Unit-1-5CLINICAL.docx

Unit 1 OVERVIEW OF CLINICAL PSYCHOLOGY Learning Objectives: 1\. Describe the development of clinical psychology from the early history up to the present. 2\. Discuss the different models used in understanding clinical psychology. What is Clinical Psychology? Lightner Witmer (1907) - the first...

Unit 1 OVERVIEW OF CLINICAL PSYCHOLOGY Learning Objectives: 1\. Describe the development of clinical psychology from the early history up to the present. 2\. Discuss the different models used in understanding clinical psychology. What is Clinical Psychology? Lightner Witmer (1907) - the first person to operate a psychological clinic. Witmer envisioned clinical psychology as a discipline with similarities to a variety of other fields, specifically medicine, education, and sociology. A clinical psychologist, therefore, was a person whose work with others involved aspects of treatment, education, and interpersonal issues. Current definition American Psychological Association (APA) defines clinical psychology as follows: "The field of Clinical Psychology integrates science, theory, and practice to understand, predict, and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and personal development. Clinical Psychology focuses on the intellectual, emotional, biological, psychological, social, and behavioral aspects of human functioning across the life span, in varying cultures, and at all socioeconomic levels." (APA, 2012a). Clinical psychology involves rigorous study and applied practice directed toward understanding and improving the psychological facets of the human experience, including but not limited to issues or problems of behavior, emotions, or intellect (A. Pomerantz, 2017). Education and Training in Clinical Psychology R.A. 10029 - Psychology Act of 2009 - Defining the job description of a psychologist and a psychometrician Bachelor's degree in psychology Master's degree in psychology Board exam for Psychometrician Board exam for Psychologist Board exam for Guidance Counselor (Master's degree in Guidance & Counselling) Psychometrician \- administer, score objective personality test, structured personality test, excluding projective tests and other higher-level form of psychological tests (e.g., individual tests, neurological tests). Interpret the results of these tests and prepare a written report of these results \- conduct preparatory intake interviews of clients for psychological intervention sessions \- provided they are under the supervision of a licensed Psychologist Psychologist \- Psychological assessment \- Psychological interventions \- Psychological programs \- Other psychological interventions (e.g., preventive & therapeutic measures, consultations, etc.) For APA (American Psychological Association)-accredited doctoral programs in clinical psychology offer (but may not require) training within a specialty track. The most common specialty areas are clinical child, clinical health, forensic, family, and clinical neuropsychology. Three models of Training 1\. The Scientist-Practitioner (Boulder) Model (1940's) To become a clinical psychologist, graduate students would need to receive training and display competence in the application of clinical methods (assessment, psychotherapy, etc.) and the research methods necessary to study and evaluate the field scientifically. 2\. The Practitioner-Scholar (Vail) Model (1970's) Extensive training as a scientist vs. practice -- a minority of clinical psychologists were entering academia or otherwise conducting research as a primary professional task. Clinical practice was the more popular career choice and many would-be clinical psychologists sought a doctoral-level degree with less extensive training in research and more extensive training in the development of applied clinical skills. 3\. The Clinical Scientist Model Stressed the scientific side of clinical psychology more strongly; very strong emphasis on the scientific method and evidence-based clinical methods. A growing emphasis in training is specific competencies, or outcome-based skills the students must be able to demonstrate. Specific competencies that may be required of students could center on intervention(therapy), assessment, research, consultation/collaboration, supervision/teaching, ethics, cultural diversity, and management/administration. What Do Clinical Psychologists Do? Clinical psychologists are engaged in an enormous range of professional activities, but psychotherapy is foremost (A. Pomerantz, 2017). Others are into teaching, research, clinical supervision, consultation, administration (Trull & Prinstein, 2015). Clinical psychologist and psychiatrist Clinical psychologists- are trained to appreciate the biological aspects of their clients' problems, but psychiatrists' training emphasizes biology to such an extent that disorders--- depression, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), borderline personality disorder, and so on ---are viewed first and foremost as physiological abnormalities of the brain. So, to fix the problem, psychiatrists tend to fix the brain by prescribing medication (Noll, 2015, as cited by Pomerantz,2017). This is not to imply that psychiatrists don't respect "talking cures" such as psychotherapy or counseling, but they favor medication more than they used to. For