Clinical Psychology PDF

CLINICAL PSYCHOLOGY Abnormal: in some way, these people don’t fit in the “norm”, but the term is getting less used nowadays. What is assessed as normal and anormal is behavior. The clinical part of psychology is relevant to all areas of psychology, so it is incredibly important. It can be relevant...

CLINICAL PSYCHOLOGY Abnormal: in some way, these people don’t fit in the “norm”, but the term is getting less used nowadays. What is assessed as normal and anormal is behavior. The clinical part of psychology is relevant to all areas of psychology, so it is incredibly important. It can be relevant to forensic psychology and child psychology. The term “clinical” derives from the Green word klinē (bed), which referred to the reclining position of the patient and the doctor bent over at the bedside. The essence of this discipline is the patient-clinician relationship. It focuses on the centrality of the person. This definitely works against new medicine because what is lost there (even though many methods and technologies are gained) is the centrality of the person, the person tends to become a disease and not be seen as a person. Clinical psychologists care for the person and take care of them, they do not cure them, and this enables them to focus on the subjective part of the disease. Clinical psychology is similar to studying how to stay close to someone who is experiencing some level of psychological pain, and it is a set of methods that we can use, and the experience we gain we can extend to everybody. There’s always interaction, always somebody in a relationship (can AI be a substitute for clinical psychologists? → no straight answer but possible discussion). The clinical relationship requires at least two people, of whom the clinician is part. This requires some form of understanding, some form of introspection and reflection on oneself. First of all, we need to work on ourselves, before we can care for others. Eventually it will be only us and our clients and we need to be ready for that. Clinical psychology is also not exactly psychotherapy: we may be wonderful clinical psychologists but not psychotherapists! Clinical psychologists assess and treat, they study human behavior (symptoms are behaviors, manifestations of issues that show in the person’s behavior) in the context of biological, psychological, social, and cultural context. Any symptom should be read in that sense. Clinical Psychology is structured as a system of autonomous yet complementary knowledge, with objectives aimed at understanding, explaining, interpreting, and reorganizing dysfunctional or pathological mental processes, both individual and interpersonal, along with their behavioral and psychobiological correlates. Clinical Psychology is also aimed at interventions designed to promote psychological wellbeing and related behaviors, including preventive measures, in various clinical and social situations. We can observe situations of: - Suffering without maladjustment - Maladjustment without suffering. People may suffer for something without necessarily having a clinical diagnosis and vice versa. This is an important point in the DSM-5 as well, a person may have all symptoms of a disorder but their functioning is not affected, therefore a diagnosis is not appropriate or needed. Vice versa, there are people who are suffering a great deal but who do not have a disorder (even though they should be helped nonetheless). Why is mental health important for overall health? The mind and body connection is very strong, in this course we will stress physical symptoms caused by psychological issues because that is the best way to care for a patient/client. Depression, for example, will cause people to stop exercising, going out, seeing people, or taking care of their health, which will increase the risk for many types of physical health problems, particularly long-lasting conditions like diabetes, heart disease, and stroke. Similarly, the presence of chronic conditions can increase the risk of mental illness. 1 Being as important as physical health, mental health should be treated by professionals. There is still a huge amount of stigma in society especially for older generations or other cultures, so we should keep driving the change that has been happening. The first step is to get people to a professional! The general public should feel comfortable seeing a mental health professional. Most medical systems are still not good at prevention and focus on fixing issues, but clinical psychology also tries to focus on prevention. It’s fundamental to increase awareness and lower stigma. No universal agreement about what is meant by abnormality or disorder. Culture plays a role in determining what is/is not abnormal; behaviors once considered abnormal may be considered normal as times/attitudes change. The influence of culture: - Affects the way abnormality is defined - Varies in the way different cultures describe psychological distress - Can shape the clinical presentation of disorders - Can influence the forms of psychopathology experienced by people in that culture Cultural stigma: mental health is viewed differently in every culture. Sometimes mental illness is seen as a weakness and it makes families avoid discussing their wellbeing. For example, Western Cultures accept the biomedical model of mental illness whereas Aboriginal, Middle Eastern, and African cultures view this as a private family matter. Understanding mental health from a cultural bias: culture influences how a child describes their thoughts and feelings. A child may choose not to discuss their emotional and/or physical symptoms of their mental illness or wellbeing. For example, it may be taboo for a child. ABNORMAL PSYCHOLOGY: OVERVIEW AND RESEARCH APPROACHES INDICATORS OF ABNORMALITY No single indicator is sufficient in and of itself to define or determine abnormality. Nonetheless, the more that someone has difficulties in the following areas, the more likely he or she is to have some form of mental disorder: 1. Subjective distress: If people suffer or experience psychological pain we are inclined to consider this as indicative of abnormality. 2. Maladaptiveness: Maladaptive behavior is often an indicator of abnormality. Maladaptive behavior interferes with our well-being and with our ability to enjoy our work and our relationships. But not all disorders involve maladaptive behavior. Consider the con artist and the contract killer, both of whom have antisocial personality disorder. The first may be able glibly to talk people out of their life savings, the second to take someone’s life in return for payment. Is this behavior maladaptive? Not for them, because it is the way in which they make their respective livings. We consider them abnormal, however, because their behavior is maladaptive for and toward society. 3. Statistical deviancy: The word abnormal literally means “away from the normal.” But simply considering statistically rare behavior to be abnormal does not provide us with a solution to our problem of defining abnormality. Genius is statistically rare, as is perfect pitch. However, we do not consider people with such uncommon talents to be abnormal in any way. 4. Violation of the standards of society: All cultures have rules. Some of these are formalized as laws. Others form the norms and moral standards that we are taught to follow. Although many social rules are arbitrary to some extent, when people fail to follow the conventional social and moral rules of their cultural group, we may consider their behavior abnormal. Of course, much depends on the magnitude of the violation and on how commonly the rule is violated by others. 5. Social discomfort: Not all rules are explicit. And not all rules bother us when they are violated. Nonetheless, when someone violates an implicit or unwritten social rule, those around him or her may experience a sense of discomfort or unease. 2  6. Irrationality and unpredictability. Although a little unconventionality may add some spice to life, there is a point at which we are likely to consider a given unorthodox behavior abnormal. 7. Dangerousness: It seems quite reasonable to think that someone who is a danger to him- or herself or to another person must be psychologically abnormal. Indeed, therapists are required to hospitalize suicidal clients or contact the police (as well as the person who is the target of the threat) if they have a client who makes an explicit threat to harm another person. One final point bears repeating. Decisions about abnormal behavior always involve social judgments and are based on the values and expectations of society at large. This means that culture plays a role in determining what is and is not abnormal. In addition, because society is constantly shifting and becoming more or less tolerant of certain behaviors, what is considered abnormal or deviant in one decade may not be considered abnormal or deviant a decade or two later. At one time, homosexuality was classified as a mental disorder. But this is no longer the case. THE DSM-5 AND THE DEFINITION OF MENTAL DISORDER Although the DSM is widely used, it is not the only psychiatric classification system. The World Health Organization (WHO) produces a document with the rather macabre title of the International Classification of Diseases. The 11th revision of this (called ICD-11) has just been published. Within DSM-5, a mental disorder is defined as a syndrome that is present in an individual and that involves clinically significant disturbance in behavior, emotion regulation, or cognitive functioning. These disturbances are thought to reflect a dysfunction in biological, psychological, or developmental processes that are necessary for mental functioning. DSM-5 also recognizes that mental disorders are usually associated with significant distress or disability in key areas of functioning such as social, occupational, or other activities. Predictable or culturally approved responses to common stressors or losses (such as death of a loved one) are excluded. Rather than thinking of the DSM as a finished product, it should always be regarded as a work in progress, with regular updates and modifications to be expected. CLASSIFICATION AND DIAGNOSIS At the most fundamental level, classification systems provide us with a nomenclature (a naming system). This gives clinicians and researchers both a common language and shorthand terms for complex clinical conditions. Another advantage of classification systems is that they enable us to structure information in a more helpful manner. Classification systems shape the way information is organized. Organizing information within a classification system also allows us to study the different disorders that we classify and therefore to learn new things. In other words, classification facilitates research, which gives us more information and facilitates greater understanding, not only about what causes various disorders but also how they might best be treated. The final effect of classification system usage is somewhat more mundane. As others have pointed out, the classification of mental disorders has social and political implications. Simply put, defining the domain of what is considered to be pathological establishes the range of problems that the mental health profession can address. As a consequence, on a purely pragmatic level, it furthermore delineates which types of psychological difficulties warrant insurance reimbursement and the extent of such reimbursement. WHAT ARE THE DISADVANTAGES OF CLASSIFICATION? Classification, by its very nature, provides information in a shorthand form. However, using any form of shorthand inevitably leads to a loss of information. If we know the specific history, personality traits, idiosyncrasies, and familial relations of a person with a particular type of disorder (e.g., from reading a case summary), we naturally have much more information than if we were simply told the individual’s diagnosis (e.g., schizophrenia). Moreover, although things are improving, there can still be some stigma (disgrace) associated with having a psychiatric diagnosis. Stigma, of course, is hardly the fault of the diagnostic system itself. But even today, people are 3 generally far more comfortable disclosing that they have a physical illness such as diabetes than admitting they have any mental disorder. Related to stigma is the problem of stereotyping. Stereotypes are automatic beliefs concerning other people that we unavoidably learn as a result of growing up in a particular culture. Because we may have heard about certain behaviors that can accompany mental disorders, we may automatically and incorrectly infer that these behaviors will also be present in any person we meet who has a psychiatric diagnosis. Finally, stigma can be perpetuated by the problem of labeling. A person’s self-concept may be directly affected by being given a diagnosis of schizophrenia, depression, or some other form of mental illness. It is important to keep in mind, however, that diagnostic classification systems do not classify people. Rather, they classify the disorders that people have. 4  HISTORY OF CLINICAL PSYCHOLOGY It was only with the advent of psychotherapy and the study of hysteria that the importance of the person became the focus. There are three sets of social and historical factors that initially shaped 1. Empirical tradition: the use of scientific research methods. 