine themselves in a certain situation.

Page 39: Correlational Methods

• Correlational studies are conducted when neither an experiment nor a quasi-experiment is plausible.

• Correlational studies examine the relationship between two or more variables.

Page 40: Case Studies

• Case studies involve a thorough, detailed observation and examination of a person or situation and individual behavior.

• Case studies stimulate systematic research which converges on important findings.

Page 41: Case Studies

• Case studies are highly regarded by researchers who prefer an idiographic approach.

• Case studies use some variation of an ABAB design.

Page 42: Meta-Analysis

• Meta-analysis is a statistical method of combining results of separate studies to create a summation of findings.

• Meta-analysis is a quantitative analysis in which the full results of previous studies each represent a small part of a larger pool of data.

Page 43: Meta-Analysis

• The process of conducting a meta-analysis should incorporate five steps: formulating the research question, obtaining a representative study sample, obtaining information from individual studies, conducting appropriate analyses, and reaching conclusions and offering suggestions.

Page 44: Cross-Sectional Versus Longitudinal Designs

• Cross-sectional designs are easier and more efficient.

• Longitudinal designs require longer periods of time and provide valid approximations for changes that take place or evolve over time.

Page 45: Use of Technology in Clinical Psychology Research

• Technology is used for data collection in clinical psychology research, such as sending e-mail surveys and using actigraphs to measure sleep quality.

• Amazon Mechanical Turk or Mturk is also used for data collection.

• Technology is also used as a clinical intervention.

Page 46: Chapter 7 Diagnosis and Classification Issues

Page 47: Defining Normality and Abnormality

• Abnormality can be defined by personal distress to the individual, deviance from cultural norms, statistical infrequency, and impaired social functioning.

Page 48: Defining Normality and Abnormality

• The harmful dysfunction theory defines a disorder as a harmful dysfunction, combining value and scientific components based on social norms.

• Harmful dysfunction refers to the failure of a mental mechanism to perform a natural function.

Page 49: Who Defines Abnormality?

• The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines mental disorder as a clinically significant disturbance in cognition, emotion regulation, and behavior.

• The DSM indicates a dysfunction in mental functioning and distinguishes it from expectable reactions to common stressors.

Page 50: Who Defines Abnormality?

• The DSM reflects a medical model of psychopathology and is influenced by the culture and values of those defining disorders.

• The DSM categorizes disorders with a list of specific symptoms.

Page 51: Importance for Professionals

• The presence or absence of a diagnostic label strongly impacts the attention it receives from clinical psychologists.

Page 52: Importance for Clients

• The absence of a diagnosis means the absence of a label.

• The label of a diagnosis can lead to stereotyping of individuals and can have an effect on the outcome of legal issues.

Page 53: Diagnosis and Classification of Mental Disorders: A Brief History

• Discussions of abnormal behavior appear in ancient Chinese, Hebrew, Egyptian, Greek, and Roman texts.

• Hippocrates' theories of abnormality emphasized natural causes and were a significant early step to current definitions.

Page 54: Diagnosis and Classification of Mental Disorders: A Brief History

• Mental asylums were established in Europe and the U.S. in the 19th century, helping to categorize disorders.

• There was an evolution of common terminology in the field of mental disorders.

Page 55: Diagnosis and Classification of Mental Disorders: A Brief History

• Emil Kraepelin is considered the founding father of the current diagnostic system.

• Kraepelin labeled specific categories, such as manic-depressive psychosis and dementia praecox.

Page 56: Diagnosis and Classification of Mental Disorders: A Brief History

• In the late 1800s and early 1900s, the collection of statistical and census data was the primary purpose of diagnostic categories.

• The Veterans Affairs developed its own early categorization system to facilitate diagnosis and treatment of soldiers returning from World War II, which had a significant influence on the creation of the first DSM.

Page 57: DSM—Earlier Editions (I and II)

• DSM-I was published by the APA in 1952.

• A revision was published as DSM-II in 1968.

• Both editions were similar to each other but different from subsequent DSM editions.