clinical psychologists, the biological aspects of clients' problems may not be their defining characteristic; nor is pharmacology the first line of defense. Instead, clinical psychologists view clients' problems as behavioral, cognitive, emotional---still stemming from brain activity, of course, but amenable to change via non-pharmacological methods. Other major professions in the Mental Health field Social Workers Social workers focused their work on the interaction between an individual and the components of society that may contribute to or alleviate the individual's problems. They saw many of their clients' problems as products of social ills---racism, oppressive gender roles, poverty, abuse, and so on. They also helped their clients by connecting them with social services, such as welfare agencies, disability offices, or job-training sites. School Psychologist/Guidance Counselor Their primary function is to enhance the intellectual, emotional, social, and developmental lives of students. They frequently conduct psychological testing (especially intelligence and achievement tests) to determine diagnoses or learning difficulties such as learning disorders and ADHD, etc. They use or develop programs designed to meet the educational and emotional needs of students. HISTORY OF CLINICAL PSYCHOLOGY (Pomerantz, 2017) Review on the history of abnormal psychology Early pioneers/traditions Specifically, in the 1700s and 1800s, the mentally ill were generally viewed and treated much more unfavorably than they are today. They were understood to be possessed by evil spirits or they were seen as deserving of their symptoms as a consequence of some reprehensible action or characteristic. They were frequently shunned by society and were "treated" in institutions that resembled prisons more than they did hospitals. William Tuke (1732--1822, England) - He raised funds to open the York Retreat, a residential treatment center where the mentally ill would always be cared for with kindness, dignity, and decency. Patients received good food, frequent exercise, and friendly interactions with staff. The York Retreat became an example of humane treatment, and soon similar institutions opened throughout Europe and the United States. Philippe Pinel (1745--1826-France) liberator of the mentally ill. He created new institutions in which patients were not kept in chains or beaten but, rather, were given healthy food and benevolent treatment. Particularly, Pinel advocated for the staff to include in their treatment of each patient a case history, ongoing treatment notes, and an illness classification of some kind--- components of care that suggested he was genuinely interested in improving these individuals rather than locking them away. Eli Todd (1762--1832, US) Todd was a physician in Connecticut in 1800. He had learned about Pinel's efforts in France, and he spread the word among his own medical colleagues in the United States. They supported Todd's ideals both ideologically and financially, such that Todd was able to raise funds to open The Retreat in Hartford, Connecticut, in 1824. Todd ensured that patients at The Retreat were always treated in a humane and dignified way. He and his staff emphasized patients' strengths rather than weaknesses, and they allowed patients to have significant input in their own treatment decisions. Dorothea Dix (1802--1887) - She was working as a Sunday school teacher in a jail in Boston and she witnessed how inmates were there not as a result of the crime they committed but as a result of mental illness or retardation. She devoted the rest of her life to improving the lives and treatment of the mentally ill. She would travel to a city, collect data on its treatment of the mentally ill, present her data to local community leaders, and persuade them to treat the mentally ill more humanely and adequately. She repeated this pattern with remarkable success. Her efforts resulted in the establishment of more than 30 state institutions for the mentally ill throughout the United States (and even more in Europe and Asia), providing more decent, compassionate treatment for the mentally ill than they might have otherwise received (Reisman, 1991). Lightner Witmer (1867--1956) in 1896, he founded the first psychological clinic at the University of Pennsylvania, where he had returned as a professor. The first time that the science of psychology was systematically and intentionally applied to people's problems. In his clinic, Witmer and his associates worked with children whose problems arose in school settings and were related to learning or behavior. They were referred by their schools, parents, physicians, or community authorities. Witmer (1907) emphasized that clinical psychology could be applied to adults as well as children, or to problems that had nothing to do with school: Witmer also founded the first scholarly journal in the field (called The Psychological Clinic) in 1907 (Benjamin, 2007). Witmer authored the first article, titled "Clinical Psychology," in the first issue. Development of the Profession In the 1940s, education and training in clinical psychology became more widespread and more standardized. The number of training sites increased dramatically, and the American Psychological Association began accrediting graduate programs