2. Psychometric tradition: the measurement of individual differences. 3. Clinical tradition: the classification and treatment of behavior disorders. 1879: Wundt, a German philosopher, established the first laboratory in Leipzig devoted to studying mental processes. With him psychology became an autonomous discipline for the first time, both from other biological sciences such as physics and physiology, and from philosophy. Plenty of important authors and figures studied in Leipzig with him and were influenced by him. All the psychometric tradition in the world came from his laboratory. He was interested in the immediate human experience. His objective was to study the atoms (he called) of the mind: the fundamental components of the mind. He started studying what constitutes the mind in terms of perception, sensation, memory, and emotions (which would be the atoms of the mind) in order to define a general structure of consciousness through atomic associationism. He used the method of introspection, where people would talk about what they were experiencing while stimulated. It’s made up of self-observation and self-examination of one's subjective experience of various physical stimuli. THE PSYCHOMETRIC TRADITION – DIFFERENTIAL PSYCHOLOGY according to Sir. FRANCIS GALTON Influenced by evolutionism (Darwin was his cousin), Sir Francis Galton was interested in individual differences in human capabilities, especially mental abilities. He was the first to scientifically investigate the genetic and environmental causes of individual differences in humans - contributing to their statistical measurement. However, he was the founder of eugenics, the rational or artificial selection for humans to reproduce, to create the “perfect human”. Questioning the relationship between heredity and environment, he was concerned with sampling and correlating somatic characteristics and simple mental activities with the aim of giving rise to a sort of 'rational/artificial' selection (eugenics) - vs. natural selection - in order to 'improve the human race'. This later partially led to Hitler’s politics, especially his pure race theory and the castration of disabled, mentally ill, and indigent people. He was a very influent person and started establishing psychometrics, as his studies on human abilities led him to formulate the first mental tests through the development of psychometry. He also established the first mental testing center in 1885 at the South Kensington Museum as he was an aristocrat. This center was open to everybody, anyone could get in, be tested, and receive feedback for a small fee. STRUCTURALISM What Galton thought of and invented (especially his methods) reached the USA and influenced, along with Wundt’s ideas, other important scholars like Titchener (one of Wundt’s scholars) who invented structuralism, the aim of which was to study the structure of the mind and how it works. FUNCTIONALISM Williams James then invented functionalism, the focus of which shifted from the elements constituting the mind to the functioning of the mind, how our mental capabilities work, etc. He wanted to study which functions are helpful (or unhelpful) for adaptation to the environment. 5 From the work of Darwin and Galton, in Principles of Psychology (1980) - the first classic psychology text – James stated that the aim of psychology is not to discover the elements of experience, but to study the functioning of man within his natural environment. Object of investigation = mental processes and functions that favor (or hinder) adaptation to the environment. Attempt to answer questions such as: - What is the meaning of a reflex? - What is the function of an emotion? - Which biological structures have evolved in an adaptive way? 1892: the American Psychological Association (APA) was founded. This was made up of scientists, not of clinicians. This becomes relevant later on. CATTELL Then came Cattell, who trained with Wundt in Leipzig and worked with Galton in his anthropometric laboratory. He became a professor of psychology at Columbia University, and he introduced the psychometric tradition in the USA. He’s the one who introduced the term mental tests. “Psychology cannot attain the certainty and exactness of the physical sciences unless it rests on a foundation of experiment and measurement” 1890: he introduced the term test to define the measurement protocols used by Galton and mental tests for those used in his studies - elementary bodily and sensorimotor measurements, with the aim of identifying the fundamental capacities and abilities that allow man to adapt to his environment in the best possible way. He also established the Psychological Corporation (1921), one of the first organizations to offer psychological services through psychometric applications in the industrial and educational fields. THE INFLUENCE OF INTELLIGENCE TESTING Binet and Henri then started speculating that Galton and Cattell’s differential method would not lead to any prediction, only description and measurement of mental capabilities. They became interested in the superior psychological capacities (not just simple part processes) of individuals. They wanted to find a use to these techniques (or better, to create some techniques which could have a practical use) and thus created the first intelligence test to measure superior mental abilities, due to France’s establishment of compulsory schooling Binet’s attention shifted to children, and he conducted a series of research (with his colleague Simon) with the aim of identifying pupils who needed particular help in school subjects. This led to the development of the first intelligence test for children (the Binet-Simon Scale, 1905) - commissioned by the French Ministry of Education. He actually worked with children, which was a huge innovation. Based on children's performance on tests of knowledge, thinking, reasoning and judgment, they were assigned a mental age. This was representative of the level of development of their intelligence, and predictive of their academic performance. Stern later coined the term IQ (Intelligence Quotient) and defined it as the result of the formula: = (mental age/chronological age) * 100. He asked children to perform tests on knowledge, thinking, reasoning, and judgment, and then assigned a mental age to them. A 10-year-old kid could be 10 mentally, and thus his IQ would be of 100. If a child has an IQ of 70, then he can be helped in the domains that he’s lacking in. Later on, the Stanford-Binet intelligence test was published in 1916, still one of the most use, which was translated and adapted for the USA. 6 However, adults could not be tested yet, since age-based quotients were only applicable to children. So Weschler composed the so called Weschler-Bellevue test (1939), which was then revised to also become the WISC (for children). Lightner WITMER (1867-1956): THE FATHER OF CLINICAL PSYCHOLOGY Witmer is considered to be the real father of clinical psychology. He worked with people for the first time. He graduated in political science first, but then met the experimental psychologist Cattell who sparked his interest in psychology. Following his graduation from the University of Pennsylvania in 1888, he pursued his PhD under Wundt at the university of Leipzig. In 1896 he founded the first psychological clinic for the diagnosis and treatment of young people \\with intellectual disabilities and educational or adaptation problems, which was revolutionary. During the same year, described his methods of diagnosis and treatment during the annual APA convention held in Boston, using terms like clinical psychology and the clinical method in psychology for the first time. In the same meeting he described his findings and his theory, saying that clinical psychology is derived from the results of an examination of many human beings, one at a time, collecting a large amount of data and establishing a theory that can help us create treatment. He proposed that a psychological clinic could be devoted to diagnosis and evaluation, individual treatment, public service, and research. He also proposed the training of students so that they could do the same. However, the association did not receive his ideas well, thinking that psychology as a science should not be applied to actual clinical problems. The notion of working with people was crazy at the time, psychologists were only scientists who did not work with people, clinical issues were ignored. Under his influence, the University of Pennsylvania began offering formal courses in clinical psychology during the 1904– 1905 academic year. Clinical psychology was on its way. On March 15th, 1907, he founded and edited the first clinical journal, the Psychological Clinic. Many of the principles developed by Witmer developed in his psychological clinic are still used today: - He favored a diagnostic evaluation prior to offering treatment procedures and services. - He favored a multidisciplinary team approach as opposed to individual consultation. - He used interventions and diagnostic strategies based on research evidence. - He was interested in preventing problems before they emerged. BEHAVIORISM - John WATSON (1878 -1958) John Watson then came and introduced behaviorism, a very pragmatic approach that believed only behavior could be observed objectively and that the mind was a black box. In this case we can predict and control any variable (experimental method making use of independent variables and observing their effect on dependent variables). They wanted to determine causal relationships and formulate general laws of behavior (now we know, however, that correlation is not causation). Model: S (stimulus) – R (response) The number of psychometric instruments for the purpose of reassurance and generalization grew. At the end of the 1930s, the criterion of statistical significance became the most widespread practice in applied research psychology. In 1913 Watson wrote the Manifesto of Behaviorism. 