Page 58: DSM—Earlier Editions (I and II)

• DSM-I and DSM-II defined only three categories: psychoses, neuroses, and character disorders.

• The definitions of disorders in these editions were not scientifically or empirically based.

Diagnosis and Classification of Mental Disorders: A Brief History

DSM—Earlier Editions (I and II)

• Language reflected psychoanalytic approach to understanding people and their problems

• Vague descriptions of clinical conditions described in prose

• Specific symptoms or criteria not listed

• Very limited generalizability or utility for clinicians

DSM—More Recent Editions (III, III-R, IV, and IV-TR)

• DSM-III (1980) relied on empirical data and used specific diagnostic criteria to define disorders

• Psychoanalytic language replaced by terminology that reflected no single school of thought

• Multiaxial assessment system introduced

• Longer and more expansive than predecessors

• Included many new disorders

• DSM-III-R, DSM-IV, and DSM-IV-TR retained major changes introduced by DSM-III and introduced significant other changes

DSM-5: The Current Edition

• Published in 2013, the first substantial revision after 20 years

• Led by David Kupfer and Darrel Regier

• Researched over 12 years

• Coordinated efforts with WHO

• Steps included the creation of Task Force, work groups, scientific review committee, field trials, and a website to communicate progress to the public

DSM-5: The Current Edition—Changes DSM-5 Did Not Make

• Changes considered but not made include the use of biological markers as diagnostic tools, rating of disorders/symptoms on a scale, and a dimensional approach toward a disorder

• Rejections of new disorders such as attenuated psychosis syndrome, mixed anxiety-depressive disorder, and internet gaming disorder

DSM-5: The Current Edition—New Features in DSM-5

• Title change to DSM-5

• Dropped multiaxial assessment system

DSM-5: The Current Edition—New Disorders in DSM-5

• Premenstrual dysphoric disorder

• Disruptive mood dysregulation disorder

• Binge eating disorder

• Mild neurocognitive disorder (mild NCD)

• Somatic symptom disorder (SSD)

• Hoarding disorder

DSM-5: The Current Edition—Revised Disorders in DSM-5

• Bereavement exclusion

• Autism spectrum disorder

• Attention-deficit/hyperactivity disorder: increased age of symptoms from 7 to 12, minimum number of symptoms in adults increased to 5

• Bulimia nervosa: frequency of binge eating reduced to once/week

• Anorexia nervosa: reduction of less than 85% of the body weight

• Substance use disorder

• Mental retardation renamed intellectual disability or intellectual development disorder

• Learning disabilities in math, reading, and writing combined as specific learning disorder

• Obsessive Compulsion Disorder removed from Anxiety Disorders to new category

• Mood Disorders split into two: Depressive Disorders and Bipolar and related disorders

DSM-5: The Current Edition—Controversy Surrounding DSM-5

• Many "work group" members quit midway

• Leaders of mental health organizations boycotted DSM-5

• Allen Frances was the most vocal critic, criticizing changes as unsafe and scientifically unsound, and arguing that DSM-5 will mislabel normal people, promote diagnostic inflation, and encourage inappropriate medication use

• Specific criticisms by others include diagnostic overexpansion, transparency of the revision process, membership of the work groups, field trial problems, and price

Criticisms of the DSM

• Recent editions of DSM widely used by all mental health professions

• Strengths include emphasis on empirical research, use of explicit diagnostic criteria, interclinician reliability, atheoretical language, and facilitated communication between researchers and clinicians

• Criticisms include breadth of coverage, controversial cutoffs, cultural issues, gender bias, nonempirical influences, and limitations on objectivity

Page 83: Alternative Directions in Diagnosis and Classification

• Categorical Approach

• Dimensional Approach

  • Five-factor model of personality

    • Neuroticism

    • Extraversion

    • Openness to experience

    • Agreeableness

    • Conscientiousness

Page 85: The Interviewer (1 of 7) General Skills

• Interviewer should acquire general skills as foundation for conducting interviews