that offered appropriate training experiences in therapy, assessment, and research. The 1950s produced more evidence that clinical psychology was a burgeoning profession. Therapy approaches proliferated, with new behavioral and humanistic/existential approaches rivaling established psychodynamic techniques. In the 1960s and 1970s, the profession of clinical psychology continued to diversify, successfully recruiting more females and minorities into the field. Clinical approaches continued to diversify as well, as behaviorism, humanism, and dozens of other approaches garnered large followings. In the 1980s, clinical psychologists enjoyed increased respect from the medical establishment as they gained hospital admitting privileges and Medicare payment privileges. Today's aspiring clinical psychologists have more choices than ever: the science/clinical balance of traditional PhD programs, PsyD programs emphasizing clinical skills, and more selected PhD programs that endorse the clinical scientist model of training and lean heavily toward the empirical side of the science/clinical continuum. Unit 2 ETHICAL AND PROFESSIONAL ISSUES IN CLINICAL PSYCHOLOGY Learning Objective: 1\. Examine the different ethical and professional issues in clinical psychology. Issues in Clinical Psychology On Prescription Issues Prescription Privileges Shortage of psychiatrists- in the US there aren't enough psychiatrists to serve the population especially in some rural areas. In the Philippines, there are a little over 500 psychiatrists in practice. The ratio of mental health workers per population in the Philippines is low, at 2-3 per 100 000 population (WHO & Department of Health, 2006). Data indicate that there are 0.52 psychiatrists (Isaac et al, 2018\) and 0.07 psychologists per 100 000 inhabitants, and 0.49 mental health nurses per 100 000 of the population (a reduction from 0.72 per 100 000 in 2011) (WHO, 2014). Clinical psychologists are more expert than primary care physicians- their training is more extensive and specialized than physicians'; therefore, clinical psychologists could be better able to diagnose problems correctly and select effective medications. Convenience for clients - treatment is streamlined, saving both time and money. Evolution of the profession - Prescriptive authority could open multiple doors to professional opportunity for clinical psychologists, from direct pharmaceutical treatment of clients to consultation with physicians about psychoactive medications for their patients. Why Clinical Psychologists Should Not Prescribe Training issues - basic competence in psychopharmacology; training in psychopharmacology? Threats to psychotherapy - "talk therapy" to pharmacological intervention. Identity confusion -prescribe or not to prescribe. The potential influence of the pharmaceutical industry - targeted by the pharmaceutical industry and will be pressured to consider factors other than client welfare when making prescription decisions. Evidence-Based Practice/Manualized Therapy How well does therapy "works"? The American Psychological Association created a task force to compile the different therapies into a list to serve as a reference for therapists who sought the most proven therapies for particular disorders. The therapies on this list were originally called "empirically validated" treatments, but the terminology soon changed to "empirically supported" treatments and eventually to "evidence-based practice." e.g., researchers have tested exposure and response prevention, a specific form of behavior therapy-for the treatment of obsessive-compulsive disorder. This change in terminology is important because the current term, evidence-based practice, incorporates not only the particular treatment itself but also factors related to the people providing and receiving it. More specifically, evidence-based practice is defined as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences" (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273, as cited by Pomerantz, 2017). Advantages of Evidence-Based Practice/Manualized Therapy Scientific legitimacy There are standards of treatment for medical doctors treating physical diseases, and if clinical psychology subscribes to the medical model of diagnosis and treatment, the same expectation should apply to our field as well. Establishing minimal levels of competence The manualized, evidence-based treatments disseminated and used by clinical psychologists ensures that a potentially incompetent or detrimental therapist will be educated in treatments with demonstrated effectiveness. Moreover, as these treatments evolve into professional standards, psychologists will be obligated to follow them to some degree. As a result, the public will receive a more consistent, proven brand of treatment for each disorder, and psychologists can be held to a greater standard of accountability (Sanderson, 2003, as cited by Pomerantz, 2017). Training improvements The APA emphasized training in evidence-based treatments so that upcoming generations of psychologists will be educated in the therapies that have empirical data supporting their success with particular disorders. Some programs may emphasize evidence-based treatments more than others. Decreased reliance on clinical judgment Clinical judgment can be susceptible