7 Following: Pavlov's theory of classical conditioning. Skinner introduced operant conditioning with the Skinner box, where the concept of reinforcement is fundamental to the learning process. Thorndike proposed that learning occurs through trial and error and is governed by two laws: the law of exercise and the law of effect. COGNITIVISM – 1950 (A. Beck, Ellis, Lazarus) Afterwards came Beck, Ellis, and Lazarus, who introduced cognitivism, saying that it is not possible to predict or control anything really because the mind exists, and it cannot be controlled (mental states). Subject of study: cognitive processes, how the mind works, not how it is made. Model: S – MENTAL STATES – R → Impossibility to predict and control variables TOTE: Test Operate Test Exit. The response (behavior) is the result of checks (tests), executions (operates), subsequent checks (tests) and responses (behavior– exit). CONSTRUCTIVISM - Paul WATZLAWICK (1921–2007) Watzlawick, from the Palo Alto school, said that there is no reality which is independent from the observer, but that reality changes based on points of view. For example, the same stimulus can produce very different reactions in people (think of arachnophobia). Subject of study: humans as active beings, constructors of meaning, and the environment as a universe of symbols and possible experiences. GESTALT Psychology or Psychology of Form (1920) In Berlin, Max Wertheimer (1880-1943), conducting experiments on perception, developed the concept of Gestalt (form) = the totality of psychic processes (perceptions, memory, thoughts...) which occur not under the influence of external causes, but by virtue of internal laws present in such processes. Wertheimer conceptualized that we can only perceive objects in their wholeness. As for Wundt, the subject of study is the immediate human experience, but the interest is not directed to the study of individual elements, but rather to the relationship that exists between them within the perceptual field. Even the variation of just one element leads to a restructuring of the entire field, creating the conditions for a different global configuration. Their position is similar to that of constructivists, with respect to the denial of a single, universal and objective reality. 8 THE CLINICAL TRADITION From the beginning of recorder history, human beings have tried to explain everything, and this includes abnormal behaviors, behaviors that are bizarre or apparently irrational. References to abnormal behavior in early writings show that the Chinese, Egyptians, Hebrews, and Greeks often attributed such behavior to a demon or god who had taken possession of a person. Whether the “possession” was assumed to involve good spirits or evil spirits typically depended on the affected individual’s symptoms. This was treated with various forms of exorcism, including trephining, the boring of holes in the skull to provide evil spirits with an exit. In early monotheistic God was also seen as a possible source of mental problems. As reported in the Old Testament, “The Lord will afflict you with madness, blindness and confusion of mind”. As God was responsible for possession, religions were responsible for fixing it, using exorcism and other barbaric practices. Where supernatural approaches to mental disorders were prevalent, religion was always dominant in explaining and dealing with them. Around 400 BC the ancient Greeks shifted the understanding of mental disorders from the work of supernatural forces to problems in the human body. The Greeks believed that the mind and body were closely interconnected, and, thus, were precursors to a biopsychosocial perspective. The Greek physician Hippocrates (460–377 BC) often referred to as the father of modern medicine, is widely considered to be largely responsible for this shift. Hippocrates felt that disease was the result of an imbalance in four bodily fluids (black bile, yellow bile, phlegm, and blood), and that the relationship between these bodily fluids also determined temperament and personality. (For example, too much yellow bile resulted in a choleric (angry, irritable) temperament, whereas too much black bile resulted in a melancholic (sadness, hopelessness) personality). He also emphasized the importance of the patient’s environment and of heredity and predisposition. “In order to cure the human body, it is necessary to have a knowledge of the whole of things.” He relied heavily on clinical observation, and his descriptions, which were based on daily clinical records of his patients, were surprisingly thorough. Hippocrates were far in advance of the exorcistic practices then prevalent. For the treatment of melancholia, for example, he prescribed a regular and tranquil life, sobriety and abstinence from all excesses, a vegetable diet, celibacy, exercise short of fatigue, and bleeding if indicated. He also recognized the importance of the environment and often removed his patients from their families. Like his contemporaries, however, Hippocrates had little knowledge of physiology, which led to some total misses. For instance, he believed that hysteria (the appearance of physical illness in the absence of organic pathology) was restricted to women and was caused by the uterus wandering to various parts of the body, pining for children. For this “disease,” Hippocrates recommended marriage as the best remedy. The Greek philosopher Plato (429–347 BC) studied individuals with mental disturbances who had committed criminal acts and how to deal with them. He wrote that such persons were, in some “obvious” sense, not responsible for their acts and should not receive punishment in the same way as normal persons. He also made provision for mental cases to be cared for in the community. Plato viewed psychological phenomena as responses of the whole organism, reflecting its internal state and natural appetites. His ideas regarding treatment included a provision for “hospital” care for individuals who developed beliefs that ran counter to those of the broader social order. There they would be engaged periodically in conversations comparable to psychotherapy to promote a person’s mental health. Despite these modern ideas, however, Plato shared the belief that mental disorders were in part divinely caused. Aristotle (384–322 BC), who was a pupil of Plato, wrote extensively on mental disorders. Among his most lasting contributions to psychology are his descriptions of consciousness. He held the view that “thinking” as directed would eliminate pain and help to attain pleasure. Aristotle generally subscribed to the Hippocratic theory of disturbances in the bile. For example, he thought that very hot bile generated amorous desires, verbal fluency, and suicidal impulses. 9 Roman and Greek physician Galen (129 – 216 AD) developed a holistic program of medical practice that became the foundation of medicine in Europe for more than 1,000 years. He made a number of original contributions concerning the anatomy of the nervous system based on dissections of animals. He believed there is no sharp distinction between the mental and the physical, and that psychological disorders could have either physical causes, such as injuries to the head, excessive use of alcohol, adolescence, menstrual changes, or mental causes, such as disappointment in love, economic reversals, shock, or fear. China was one of the earliest developed civilizations in which medicine and attention to mental disorders were introduced. Chinese medicine was based on a belief in natural rather than supernatural causes for illnesses. Chinese medicine reached a relatively sophisticated level during the second century, and Chung Ching, who has been called the Hippocrates of China, based his views of physical and mental disorders on clinical observations, and he implicated organ pathologies as primary causes. However, he also believed that stressful psychological conditions could cause organ pathologies, and his treatments utilized both drugs and the regaining of emotional balance through appropriate activities. As in the West, Chinese views of mental disorders regressed to a belief in supernatural forces as causal agents. From the later part of the second century through the early part of the ninth century, ghosts and devils were implicated in “ghost-evil” insanity, which presumably resulted from possession by evil spirits. The “Dark Ages” in China, however, were neither so severe (in terms of the treatment of patients with mental illness) nor as long lasting as in the West. In the Middle Ages (about AD 500 to AD 1500) the Church returned as the main institution and demonological explanations of abnormal behavior returned dramatically, with the creation of asylums in the 1500s mental hospitals (but more similar to prisons), where people who are considered to be crazy were sent and imprisoned. These people did not have any right and though the goal was treatment there was no reestablishment. One of the most famous asylums was nicknamed Bedlam, St. Mary of Bethlehem, organized in 1547. Here, people lived and were kept in awful conditions, and they received grossly inadequate care → the more violent patients were exhibited to the public for one penny a look, and the more harmless inmates were forced to seek charity on the streets of London. An explanation for this could be that asylums were initially created to remove from the community troublesome individuals who could not care for themselves. The treatment techniques were aggressive, aimed at restoring a “physical balance in the body and brain.” These techniques, based on the scientific views of the day, were designed to intimidate patients. They included water treatments, bleeding and blistering, electric shocks, and physical restraints. With increases in scientific discoveries in the Renaissance, mental problems were now seen as issues of the body. New medical discoveries during the Renaissance resulted in biomedical reductionism: mental illness, could be understood by scientific observation and experimentation rather than beliefs about mind and soul. Paracelsus (1490–1541), a Swiss physician, was an early critic of superstitious beliefs about possession. He insisted that mania was not a possession but a form of disease, and that it should be treated as such. Although Paracelsus rejected demonology, his view of abnormal behavior was colored by his belief in astral influences (lunatic is derived from the Latin word luna, or “moon”). He was convinced that the moon exerted a supernatural influence over the brain. Johann Weyer (1515–1588), a German physician and writer, was deeply disturbed by the imprisonment, torture, and burning of people whose strange behavior led them to be accused of witchcraft. Weyer argued that those accused of witchcraft were really mentally ill and not deserving of persecution. Weyer was one of the first physicians to specialize in the study and attempted treatment of mental disorders, and his wide experience and progressive views justify his reputation as the founder of modern psychopathology. Unfortunately, however, he was too far ahead of his time. He was scorned by his peers who made fun of him and considered him to be insane. The clergy, however, were also beginning to question the practices of the time. For example, St. Vincent de Paul (1576–1660), at the risk of his life, declared, “Mental disease is no different than bodily disease and Christianity demands of the humane and powerful to protect, and the skillful to relieve the one as well as the other”. 