• Requirements

  • Quieting themselves

  • Being self-aware

  • Developing positive working relationships with clients

Page 86: The Interviewer (2 of 7) Specific Behaviors: Eye Contact

• Eye contact

  • Facilitates and communicates listening

  • Makes client feel heard

  • Requires interviewer to have cultural knowledge and sensitivity

Page 87: The Interviewer (3 of 7) Specific Behaviors: Body Language

• Culture shapes connotations of body language

• General rules for interviewer

  • Face the client

  • Appear attentive

  • Minimize restlessness

  • Display appropriate facial expressions

Page 88: The Interviewer (4 of 7) Specific Behaviors: Vocal Qualities

• Skilled interviewers

• Use pitch, tone, volume, and fluctuation

• Attend closely to the vocal qualities of clients

Page 89: The Interviewer (5 of 7) Specific Behaviors: Verbal Tracking

• Effective interviewers monitor the client's train of thought by

  • Repeating key words and phrases

  • Weaving clients' language into their own

  • Shifting topics smoothly

Page 90: The Interviewer (6 of 7) Specific Behaviors: Referring to the Client by the Proper Name

• Inappropriate addressing can jeopardize the client's sense of comfort with interviewer

• Mistakes

  • Using nicknames or shortening names

  • Omitting essential "middle" name

  • Addressing client by first name

Page 91: The Interviewer (7 of 7) Specific Behaviors: Observing Client Behaviors

• Important decisions can be informed by behavioral observations of client

• Observing behaviors allows psychologist to consider nonverbal components

Page 92: Components of the Interview (1 of 13) Rapport

• Strong sense of rapport brings sense of connect with interviewer

• To establish good rapport with clients

  • Make an effort to put the client at ease

  • Acknowledge unique, unusual situation of clinical interview

  • Enhance rapport by following client's lead

Page 93: Technique: Directive Versus Nondirective Styles

• Directive questioning approach

  • Tends to be targeted toward specific pieces of information

  • Client responses are typically brief

  • Can sacrifice rapport in favor of informational data that clients may not otherwise choose to disclose

• Nondirective questioning approach

  • Client may choose to spend time on some topics

  • Can provide crucial information that interviewers may not otherwise know to inquire about

  • Can fall short in terms of gathering specific information

• Best strategy involves balance and versatility

  • Using only a directive approach could sacrifice rapport in favor of information

  • Using only a nondirective approach can facilitate rapport but fall short of gathering specific information

Page 96: Technique: Specific Interviewer Responses

• Open- and closed-ended questions

• Clarification

• Confrontation

• Paraphrasing

• Reflection of feeling

• Summarizing

Page 104: Conclusions

• Depends on interview type, setting, client's problem, etc.

• Provides initial conceptualization of client's problem

• May consist of specific diagnosis

• May involve recommendations

Page 105: Pragmatics of the Interview (1 of 4) Note Taking

• Documents the interview

• More reliable than interviewer's memory

• Could be a distraction to client

• Distracts from noticing important client behaviors

• Effect of taking notes highly dependent on situation

Page 106: Pragmatics of the Interview (2 of 4) Audio and Video Recordings

• Recording interview requires client's written permission

• Could hinder openness and willingness to disclose information

• Client appreciates explanation of rationale for recording

Page 107: Pragmatics of the Interview (3 of 4) The Interview Room

• Types

  • Traditional, psychoanalytic arrangement

  • Interviewer and client sitting face-to-face

  • Interviewer and client in chairs at an angle between 90° and 180°

• Setting should facilitate fundamental goals of interview

• Should steer clear of overtly personal items

Page 108: Pragmatics of the Interview (4 of 4) Confidentiality

• Many assume that sessions are absolutely confidential

• Some situations require psychologist to break confidentiality

• Some assume that related others have access to interview records hence, disclose very little

• Interviewers should explain policies regarding confidentiality

Types of Interviews

• The form of an interview depends on the setting, client's presenting problem, and the issues the interview is intended to address.

• There are several types of interviews, including intake interviews, diagnostic interviews, mental status exams, and crisis interviews.