to bias and, as a result, quite flawed so it should be based on empirical evidence. Disadvantages of Evidence-Based Practice/Manualized Therapy Threats to the psychotherapy relationship Psychologists argue that it's the relationship, not the technique, that should be evidence- based. Therapist--client relationship should not be neglected but should be recognized and studied as a focal point of what makes therapy work. Diagnostic complications Each evidence-based treatment manual targets a particular disorder or issue. However, in the real world of clinical psychology, that's not necessarily how clients present themselves in the real world of clinical psychology. A client with panic disorder might also have something else---another anxiety disorder, a mood disorder, a personality disorder, or cognitive limitations, perhaps. This comorbidity means that the therapy that worked on clients with "clean" (i.e., uncomplicated) disorders in a treatment outcome study may not work as well on clients with more "messy" diagnostic features who commonly seek therapy from clinical psychologists in real-world settings (Angold, Costello, & Erkanli, 1999; Kessler, 1994; Zedlow, 2009). Restrictions on practice Flexibility, as opposed to required, rigid adherence manualized therapies. Therapists who demonstrate flexibility while using manuals are more successful in terms of engaging clients in therapy and ultimately producing betteroutcomes. Debatable criteria for empirical evidence "As practitioners, we cannot manage without nomothetic and idiographic data, findings based onquantitative and qualitative method, and a mixture of scientific and humanistic outlooks, which are psychology's dual heritage" (p. 586, as cited by Pomerantz, 2017). Influence of Pharmaceutical Companies-Do financial connections with drug companies really influence mental health professionals? Emerging Professional Issues Telehealth (Telepsychology) refers to the delivery and oversight of health services using telecommunication technologies. Different technologies may be used in various combinations and for different purposes during the provision of telepsychology services. For example, videoconferencing and telephone may also be utilized for direct service while email and text are used for non-direct services (e.g., scheduling). Cybertherapy - therapy online; "e-therapy"; online counseling; telepsychiatry (Ethical Code- Taken from the American Psychological Association (2002) ethical code) Obtain informed consent from clients about the services they may receive, the technologies that may be used to provide them, and the confidentiality of the communication. Know and follow any applicable laws on telehealth and telemedicine. Know and follow the most recent version of the American Psychological Association ethical code, especially the portions that address technological issues. Ensure client confidentiality as much as possible by using encryption or similar methods. Keep updated on ways clinical information could be accessed by hackers and techniques for stopping them. Appreciate how issues of culture may be involved. As technological tools replace face-to-face meetings, psychologists may need to make special efforts to assess the cultural backgrounds of the clients they serve. Do not practice outside the scope of your expertise. Merely having a license may not be enough. Advanced training---either clinical or technological---may be necessary to use a particular technique. Be knowledgeable about emergency resources in any community from which your clients may seek services. A crisis related to suicide or psychosis, for example, may require an immediate face-to-face intervention that the psychologist is simply too far away to provide. Stay abreast of changes to the laws, ethical codes, and technology relevant to your practice Psychologists' Ethical Beliefs What ethical beliefs do psychologists hold? (Psychotherapy-related behaviors) Although the American Psychological Association's (2002) ethical code serves as a guiding force, the beliefs psychologists actually hold, which correspond strongly with the behaviors they act out may be subject to other influences. Confidentiality "Psychologists have a primary obligation and take reasonable precautions to protect confidential information" (American Psychological Association, 2002, p. 1066) Our profession is entrusted by the public to provide professional services without sharing the private, personal details offered in the process. However, the public may be unaware of the fact that confidentiality is not absolute. Although most people outside of the mental health profession may assume that psychologists hold all information confidential. The truth is that situations arise in which psychologists are obligated to break confidentiality. RA 10029 - AN ACT TO REGULATE THE PRACTICE OF PSYCHOLOGY CREATING FOR THIS PURPOSE A PROFESSIONAL REGULATORY BOARD OF PSYCHOLOGY, APPROPRIATING FUNDS THEREFOR AND FOR OTHER PURPOSES ARTICLE VII-PRIVILEDGED COMMUNICATION AND PROFESSIONAL INTEGRATION Section 30. Rights to Privilege Communication for Psychologists and Psychometricians. -- A psychologists or psychometrician cannot, without the consent of the client/patient, be examined on any communication or information disclosed and/or acquired in the course of