10 René Descartes (1596–1650), a French philosopher, argued that the mind and body were separate. As such, diseases of the body were studied by the medical sciences while problems with the mind or emotional life were delegated to the philosophers and clergy. This dualism became the basis for Western medicine until recently. However, mental illness was often considered a disease of the brain, and thus the individuals were treated using the medical orientation of the time. Premises for a scientific approach to the diagnosis and treatment of mental illness: Psychiatric Positivism. In the US and Great Britain, movements to improve the treatment of persons with severe disorders paralleled those in France. The role of physicians in treating mental disorders was further solidified when, later in the 19th century, syphilis was identified as the cause of general paresis, a deteriorative brain syndrome that had once been treated as a form of insanity. Finding an organic cause for this mental disorder bolstered the view that all mental disorders are organically based. The notion that there could be “no twisted thought without a twisted molecule” triggered a psychiatric revolution in which doctors searched feverishly for organic causes of and physical treatments for all forms of mental illness. In Frances, Philippe Pinel was the first person to think that asylums were prisons that made people feel even worse. He stated: “It is my conviction that these mentally ill are intractable only because they are deprived of fresh air and liberty”. He instituted the removal of chains from some of the patients as an experiment to test his views that people with mental illness should be treated with kindness and consideration—as sick people, not as criminals or dangerous animals when he was put in charge of La Bicêtre, a hospital in Paris. His experiment was a great success and chains were removed; sunny rooms were provided; patients were permitted to exercise on the hospital grounds; and kindness was extended to these patients, some of whom had been chained in literal dungeons for 30 or more years. In 1795 he initiated the so-called moral treatment of psychiatric patients, which focuses on strengthening the healthy part of their personality through education, persuasion, and discipline (frees the insane from the ‘chains at Salpêtrière'). It is a wide-ranging method of treatment that focused on a patient’s social, individual, and occupational needs. At about the same time an English Quaker named William Tuke (1732– 1822) established the York Retreat, a pleasant country house where patients with mental illness lived, worked, and rested in a kindly, religious atmosphere. As word of Pinel’s amazing results spread to England, Tuke’s small force of Quakers gradually gained the support of English medical practitioners such as Thomas Wakley and Samuel Hitch, who introduced trained nurses into the wards of the Gloucester Asylum and put trained supervisors at the head of the nursing staffs. In 1842, following Wakley’s lobbying for change, the Lunacy Inquiry Act was passed, which included a requirement that asylums and houses be effectively inspected every 4 months to ensure proper diet and the elimination of the use of restraints. In the United States, this revolution was reflected in the work of Benjamin Rush (1745–1813), the founder of American psychiatry and also one of the signers of the Declaration of Independence. Rush encouraged more humane treatment of patients with mental illness; wrote the first systematic treatise on psychiatry in America, Medical Inquiries and Observations upon Diseases of the Mind; and was the first American to organize a course in psychiatry. However, some of his practices can still be considered as violent. Dorothea Dix (1802–1887) was an energetic New Englander who became a champion of poor and “forgotten” people who had been consigned to prisons and mental institutions. In 1841, she began to teach in a women’s prison. Through this contact she became acquainted with the deplorable conditions in jails, almshouses, and asylums. As a result of what she had seen, Dix carried on a zealous campaign between 1841 and 1881 that aroused people and legislatures to do something about the inhuman treatment accorded to people with mental illness. Through her 11 efforts, the mental hygiene movement, which advocated a method of treatment that focused almost exclusively on the physical well-being of hospitalized patients, grew in America. She is credited with establishing 32 mental hospitals, an astonishing record given the ignorance and superstition that still prevailed in the field of mental health at that time. Medical professionals—or “alienists,” as psychiatrists were called at this time in reference to their treating the “alienated,” or insane—had a relatively inconsequential role in the care of the insane and the management of the asylums of the day. Over time, the alienists acquired more status and influence in society and became influential as purveyors of morality, touting the benefits of Victorian morality as important to good mental health. The twentieth century began with a continued period of growth in asylums for people with mental illness, although the fate of patients with mental illness during that time was neither uniform nor entirely positive. Then came Beers (1876–1943), a Yale graduate who described his own struggle with mental illness and the mistreatment he received in three different institutions. Beers had experienced straitjackets, and he supplied a vivid portrayal of what such painful immobilization of the arms means to an overwrought mental patient. After Beers recovered in the home of a kind attendant, he launched a campaign to make people realize that such treatment was no way to handle the sick. He soon won the interest and support of many influential people, including the eminent psychologist William James and the “dean of American psychiatry,” Adolf Meyer. New ways of thinking about mental illness required new ways of categorizing it. Emil Kraepelin (1855-1926) was a German psychiatrist who in 1883 wrote a textbook entitled Compendium der Psychiatrie, the first formal classifications of psychological disorders. His classification schema is still cited today in contemporary writings as seminal in the evolution of diagnostic classification systems. He also identified manic depression as a major category of depression. Kraepelin noted that certain symptoms occurred together regularly enough to be regarded as specific types of mental disease. Kraepelin differentiated exogenous disorders (caused by external factors) from endogenous disorders (caused by internal factors) and suggested that exogenous disorders were the far more treatable type. Kraepelin’s approach is still evident in the current system of classification, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Kraepelin saw each type of mental disorder as distinct from the others and thought that the course of each was as predetermined and predictable as the course of measles. There are constant revisions in the DSM because of many reasons: we constantly have new discoveries, some disorders that were grouped together are differentiated, such as binge eating disorder, which was under the category of “Other” until 2013, when its prominence made it recognized as its own disorder. The same goes for cultural changes (see DSM-III-TR in 1987). - 1939-1948: ICD (International Classification of Diseases). - 1952: The APA publishes the DSM-I. - 1968: The world health organization (WHO) establishes a committee to review classification systems worldwide, leading to the development of ICD-8 and DSM-II. - 1980: DSM-III (the term neurosis and psychosomatic disorders disappears, and the medical model becomes increasingly explicit). - 1987: DSM-III-TR (homosexuality is no longer a psychiatric illness). - 1994: DSM-IV. - 2000: DSM-IV-TR. - 2013: DSM 5. Premises for a scientific approach to the diagnosis and treatment of mental illness: Psychogenesis Mental problems were no longer seen as only physical during the 19th century. The revolution that viewed mental illness as disease also led to the idea that mental disorders might have psychological causes, too. 12 In the mid-1800s, Jean-Martin Charcot (1825-1893), head of the Salpêtrière Hospital in Paris and the leading neurologist of his time (the first to describe multiple sclerosis) found that hypnosis could alleviate certain behavior disorders, particularly hysteria (today known as conversion disorder). Previously, people with hysteria – suffering from physical disorders in the absence of organic lesions – were considered to be unreliable liars, or victims of an overall weakened nervous system that produced random functional disturbances. Working with patients suffering from hysteria, Charcot suggested that the condition resulted from psychological trauma rather than problems with brain function. Charcot’s lectures were well attended—among the regulars were Sigmund Freud, and a French neurologist named Pierre Janet (1859-1949). Charcot's innovative ideas were developed by Sigmond Freud (1856-1939) with the Viennese psychiatrist Josef Breuer (1842 –1925). Freud and Breuer started directing patients (i.e. Bertha Pappenheim) to talk freely about their problems while under hypnosis. This simple innovation in the use of hypnosis proved to be of great significance: the patients usually displayed considerable emotion and, on awakening from their hypnotic states, felt a significant emotional release, which was called a catharsis. This approach led to the discovery of the unconscious—the portion of the mind that contains experiences of which a person is unaware—and with it the belief that processes outside of a person’s awareness can play an important role in determining behavior. Freud soon discovered, moreover, that he could dispense with hypnosis entirely. By encouraging patients to say whatever came into their minds without regard to logic or propriety, Freud found that patients would eventually overcome inner obstacles to remembering and would discuss their problems freely. He proposed a theory in which behavior disorders were consequence of the dynamic struggle of the human mind to satisfy instinctual (mainly sexual) desires while also coping with the rules and restrictions of the outside world. Methods employed: - free association: having patients talk freely about themselves, thereby providing information about their feelings, motives, and so forth. - dream analysis: having patients record and describe their dreams. 1909: The "Clark University Meeting" and the beginning of the spread of Psychoanalysis in the United States. In 1917, clinicians broke away from APA to form American Association of Clinical Psychology (AACP). However, they were able to find an agreement and in 1919 the Clinical Psychology section was established within the APA. 1921 was a monumental year for psychology in general: - Carl Gustav Jung (1875-1961). He published "Psychological Types", where he introduced the distinction between introvert and extrovert. - Gordon Allport (1897-1967). He proposed the notion of trait (vs. "psychological type") for the study of personality. - Hermann Rorschach (1884-1922). The Rorschach Inkblot Test. The World Wars played a key role in transforming clinical psychology into a professional discipline that integrated the assessment of intellectual and psychological functioning with the treatment of not only traumatized military personnel, but also their families and other individuals in their communities who had been affected by the war. 13 The U.S. government (the Veterans Administration, specifically) responded by requesting that the American Psychological Association formalize the training of clinical psychologists and provided significant funding to ensure the availability of such training opportunities. 