Intake Interviews

• Intake interviews are used to determine whether a client needs treatment and what form of treatment is needed.

• These interviews involve detailed questioning about the client's presenting complaint.

Diagnostic Interviews

• Diagnostic interviews are used to assign DSM diagnoses to a client's problems.

• They include questions that relate to the criteria of DSM disorders.

Structured Interviews vs. Unstructured Interviews

• Structured interviews have advantages such as producing a diagnosis based explicitly on DSM criteria, being empirically sound, and being standardized.

• However, they have disadvantages such as inhibiting rapport and the client's opportunity to elaborate or explain, not allowing for inquiries not related to DSM diagnostic categories, and requiring a more comprehensive list of questions.

• In unstructured interviews, interviewers improvise and determine questions on the spot to seek relevant information.

• The SCID is an example of a structured interview that asks about specific symptoms of disorders listed in the DSM.

Mental Status Exam

• The mental status exam is most often employed in medical settings and is intended for brief, flexible administration requiring no manual or other materials.

• It captures the psychological and cognitive processes of an individual "right now."

• The exam lacks standardization, with different questions within the same category.

• Some main categories include appearance, behavior, mood, speech, orientation, and memory.

Crisis Interviews

• Crisis interviews assess problems demanding urgent attention, such as suicide, and provide immediate and effective intervention.

• Key components of crisis interviews include quickly establishing rapport and expressing empathy.

Cultural Components

• Interviewers should be culturally competent and appreciate the cultural context.

• There is variability among individuals within cultural groups.

• Consideration of religion as a component of culture is important.

Acknowledging Cultural Differences

• Open, respectful discussion of cultural variables can enhance rapport and increase the client's willingness to share information.

• Interview questions can be used to inquire about the cultural backgrounds of clients.

Intelligence Testing

• There is no consensus regarding the definition of intelligence.

• Classic theories of intelligence include Charles Spearman's theory of a singular intelligence and Louis Thurstone's theory of many intelligences.

• More contemporary theories of intelligence include James Cattell's theory of fluid and crystallized intelligence and John Carroll's Three Stratum Theory of Intelligence.

Wechsler Intelligence Tests

• The Wechsler intelligence tests, including the WAIS-IV, WISC-V, and WPPSI-IV, are widely used.

• These tests assess intelligence in different age ranges.

At-a-Glance Information About the Tests

• The table provides information about the most recent editions, year published, and age ranges for the Wechsler intelligence tests and other related tests.

Neuropsychological Tests

• Neuropsychological tests, such as the Halstead-Reitan Neuropsychological Test Battery and the Bender Visual-Motor Gestalt Test, are used to assess cognitive functioning.

Intelligence Testing

Wechsler Intelligence Tests

• Cover entire life span

• Vary as per demands of measuring intelligence at different ages

• Separate tests, not variants of one another

• Single full-scale intelligence score, four and five index score, and specific subtest scores

• Administered one-on-one and face-to-face

• Brief subtest with items of increasing difficulty levels

• Core or supplemental subtests

• Five categories of subtests of WISC and WPPSI

  • Share three with WAIS

  • Perceptual Reasoning Index has

    • Visual Spatial Index

    • Fluid Reasoning Index

• Four categories of subtests of WAIS

  • Verbal Comprehension Index

  • Perceptual Reasoning Index

  • Working Memory Index

  • Processing Speed Index

• Large sets of normative data

• Scores reflect IQ

• Backed by impressive psychometric data

• Used for wide range of clinical applications

• Limited connection between tests and day-to-day life

• Complex or subjective scoring on some subtests

Stanford-Binet Intelligence Scales—Fifth Edition

• Similar to Wechsler tests

• Administered face-to-face and one-on-one

• Employs hierarchical model of intelligence

• Yields singular measure of full-scale IQ, five factor scores, many specific subtest scores

• Features same means and standard deviations

• Psychometric data similarly strong

• Covers entire life span as a single test

• Includes normative data for specific relevant diagnoses

• Features exactly five factors measured both verbally and nonverbally

Additional Tests of Intelligence: Addressing Cultural Fairness

• Universal Nonverbal Intelligence Test-2 (UNIT-2)