giving psychological services to such client. The protection accorded herein shall extend to all pertinent records and shall be available to the secretary, clerk or other staff of the licensed psychologist or psychometrician. Any evidence obtained in violation of this provision shall be inadmissible for any purpose in any proceeding. Section 32. Code of Ethics and Code of Practice for Psychologists and Psychometricians. -- The Board shall adopt and promulgated the Code of Ethics and Code of Practice for Psychometricians prescribed and issued by the accredited professional organization of psychologists. When the Client Is a Child or Adolescent In the US, every state has laws requiring mental health professionals to break confidentiality to report known or suspected child abuse. The goal of treatment may remain simple---the well-being of the child---but in cases in which child abuse is suspected, determining the means to attain this goal can become complex. Both legal standards and ethical standards can be both observed by the clinical psychologist (ex. Duty-to-warn people) Laws in the Philippines protecting the rights of women and children 1\. Republic Act No. 7610 - Special Protection of Children Against Abuse, Exploitation and Discrimination Act (June 17, 1992) 2\. Republic Act No. 9262 - Anti-Violence Against Women and Their Children (March 08, 2004) Section 44. Confidentiality. -- All records pertaining to cases of violence against women and their children including those in the barangay shall be confidential and all public officers and employees and public or private clinics to hospitals shall respect the right to privacy of the victim. Whoever publishes or causes to be published, in any format, the name, address, telephone number, school, business address, employer, or other identifying information of a victim or an immediate family member, without the latter\'s consent, shall be liable to the contempt power of the court. Other Issues in clinical psychology Multiculturalism "We must incorporate cultural acknowledgment into our theories and into our therapies, so that clients not of the dominant culture will not have to feel lost, displaced, or mystified" (McGoldrick, Giordano, and Garcia-Preto (2005, p. 4), as cited by Pomerantz, 2017). Culture is such a powerful force in the clinical and counseling fields is that it shapes the way the client understands the very problem for which he or she is seeking help. This understanding---applied to psychological problems---is what the therapist should appreciate as he or she devises an approach to helping the client. Sample questions (Pomerantz, 2017) What do you call your problem (or illness or distress)? What do you think your problem does to you? What do you think the natural cause of your problem is? Why do you think this problem has occurred? How do you think this problem should be treated? How do you want me to help you? Who else (e.g., family, friends, religious leader) do you turn to for help? Who (e.g., family, friends, religious leader) should be involved in decision making about this problem? (Adapted from p. 875) DSM on multiculturalism The term distress (many of which were called "culture-bound syndromes" in previous DSM. The glossary of cultural concepts of distress includes nine terms that represent psychological problems observed in groups from various parts of the world. Examples include: taijin kyofusho, in which a person anxiously avoids interpersonal situations because he or she believes that his or her appearance, actions, or odor will offend other people (found in Japanese and some other cultures); sutso, in which a frightening event is thought to cause the soul to leave the body, resulting in depressive symptoms (found in some Latino/Latina/Hispanic cultures); maladi moun, in which one person can "send" psychological problems like depression and psychosis to another, usually as a result of envy or hatred toward the other person's success (found in some Haitian communities; similar experiences called the "evil eye" are more common in other parts of the world). Clinical psychologists should strive for cultural competence because when clients perceive their therapists as culturally competent, they are more likely to form strong working relationships with them, which leads to better therapy outcomes. Cultural Self-Awareness A therapist' viewpoint is (like everyone's) unique and idiosyncratic\--the psychologist may come to recognize that the differences between people are not necessarily deficiencies, especially if the difference demonstrated by the client is common or valued in his or her own cultural group. Cultural self-awareness is important regardless of the psychologist's own cultural background---they will encounter clients whose cultural backgrounds differ---sometimes slightly, sometimes considerably---from his or her own. Cultural knowledge Knowledge should include not only the current lifestyle of the members of the culture but also the group's history, especially regarding major social and political issues. Culturally Appropriate Clinical Skills The approaches and techniques that a psychologist uses to improve a client's life should be consistent with the values and life experience of that client. For example: "talk therapy" may work well for many, but for some