1933: Adolf Hitler became Chancellor of the Reich and initiated a sterilization process for individuals with intellectual disabilities, epilepsy, schizophrenia, manic-depressive psychosis, deafness, blindness, and various deformities. He also banned psychoanalysis in Germany. Many influential figures in clinical psychology — most notably, Sigmund Freud — were forced to flee their home countries. This relocation facilitated the spread of their theories and clinical approaches to England and to the US. Eysenck’s The Effects of Psychotherapy: An Evaluation. Are the results of psychotherapy long term? This was the Birth of the line of research on the effectiveness of psychotherapy. In 1977 there was also the first Meta-Analysis of psychotherapy outcome studies, by Smith and Glass. (Meta-analysis is the quantitative summary of a specific aspect you want to investigate.) 14 15 16  CLINICAL ASSESSMENT AND DIAGNOSIS Psychological assessment: procedure by which clinicians, using psychological tests, observation, and clinical interviews etc. develop a global summary of a client’s symptoms and problems, including the inner perception of the patient about their symptoms. It is the process of collecting, analyzing and processing information aimed at answering one of the many questions within the scope of clinical psychology. We are interested in knowing not only what the patient I present like the disease itself, but also the illness, that is, th e perception of the patient about their symptoms. Clinical diagnosis: process through which a clinician arrives at a general summary classification of the patient’s symptoms by following a clearly defined system such as DSM-5 or ICD-11 (international classification of Diseases). THREE FUNDAMENTAL CONCEPTS Reliability: a tool is considered reliable when if used in different contexts it leads to the same results. Thus, reliability is a term describing the degree to which an assessment measure produces the same result each time it is used to evaluate the same thing. - Test-retest reliability is whether a test result gives us a similar value today as it did a few days earlier. - Inter-rater reliability would describe, for example, the degree to which different clinicians agree on a diagnosis. Validity is the extent to which a measuring instrument actually measures what it is supposed to measure (construct validity). There are different types of validity. If we have two tools aiming to measure the same construct, do they correlate? In like manner, reliable assignment of a person’s behavior to a given class of mental disorder will prove useful only to the extent that the validity of that class has been established through research. Standardization is the process by which a psychological test is administered, scored, and interpreted in a consistent (or standard) manner. Many tests are standardized to allow the test user to compare a particular individual’s score to a normative sample. Subject’s responses to the standardized stimuli are compared with those of others with comparable demographic characteristics. Standardized tests are considered to be more fair than non-standardized tests in that they are applied consistently and in the same manner to all people taking them. Most measures are validated in English but not validated and standardized in other languages such as Italian, therefore, we need to translate and adapt the measurement, and we need to demonstrate to a peer review process that that measure is valid and standardized in our country. THE NATURE AND GOALS OF ASSESSMENT Assessment is an ongoing process structured according to a systematic and intelligently organized succession of subsequent insights. - May be important at various points during treatment, not just at the very beginning. - In the initial clinical assessment, the clinician tries to identify the main dimensions of a client’s problems. It is at this initial stage that crucial decisions have to be made—such as what (if any) treatment approach is to be offered, whether the problem will require hospitalization, to what extent family members will need to be involved, and so on. - It establishes baselines for various psychological functions: at the start a person may have a memory issue and then it can be measured again in the final stages of treatment. For most clinical purposes, however, assigning a formal diagnosis may be much less important than having a clear understanding of the individual’s behavioral history, intellectual functioning, personality characteristics, and environmental pressures and resources. That is, an adequate assessment includes much more than the diagnostic label; there is a focus on the person. Adequate assessment includes much more than the diagnostic label, it should focus on the person and on their goals and perceptions. 17 Assessment should include a description of any relevant long-term personality characteristics. It is also important to assess the social context in which the individual functions: environmental demands, support, and/or special stressors. All of this information must be integrated into a consistent and meaningful picture. Some clinicians refer to this picture as a “dynamic formulation” because it not only describes the current situation but also includes hypotheses about what is driving the person to behave in maladaptive ways. Where feasible, we should make treatment decisions collaboratively with consent and approval from the individual. In some cases, however, decisions may have to be made without the client’s participation or, in rare instances, even without consulting responsible family members. Let’s say a person has an issue with addiction: the goal of the interview is known to both the clinician and the client, but the person may not want to talk about it. We need to assess the frequency of substance abuse, the situations in which it happens, the motivations to change, but the person may not want to talk about it. One idea is to have the patient talk about something that may be related to substance abuse to then slowly shift attention to the disorder at hand. However, we absolutely need to redirect the conversations to make our assessment if we are asked to: it is not like psychotherapy where you have the chance to talk with the client multiple times. What does a clinician need to know? First, the presenting problem, or major symptoms and behavior the client is experiencing, must be identified. Is there any evidence of recent deterioration in cognitive functioning? What is the duration of the current complaint, and how is the person dealing with the problem? What, if any, prior help has been sought? Are there indications of self-defeating behaviors or is the individual using all available personal and environmental resources in a good effort to cope? How pervasively has the problem affected occupational or social functioning? If the person does not want to make any change and they are in a precontemplation stage (I do not have an issue! This is not my problem!) trying to force the person to make a change usually makes it worse. IMPORTANT FACTORS INFLUENCING ASSESSMENT Some factors can have significant impact on the assessment process. These include the role of culture, the influence of professional orientation, and the trust and rapport between the clinician and the client. All factors (see picture) are measured with a certain scale/measurement. First, however, you have to cross-culturally validate measures for all countries. Cultural competence is important when dealing with culturally diverse populations. The APA recommends that psychologists consider various test factors, test-taking abilities, and other characteristics of the person being assessed. In using Western-developed tests, users need to take into account the dominant language, socioeconomic status, ethnicity, and gender of the clients. When using a translated version of a test, interpreters need to be mindful of the possible differences that can arise when using an adapted version. Thus, psychologists need to be aware of the available research on the instrument’s use with the target population in order to assess whether the adapted version measures the same variables in the new cultures. Finally, test users need to be concerned with the impact and fairness of the instruments they employ with clients from diverse groups—for example, whether there are any possible performance differences on the scales between groups. 18 The influence of Professional Orientation. We cannot get rid of our attitude, education, and even emotions, and these will always influence assessment. How clinicians go about the assessment process often depends on their basic treatment orientations. → Psychodynamic or psychoanalytically oriented clinicians may choose unstructured personality assessment techniques → Behaviorally oriented clinicians determine the functional relationships between environmental events or reinforcements and abnormal behavior → Cognitively oriented therapists focus on dysfunctional thoughts Such trends are instead a matter of emphasis and point to the fact that certain types of assessments lend themselves more than others to uncovering particular causal factors or for eliciting information about symptomatic behavior central to understanding and treating a disorder within a given conceptual framework. Trust and Rapport Between the Clinician and the Client. The client must feel comfortable with the clinician. They should understand the underlying rationale for assessment and receive assurances of confidentiality. Clients need to be assured that the information they are disclosing will be used appropriately, will be kept in strict confidence, and will be made available only to therapists or others involved in the case. An important aspect of confidentiality is that the test results are released to a third party only if the client signs an appropriate release form. People being tested in a clinical situation are usually highly motivated and interested in test results. Providing test feedback can be an important element of the treatment process. Interestingly, when patients are given appropriate feedback on test results, they tend to improve—just from gaining a more informed perspective on their problems. 