  • Language free test

  • Administered one-on-one and face-to-face

  • No verbal instructions

  • Instructions via eight specific hand gestures

  • Appropriate for clients aged 5 to 21 years

  • Six subtests: Two tiers

    • Memory

    • Reasoning

• Assesses limited range of abilities

• Appropriate only for young clients

• Limited psychometric data

Achievement Testing

Achievement Versus Intelligence

• Intelligence—cognitive capacity

• Achievement—person’s accomplishments

• Comparison of intelligence and achievement key factor in determining learning disabilities

• Terminology changed in DSM-5

• Achievement Tests

  • KeyMath achievement test

  • Gray Oral Reading achievement test

  • Woodcock Tests of Achievement (WJ-ACH)

  • Kaufman Test of Educational Achievement (KTEA)

  • Wechsler Individual Achievement Test (WIAT)

• Wechsler Individual Achievement Test—Third Edition

  • For ages 4 to 50 years

  • Administered face-to-face and one-on-one

  • Measures achievements in four broad areas

    • Reading

    • Math

    • Oral language

    • Written language

• Yields standard scores on same scale as intelligence tests

• Linked to Wechsler IQ tests

• Strong reliability and validity data supports WIAT-III

Neuropsychological Testing

Specialized area of assessment within clinical psychology

• Measures cognitive functioning or impairment of the brain

• Fixed-battery phase to flexible-battery phase

• Full Neuropsychological Batteries

  • Halstead-Reitan Neuropsychological Battery (HRB)

  • Luria-Nebraska Neuropsychological Battery (LNNB)

  • NEPSY-II

  • Bender Visual-Motor Gestalt Test—Second Edition (Bender-Gestalt-II)

  • Rey-Osterrieth Complex Figure Test

  • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

  • Wechsler Memory Scale—Fourth Edition (WMS-IV)

Full Neuropsychological Batteries (Page 154)

• Halstead-Reitan Neuropsychological Battery (HRB)

  • Battery of eight standardized neuropsychological tests

  • Suitable for ages 15 years and above

  • Alternate versions available for younger clients

  • Administered only as a whole battery

  • Primary purpose to identify people with brain damage

  • Helps in diagnosis and treatment of problems related to brain malfunction

Full Neuropsychological Batteries (Page 155)

• Luria-Nebraska Neuropsychological Battery (LNNB)

  • Wide-ranging test of neuropsychological functioning like HRB

  • Consists of 12 scales

  • Emphasis on qualitative data in addition to quantitative data

Full Neuropsychological Batteries (Page 156)

• NEPSY-II

  • Designed specifically for children between 3 and 16 years

  • Based on the general principles of Luria-Nebraska test

  • Includes 32 separate subtests across 6 different categories

Brief Neuropsychological Measures (Page 157)

• Bender Visual-Motor Gestalt Test—Second Edition (Bender-Gestalt-II)

  • Most commonly used test

  • Straightforward copying task

  • Measures visuoconstructive abilities

  • Takes only 6 minutes to administer

Brief Neuropsychological Measures (Page 158)

• Rey-Osterrieth Complex Figure Test

  • Brief pencil-and-paper drawing task comprising single complex figure

  • Involves use of colored pencils at various points in test

  • Examiner can trace client’s sequential approach to complex copying task

  • Includes a memory component

Brief Neuropsychological Measures (Page 159)

• Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

  • Focuses on a broader range of abilities than Bender-Gestalt or Rey-Osterrieth

  • Measures verbal skills, attention, and visual memory

  • Takes 20 to 30 minutes to complete

  • Includes 12 subtests in 5 categories

Brief Neuropsychological Measures (Page 160)

• Wechsler Memory Scale—Fourth Edition (WMS-IV)

  • Often used to assess individuals between 16 and 90 years with suspected memory problems

  • Assesses

    • Visual and auditory memory across seven subtests

    • Immediate and delayed recall