cultural groups, it may be a bad fit. Similarly, clients from some cultures may place great value on "insight" into their psychological problems obtained over many months, but clients from other cultures may respond much more positively to action-oriented therapies with a short-term focus. Microaggressions- comments or actions made in a cross-cultural context that convey prejudicial, negative, or stereotypical beliefs and may suggest dominance or superiority of one group over another. The best way for psychologists to avoid microaggressions is to examine the thoughts and beliefs that underlie them, which can result in greater humility and self-awareness for the psychologist. Etic Versus Emic Perspective Etic perspective- emphasizes the similarities between all people. It assumes universality among all people and generally does not attach importance to differences among cultural groups. Emic perspective- it recognizes and emphasizes culture-specific norms. Compared with the etic perspective, the emic perspective allows psychologists more opportunity to appreciate and understand how the client might be viewed by members of his or her own cultural group. In short, the emic approach stresses that individuals from various cultural groups "must be understood on their own terms. Tripartite Model of Personal Identity A psychologist who can appreciate a client on all three levels will be able to recognize characteristics that are entirely unique to the client, others that are common within the client's cultural group, and still others that are common to everyone. Sue and Sue (2008) argue that appreciation of all three levels is indeed the goal but that the group level has been overlooked traditionally in psychology, especially when the group is a minority culture, so psychologists may need to make more deliberate efforts in that direction. (Source: Pomerantz, 2020) Individual level - "all individuals are, in some respects, like no other individuals." Group level, where the premise is that "all individuals are, in some respects, like some other individuals." Universal level, based on the premise that "all individuals are, in some respects, like all other individuals. Unit 3 RESEARCH IN CLINICAL PSYCHOLOGY Learning Objectives 1\. Discuss the different methods in conducting research in clinical psychology. 2\. Examine the various issues related to research in clinical psychology. Research in Clinical Psychology Treatment Outcome - to determine how well therapies work. In the decades subsequent to Eysenck's review, researchers established that psychotherapy is indeed effective and ultimately moved on to exploring which particular therapies are most successful at treating which particular disorders. It is important to distinguish studies of psychotherapy outcome into studies that measure efficacy and those that measure effectiveness. Efficacy Versus Effectiveness Efficacy refers to the success of a particular therapy in a controlled study conducted with clients who were chosen according to particular study criteria. In short, the efficacy of a form of therapy is how well it works "in the lab," where it is practiced according to manualized methods and where outcome for treated individuals is compared via clinical trial with outcome for individuals who receive alternate or no treatment. Effectiveness - refers to the success of a therapy in actual clinical settings in which client problems span a wider range, and clients are not chosen as a result of meeting certain diagnostic criteria. In short, the effectiveness of psychotherapy is how well it works "in the real world," or how well it translates from the lab to the clinics, agencies, hospitals, private practices, and other settings where clinical psychologists conduct therapy. NOTE: When measuring the outcome of therapy in either an efficacy or an effectiveness study, researchers must be careful to distinguish statistical significance from clinical significance when interpreting their results. Statistical significance vs. clinical significance Statistically significant difference doesn't necessarily mean that the two groups differ much in real-world terms (clinical). Both statistical significance, which is assessed quantitatively, and clinical (or real-world) significance, which is measured more qualitatively, should be taken into account when interpreting the results of a therapy outcome study. Internal Versus External Validity Internal validity -refers to the extent to which the change in the dependent variable is due solely to the change in the independent variable. External validity refers to the generalizability of the result---to what extent is the same finding valid for different settings and populations? The more "controlled" and internally valid an efficacy study is, the more dissimilar it can become from therapy in the "real world," thus undermining external validity. Efficacy studies are often respected for their internal validity but discounted for their external validity, whereas the opposite is often true for effectiveness studies. Why Clinical Psychologists conduct research? Clinical psychologists conduct research to evaluate and improve the assessment methods they use with clients. \- involve the development, validation, or expanded use of new instruments; the establishment of normative data