19 INSTRUMENTS During the assessment process clinicians try to collect as much information as they can about their client. They then seek to integrate these pieces of information together into a meaningful pattern, developing a working hypothesis about what might have gone wrong and why. This working hypothesis will later be elaborated and confirmed, or perhaps sometimes discarded as time progresses. Typically, assessment starts with a more global approach, such as a clinical interview. Later, more specific assessment tasks or tests may be used → The Clinical Interview → Structured/semi-structured interviews → Psychophysiological assessment → Observation → Self-report questionnaires → Projective Testing → Intelligence test → Cognitive Assessment CLINICAL INTERVIEW (1) A clinical interview, often considered the central element of the assessment process, usually involves a face-to-face interaction in which a clinician obtains information about various aspects of a client’s situation, behavior, and personality. Collection of information in which the therapist and patient actively collaborate to understand the problem presented by the patient and respond to the individuals’ needs The clinical interview has a dual purpose: - Empathetically understanding the patient's experience: This involves understanding how the patient perceives their problem and the emotions that accompany it. It also implies justifying and accepting the person without justifying inappropriate behaviors. The interview allows the patient to speak and externalize their thoughts to reflect on them (illness). - Identifying functional variables: The interview helps in uncovering factors that are relevant to understanding and solving the patient's problems (disease). This is what the person needs to feel: somebody is listening to them and responding to their needs. General characteristics: 1. the presence of two people in an asymmetrical relationship; it is a meeting between a person who is suffering and seeking help, and another who is presumed to be capable of providing that help. The clinician needs to remember that the patient is not educated on these issues, they know nothing that we as clinicians do. 2. a topic that constitutes the focus of the exchange; 3. a shared goal or purpose; 4. an atmosphere that fosters communicative exchange. Sources of information: → Verbal channel to explore the patient's cognitive-verbal system → Direct observation of the patient's behavior Active Listening The clinician is required to do more than simply listen. → Listening and observing what the client says (verbal) → Listening and observing what the client doesn't say (silence) → Listening and observing how the client says it (paraverbal) 20  → Observation of how the client looks and moves (not verbal) A person needs about 30 seconds to make an impression or to get an impression from someone. How we introduce ourselves, the setting we’re in (temperature, lighting, smell) is fundamental, but especially our non-verbal communication. Nonverbal: Everything that is conveyed through one’s posture, movements, and even through the position occupied in space (such as which area of an environment one occupies, the distance from the interlocutor, etc.) and aesthetic aspects (such as how one dresses or cares for oneself). Non-verbal component of writing: the medium that hosts the written piece, whether it is handwritten or typed, the handwriting or font used, and so on. Paraverbal: The way in which something is said refers to the tone, speed, timbre, volume, etc., of the voice. In writing, we can think of the use of punctuation, which can infuse a certain rhythm into what is being read. The strategic use of pauses also serves to make our speech more effective and persuasive. If I want the listener to pay close attention to what I'm about to say, it will be effective to pause beforehand to create an "expectation effect," and then pause afterward to create an "echo effect." Becoming aware of the different facets that make up our communication allows us to make it heterogeneous, multifaceted, and adaptable to various needs. For communication to be effective, all its constituent elements must relate to one another and be appropriate. Active listening: 5 fundamental steps 1. Listen to the content and ask for clarifications 2. Understand the purposes of the communication (do not interpret!) 3. Evaluate the interlocutor's non-verbal communication 4. Check your non-verbal communication 5. Listen with participation and without judging There are many factors that might influence the way we listen: Memories, Values, Interests, Beliefs, Past experiences, Expectations, Setting, Attitudes, Feeling/emotions. Paraphrasing: once the client has finished expressing a thought, paraphrase what they said to make sure you understand and to show that you are paying attention. Things you can say are “What I hear you saying is…,” “It sounds like…,” or “If I understand you right….” When paraphrasing, all that is needed is grasping a few points of what they’re saying and asking for confirmation on whether you understood what they said. Reflecting: involves the clinician reflecting back on what the client is saying. What is an example of reflecting in active listening? “So, you feel…” “It sounds like you…” “You're wondering if...” “For you, it's like…” Clarifying: ask for clarification: “Do you mean that?...“ Summarize: repeating a summary of what has been said back to the client. “Well, what you've told me so far is...Did I get it right?" Use of open-ended questions that stimulate deeper conversations. Closed question: "Have you had sleep problems?" Open question: "Can you tell me how you've been sleeping lately?”. Closed question: "Have you ever thought about changing jobs?" Open question: "What thoughts have you had regarding your work situation?". Closed question: "Do you feel anxious?". Closed question: "Are you satisfied with your current life?". 21 STRUCTURED/SEMI-STRUCTURED/UNSTRUCTURED INTERVIEWS (2) Degree of structuring: → Structured Interview: The questions and their order are strictly predetermined from the beginning (the most extreme form of structuring results in a questionnaire, with a fixed number of possible responses). → Semi-Structured Interview: There is less rigidity in the type, order, and execution of questions, as well as the possibility of asking additional questions based on the flow of the interaction. → Unstructured Interview: The type and order of questions are guided by adherence to specific areas or themes for which the interviewer has a pre-constructed list. The interview is considered the tool that grants the greatest freedom to the interviewer regarding the type and sequence of questions to be asked, and it can undergo significant modifications based on the dynamics of the interaction between the two participants Structured interviews Characteristics: Follow a predetermined format. All questions are asked of each client in a preset way, and the interviewer is not supposed to change the order of the questions or to deviate from them in any way. One advantage of fully structured interviews is that they can be used either by clinicians or by people who have no formal clinical training (lay interviewers). They can be useful in epidemiological studies where lots of interviewers are needed, costs need to be contained, and the goal is to try and establish the prevalence of various disorders in a community setting. Research data show that a structured format yields far more reliable results than unstructured or flexible format → standardization. They delve deeper into a specific construct They allow a classification/score by the subject with respect to a construct In a structured interview there is a specific aim and the order of questions, for example, is previously decided. This kind of interview is the best in terms of validity. Examples of structured interviews are: Adult Attachment Interview Hamilton Rating Scale for Depression Structured Clinical Interview for the DSM-5 (SCID) Eating Disorder examination (EDE-Q 16.0D) https://www.corc.uk.net/media/1274/ede_rcpsychinformation.pdf Semi-structured interviews The interviewer is required to ask questions in a specific order and in a specific way but is free to ask follow-up questions to better determine if the interviewee actually has the symptom being assessed. A benefit is that the resulting diagnoses tend to have greater validity. A disadvantage is that they require much more interviewer training and take longer to complete. Psychologists take these considerations into mind when deciding which type of interview to use. For instance, a psychologist conducting an epidemiologic study of 10,000 people might prefer a structured interview, whereas a clinician in a private practice assessing one client at a time might prefer to use a semi-structured interview. 22 Unstructured interviews The type and sequence of the questions are not predetermined but must adhere to specific topics. The content of the interview questions is influenced by the habits or theoretical views of the interviewer. The beginning statements in the interview are usually general, and follow-up questions are tailored for each client. Advantage: Clients may view the questions as being more sensitive to their needs or problems. However, this does not have to be the case. A well-conducted structured or semi-structured interview is valuable for the patient because it is comprehensive. Most patients appreciate this. Moreover, provided it is conducted by a skilled interviewer who is familiar with the questions that need to be asked, a structured or semi-structured interview can sound natural and conversational. Disadvantages: Important information needed for a DSM-5 diagnosis might be skipped, and the responses are difficult to quantify. Distinction Between Interview and Clinical Interview Applicability: - The interview is widely applicable but cannot deeply investigate the “inner world” of the interviewee. - The clinical interview is characterized by a notable in-depth knowledge of the client, in relation to the contents explored. Motivation: - In the interview the client is usually driven by extrinsic motivation, since the encounter is not meant to respond to his/her needs, but rather to the needs of others (the interviewer). - In the clinical interview, the client is usually motivated by the personal need (intrinsic motivation) to communicate with the professional regarding issues that are relevant to him/her. The role of the interviewer: - In the interview, the interviewer directly handle the times, methods and contents of the interaction. - In the clinical interview, the professional has the role of facilitating the interactive exchange while respecting the times, contents and needs of the client. PSYCHOPHYSIOLOGICAL ASSESSMENT (3) It is the evaluation of the subject's psychophysiological responses. It is particularly important for disorders that present with physical problems, such as panic disorder or conversion disorder. The clinician is interested in comparing the client’s level of activation at rest (baseline) with his/her level of activation in the presence of a given stimulus (activation reaction). It is possible to find very low correlations between the subjective report and the psychophysiological profile of the person. 23 Examples of psychophysiological assessment: - Electroencephalogram (EEG): assesses brain wave patterns; changes in the brain can be recorded almost immediately after they occur. Using EEG we can measure and record electrical activity in the brain using special sensors (electrodes). A major advantage of EEG is that it has good temporal resolution. What this means is that changes in the brain (such as might happen when a stimulus is presented) can be recorded almost immediately after they occur. - Computed Tomography (CT): scan that can reveal images of parts of the brain that might be diseased. Information from a CT scan can be used to detect bone injuries, cancers, or problems in organs of the body, including the brain. - Magnetic Resonance Imaging (MRI): another technique used to provide images of the brain. A major advantage is that it does not involve radiation and can be safely used with a wide range of people. A major advantage of MRI is that it has good spatial resolution. This means that it can generate fine-grained images that are clear and detailed. - Functional MRI tells us about neuronal activity (the working brain). - Position Emission Tomography (PET): radioactive agents are injected into a person to show how an organ is functioning. THE CLINICAL OBSERVATION OF BEHAVIOR (4) The main purpose of direct observation is to learn more about the person’s psychological functioning by attending to their appearance and behavior in various contexts. Naturalistic: takes place in the natural environment in which the behavior in question occurs spontaneously. Some practitioners and researchers use a more controlled, rather than a naturalistic, behavioral setting for conducting observations in contrived situations. These analogue situations, which are designed to yield information about the person’s adaptive strategies, might involve such tasks as staged role-playing, event reenactment, family interaction assignments, or think-aloud procedures. Reactivity of a behavior = change that might occur in the person's behavior for the fact of being observed (HAWTHORNE EFFECT). Self-monitoring: the subjects themselves observe their behaviors: Es. Performance Anxiety Checklist https://peakperformance101.com/wpcontent/uploads/2016/02/PerformanceAnxietyChecklist.pdf Many instruments have been published in professional literature and are commercially available to clinicians. These approaches recognize that people can be excellent sources of information about themselves. Assuming that the right questions are asked and that people are willing to disclose information, the results can have important implications for treatment planning. There are no episodic observations but observation periods. Rating scales can help both to organize information and to encourage reliability and objectivity (Aiken, 1996; Garb, 2007). That is, the formal structure of a scale is likely to keep observer inferences to a minimum. The most useful rating scales are those that enable a rater to indicate not only the presence or absence of a trait or behavior but also its prominence or degree. Behavior checklist - It helps to understand the relevance of the problem. - It helps to understand if there are more problematic moments, times or situations during the day. - It helps to understand whether problem behavior occurs only in certain contexts. - It allows you to check the reduction of problem behavior pre-post intervention 24 The Facial Action Coding System (FACS) By Paul Ekman is a comprehensive, anatomically based system for describing all visually discernible facial movements. It breaks down facial expressions into individual components of muscle movement, called Action Units (AUs). SELF-REPORT QUESTIONNAIRES (5) They strengthen the exploratory work of the clinical interview and provide "measurements" of specific constructs. 25 Examples are: - Minnesota Multiphasic Personality Inventory (MMPI). It is today the most widely used personality test for clinical and forensic (court-related) assessment and for psychopathology research in the United States. Typically, clients are encouraged to answer all of the items either “true” or “false.” 10 clinical scales were constructed, each consisting of items that were answered by one of the patient groups in the direction opposite to the predominant response of the normal group. This rather ingenious method of selecting scorable items, known as “empirical keying.” Note that it involves no subjective prejudgment about the “meaning” of a true or false answer to any item; that meaning resides entirely in whether the answer is the same as the answer defiantly given by patients of varying diagnoses. Should an examinee’s pattern of true and false responses closely approximate that of a particular pathological group, it is a reasonable inference that he or she shares other psychiatrically significant characteristics with that group—and may in fact “psychologically” be a member of that group. By drawing a line connecting the scores for the different scales, a clinician can construct a profile that shows how far from normal a patient’s performance is on each of the scales. The MMPI also includes a number of validity scales to detect whether a patient has answered the questions in a straightforward, honest manner. For example, there is one scale that detects lying by one’s claiming of extreme virtue and several scales that detect possible malingering or faking of symptoms. - Cognitive Behavioral Assessment (CBA) - State-Trait Anxiety Inventory (STAI) - Beck Depression Inventory (BDI) Self-report inventories such as the MMPI have a number of advantages over other types of personality tests. They are cost effective, highly reliable, and objective; they also can be scored and interpreted (and, if desired, even administered) by computer. A number of general criticisms, however, have been leveled against the use of self-report inventories. Some clinicians consider them too mechanistic to portray the complexity of human beings and their problems accurately. Also, because these tests require reading and comprehension, patients who are illiterate or confused cannot take them. Furthermore, the individual’s cooperation is required in self-report inventories, and it is possible that the person might distort his or her answers to create a particular impression. The validity scales of the MMPI-2 are a direct attempt to deal with this issue. PROJECTIVE PERSONALITY TESTING (6) This is an examination that commonly employs ambiguous stimuli - notably inkblots (Rorschach Test) and enigmatic pictures (Thematic Apperception Test) - to evoke responses that may reveal facets of the subject’s personality by projection of internal attitudes, traits, and behavior patterns upon the external stimuli. There can be different types of projective personality tests: interpretation of stimuli without content (Rorschach test) interpretation of stimuli with incomplete meaning (Murray thematic apperception test) Drawings production (house drawing, tree and human figure drawing, family drawing) Choice of colors (The Luscher color test) https://psychotests.com/test/lusher-color Manipulation and play (Es. Sand, Sceno test) The Forer effect (or Barnum effect) is a psychological phenomenon where individuals believe that vague, general statements about personality, which could apply to many people, are uniquely accurate and tailored to them. Results of many of these tests seem to apply due to this effect. In the Rorschach inkblot test, the person is asked to describe what they see in ambiguous inkblot images. 10 inkblot images: 5 monochrome, 2 two-toned and 3 colored. The interpretation of the Rorschach test is not only based on "what" the person sees in the inkblot, but includes: 26  The description of the inkblot contents The justification provided by the client for their choice The time taken The non-verbal language The rotations of the inkblot carried out by the client Unfortunately, the results of the Rorschach can be unreliable because of the subjective nature of test interpretations. For example, interpreters might disagree on the symbolic significance of the response “a house in flames.” One person might interpret this particular response as suggesting great feelings of anxiety, whereas another interpreter might see it as suggesting a desire on the part of the patient to set fires. The Rorschach was shown to “over-pathologize” persons taking the test—that is, the test appears to show psychopathology even when the individual is a “normal” person randomly drawn from the community. Another one is the Thematic Apperception Test (TAT). The TAT is a widely used projective test for the assessment of children and adults. Thirty-one picture cards serve as stimuli for stories and descriptions about relationships or social situations. Cards include specific subsets for boys, girls, men, and women. Several scoring and interpretation systems have been developed to focus on different aspects of a subject’s stories, such as expressions of needs (Atkinson, 1992), the person’s perception of reality (Arnold, 1962), and the person’s fantasies (Klinger, 1979). It is time consuming to apply these systems, and there is little evidence that they make a clinically significant contribution. The TAT has been criticized on several grounds (Lilienfeld et al., 2001). There is a “dated” quality to the test stimuli: The pictures, developed in the 1930s, appear old-fashioned to many subjects, who have difficulty identifying with the characters in the pictures. Subjects often preface their stories with statements like “This looks like something I saw in a late-night movie.” Additionally, the TAT can require a great deal of time to administer and interpret. As with the Rorschach, interpretation of responses to the TAT is generally subjective. This limits the reliability and validity of the test. Another projective procedure that has proved useful in personality assessment is the sentence completion test (Fernald & Fernald, 2010). A number of such tests have been designed for children, adolescents, and adults. Such tests consist of the beginnings of sentences that an adult might be asked to complete, as in these examples: 1. I wish _____________ 2. My mother ____________ 3. Sex ___________ 4. I hate _____________ 5. People ______________ Despite the fact that the test stimuli (the sentence stems) are standard, interpretation is usually done in an ad hoc manner and without benefit of normative comparisons. INTELLIGENCE TESTS (7) Intelligence testing can be either an overall and unitary estimate (reference to the concept of intelligence) or a collection of indices relating to individual aspects of mental functioning (perception, thinking, memory, learning, visualization, attention). The most used intelligence test is the Weschler scale. Wechsler Intelligence Scale for Children (WISC) for subjects aged 6 to 17 years 27  Wechsler Preschool e Primary Scale of Intelligence (WPPSI), for children aged 4 to 6 years Another test that is widely used is Raven's Progressive Matrices. They come from an attempt to make tests culture free. It focuses on inductive reasoning about visual stimuli. Administration time: 20-45 minutes. Items: 12 to practice and 36 of increasing difficulty. Participants need to choose from 6 or 8 figures the one that completes the model presented, and to do so they need to identify both horizontal and vertical relationships. There is a colored version for children and the elderly. COGNITIVE AND NEUROPSYCHOLOGICAL ASSESSMENT OF SPECIFIC FUNCTIONS (8) They are a Clinical evaluation of specific aspects of mental functioning. Advantages: They provide important clues about the extent and location of brain damage and information about the best treatment option. These tests are performance based and standardized, with the person’s performance being compared with normative standards. This allows for the person to be compared to a reference group. There are a few available tools: With reference to the examined cognitive functions (memory, attention, language, etc.) we have the Rey–Osterrieth complex figure, while with reference to the areas of the brain that are hypothesized to be impaired we can use Wisconsin card sorting. Rey–Osterrieth complex figure It is Used to evaluate visuospatial abilities, memory, attention to detail, and planning skills. Participants are asked to reproduce a complex, abstract geometric figure first by copying it and later from memory. The figure consists of various shapes and elements organized in a way that requires careful. Wisconsin card sorting It is used to assess cognitive flexibility, problem-solving, and executive functioning. Participants are presented with a set of cards that vary by color, shape, and number. The goal is to sort the cards into categories, but the sorting rule (e.g., by color, shape, or number) is not given; instead, the participant must deduce the rule through trial and error based on feedback (correct/incorrect) from the examiner. After the participant correctly follows the rule for a number of trials, the sorting rule changes without warning, requiring the participant to shift their strategy. Trail Making Test It is used to assess visual attention and task switching abilities. The participant is required to connect numbers sequentially as quickly as possible. In Trails B, the task becomes more complex, as it involves alternating between numbers and letters (e.g., 1- A2-B). This test evaluates key cognitive functions, including processing speed, mental flexibility, and executive functioning. As a result, it is often used to identify cognitive impairment and brain damage. 28 PHYSICAL EXAMINATION (9) When physical symptoms are part of the presenting clinical picture, a referral for a medical evaluation is recommended. This part of the assessment procedure is of obvious importance for disorders that present with physical problems, such as a panic disorder. In addition, a variety of medical problems, including various hormonal irregularities, can produce behavioral symptoms that can mimic those of mental disorders. Before initiating psychologically based interventions, medical evaluation is often wise. INTEGRATING ASSESSMENT DATA AND OPTIMIZING DECISION MAKING Once assessment data are collected, their significance must be interpreted and integrated into a coherent working model for planning. It is important to keep several factors in mind: - The potential cultural bias of the instrument or the clinician. Some psychological tests may not elicit valid information for a patient from a minority group. A clinician from one sociocultural background may have trouble assessing objectively the behavior of someone from another background. - The theoretical orientation of the clinician. Assessment is inevitably influenced by a clinician’s assumptions, perceptions, and theoretical orientation. - Under emphasis on the external situation. Many clinicians overemphasize personality traits as the cause of patients’ problems without paying enough attention to the possible role of stressors and other circumstances in the patients’ life situations. - Insufficient validation. Some psychological assessment procedures in use today have not been sufficiently validated. - Inaccurate data or premature evaluation. There is always the possibility that some assessment data—and any diagnostic label or treatment based on them—may be inaccurate or that the team leader (usually a psychiatrist) might choose to ignore test data in favor of other information. CLASSIFYING ABNORMAL BEHAVIOR In abnormal psychology, classification involves the attempt to delineate meaningful subvarieties of maladaptive behavior. Like defining abnormal behavior, classification of some kind is a necessary first step toward introducing order into our discussion of nature, causes, and treatment of such behavior. Classification makes it possible to communicate about particular clusters of abnormal behavior in agreed-on and relatively precise ways. Any classification system should be regarded as a work in progress, to be modified and updated as new knowledge becomes available. THE CATEGORICAL APPROACH As the name suggests, the categorical approach seeks to classify behavior into distinct categories. Fundamental to this approach is the idea that human behavior can be sorted into the categories of “healthy” and “disordered,” as is done in medicine with various diseases. Another assumption is that within the broad class of disordered behavior there are non-overlapping sub-classes or types of disorder that have a high degree of within-class similarity in both symptoms displayed and the underlying organization of the disorder identified. This is the approach that is used in the DSM. Of course, creating a viable taxonomy of psychopathology is easier said than done. 1. The first problem concerns what we are trying to classify. Can we be sure that the disorders we are trying to organize into a logical and coherent framework are really discrete and distinct entities (natural kinds) that exist in nature? 29  2. Another potential problem is how many categories to create. Should they be broad and potentially heterogeneous? Or should we create more narrow categories that are (we presume) more homogeneous? Although research can help us with this question, the categories that get created tend to be regarded as real disease entities well before we have solid evidence that this should be the case. 3. Another major concern involves comorbidity. Comorbidity is the concurrent presence of two or more disorders in the same person. Of course, it is possible that the person does indeed have two or more separate and distinct disorders. But comorbidity is surprisingly common. This suggests that, at least in some cases, comorbidity might reflect problems with our classification system. 4. Yet another concern is that categorical approaches do not consider severity very well. Mild, moderate, and severe forms of a disorder all get grouped together. In spite of all these concerns and limitations, the appeal of categorical classification in psychiatry and psychology has endured for well over 100 years. THE DIMENSIONAL APPROACH People naturally tend to vary in terms of how much of a given characteristic (e.g., anxiety, negative mood) they may have. In the dimensional approach, it is assumed that a person’s typical behavior is the product of the differing strengths or intensities of definable dimensions such as mood, emotional stability, aggressiveness, clarity of thinking and communication, social introversion, and so on. One advantage of a dimensional approach is that it preserves information about variability. This is inevitably lost when we create simple categories. On the other hand, considering where a person lies on a broad range of dimensions adds complexity to any communication about how that person behaves and functions. Moreover, even when a characteristic is measured dimensionally (such as might be the case in medicine, for blood pressure) there is still a tendency to use cut-points to create categories. Nonetheless, one appealing feature of a dimensionally-based approach is that cut-points can be used to define mild, moderate, or severe levels of dysfunction. This has the benefit of directly informing treatment options. Many authors are now suggesting that our thinking about mental disorders would benefit from adopting a dimensional perspective. This is especially so with respect to personality disorders THE PROTOTYPAL APPROACH A prototype (as the term is used here) is a conceptual entity that represents the ‘perfect case’ or ‘theoretically ideal’ case. This kind of approach was used in DSM-I and DSM-II. These early versions of the DSM provided rather vague and impressionistic descriptions of the various disorders and then relied on the clinician to decide if their patient fit the overall pattern described. Today, any clinician who is not using a structured or semi-structured clinical interview or is too busy to conduct a full clinical assessment is essentially using an informal prototype matching approach. One advantage of a prototype matching approach is that it fits the way people actually think. Westen, Shedler, and Bradley (2006), for example, suggested that the DSM should provide a narrative description of a prototypical case of each personality disorder rather than having a listing of diagnostic criteria as it now has. The clinician would simply rate the overall similarity or “match” between a patient and the prototype on a simple 5-point scale. A rating of 4 or 5 would mean the patient has enough of a resemblance to the prototype to be considered as having the disorder. A rating of 3 would mean that the patient has some features of the condition; a rating of 1 (the default) would indicate no resemblance to the prototype. Dimensional data can be collected on large samples of people. These data can then be statistically analyzed to identify clinically meaningful prototypes via a bottom-up (as opposed to top-down) strategy. 30  OCD – OBSESSIVE COMPULSIVE DISORDER In October one week is dedicated to OCD awareness disorder. OCD Awareness Week takes place on the second week of October and was developed in 2009. The focus of OCD Awareness Week is to bring awareness to the condition and reduce stigma. Even professionals see this disorder as very intimidating. Various factors can trigger OCD → COVID-19 confirmed that it can be triggered by stressful situations, as during the pandemic many people developed obsessive behaviors to feel safe, which are hard to let go of. A stressful situation does not have to be traumatic! Obsessive-compulsive disorder (OCD) is a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both. People with OCD have time- consuming symptoms that can cause significant distress or interfere with daily life. However, treatment is available to help people manage their symptoms and improve their quality of life. Obsessive-compulsive and related disorders used to be classified in the DSM as anxiety disorders; however, as of DSM-5 they have been classified separately as their own type of disorder. People are caught in a vicious circle of obsessions that they try to soothe with compulsion, but those compulsions fuel the same fears/obsession (many obsessive-compulsive disorders are “phobic”). One thing feeds the other. In some cases, compulsions can cause obsessions! For example, if I start wearing a green shirt for exams for luck and I manage to pass them well, continuing this behavior may make me believe that I am doing good because I am wearing that specific item of clothing. The issue arises if the shirt is unavailable the day of an exam (I may become violent), but also especially because I am feeding myself the idea that passing an exam is due to the shirt and not to myself → external locus of control, low level of self-esteem. Wearing the shirt is a propitiatory ritual, but I may keep checking things over and over again, whether I understand, whether I’m studying the right things, whether I have the date of the exam correctly. This is then invalidating. Usually, we do not have just one compulsion, but multiple, which becomes extremely time-consuming and invalidating (intrusive thoughts are connected to this), the person loses control in the process of trying to have more control. To be precise, a compulsion is something that the person repeats to sedate the anxiety of those unwanted thoughts. It is very similar to an addiction. However, the more I sedate, the more I cannot tolerate. OCD is on the rise because a lot of us cannot handle anxiety, especially because we are used to getting everything we need immediately (a reason why people want others to respond to their texts immediately). OCD occurs when a compulsion becomes continuous and irresistible, when clients start doing things again and again and again → they become stuck in that repetition. OCD patients also tend to see things in black and white (this gives a sense of security and avoids ambiguity: am I male or female? Am I good or not?). Each of us tries to put oneself into categories, but this can become excessive: am I clean or not? Am I honest or not? Am I a good person or not? To be good, clean, honest, etc. I may, as a patient, need to perform a compulsion to calm my anxiety. Thoughts get fueled and can become obsessions. OCD can also involve avoidances rather than compulsions: avoiding all situations which may heighten anxiety. Remember that phobias only involve avoidance, while OCD also includes reparative behaviors. MISCONCEPTIONS and MYTHS Sadly, there are a lot of misconceptions about OCD. Numerous myths and misconceptions surround OCD, which can promote stigma for the people who have it. This can lead to numerous harmful consequences, such as feelings of isolation and self-doubt for those affected. Additionally, people who experience the stigma have fewer chances for social interaction and employment. 31  1. OCD Myth #1: OCD is just being overly clean or organized. There can be numerous kinds of obsession: someone may fear that they could hurt others or even themselves. 2. OCD Myth #2: OCD is rare and doesn't affect many people. It is one of the most common psychiatric problems, on the rise after COVID-19 (which not only created fear of contamination but also is