for specific populations on an assessment tool; a comparison of multiple assessment tools to one another; or other research questions. CP conduct research to explore issues of diagnosis and categorization regarding psychological problems. \- such studies may examine the validity or reliability of existing or proposed diagnostic constructs, the relationships between disorders, the prevalence or course of disorders, or numerous related topics. Clinical psychologists also examine elements of their own profession through empirical research. \- they study clinical psychologists' activities, beliefs, and practices, among other aspects of their professional lives. Clinical psychologists also pursue research questions related to how to educate those entering the profession. \- training philosophies, specific coursework, opportunities for specialized training, and the outcome of particular training efforts all represent areas of study Research Methods Used by CP The Experimental Method In clinical psychology, experimental studies often take the form of randomized clinical trials (RCTs). In an RCT, researchers test the outcome of a particular, manualized therapy on a particular diagnosis. An RCT begins with recruitment and selection of participants who meet the criteria for the diagnosis. Then, each participant is randomly assigned to a group that receives the therapy or another group that does not receive the therapy. In both groups, the target variables (typically objective measures of symptoms, like frequency of panic attacks or self-reported depression symptoms) are assessed at the outset and at the end of the study, and the comparison between the two groups indicates the degree to which the treatment was helpful. Pros: Maximize internal validity by ensuring that improvements in participants receiving the therapy are indeed due to the therapy rather than extraneous factors. Cons: RCTs have been criticized for oversimplifying clinical problems by reducing them to objective and easily measured symptoms, and for producing results that may not translate to "real-world" settings where clients may not match the clients selected for the study. Quasi-Experiments Instead of using experimental design, the researchers may choose to use a quasi- experimental design, because often, ED involves variables that the researcher is not entirely able to control. \- For example, you want to examine the outcome of a particular therapy for specific phobias. If the researchers were designing a true experiment, they would need to take identical individuals, induce in them identical fears, and then assign them to different Conditions. \- CP acknowledge that individuals in the two comparison groups will necessarily have phobias of different objects and different intensities and that they will differ in many other ways as well (age, personality characteristics, ethnicity, etc.) even if the researchers make attempts to "match" the groups as much as possible. Between-Group Versus Within-Group Designs Between-group design- participants in different conditions receive entirely different treatments. Within-group design- involves comparisons of participants in a single condition to themselves at various points in time. At times, clinical psychology researchers will combine aspects of between-group and within- group designs, creating a mixed-group design. \- As an example, researchers could merge the approaches to studying exercise and depression described assigning participants to two conditions (exercise regimen vs. no exercise regimen) and by measuring changes of all participants on a weekly basis. \- A researcher who examines the relationship between physical exercise and depression. Analogue Designs Analogue- a study of that involves an approximation of the target client or situation as a substitute for the "real thing." At times, it can involve using participants whose characteristics resemble (but don't exactly match) those of the target population, or asking participants to remember or imagine themselves in a certain situation. \- For ex: if a researcher could not access this population (depressed individuals) in sufficient numbers, they might access a more available population, such as undergraduates at their university whose depression levels are mild to moderate according to a self-report depression questionnaire. Correlational Methods Correlational design- examine the relationship that exists between two or more variables. (correlational study can conclude that one variable predicts or associates with another) Sometimes, correlational studies constitute important early steps in an evolution of research on a particular topic, leading eventually to more experimental or quasi-experimental studies. Case Studies Case study- involve a thorough and detailed examination of one person or situation. Typically, they include descriptive observations of an individual's behavior and an attempt by the researcher to interpret it. The researcher may speculate about how explanations about the target individual may also apply to others who are similar in some way. Case studies tend to be held in high regard by researchers who prefer the idiographic approach---emphasizing or revealing the unique qualities of each person---to the nomothetic approach---determining similarities or common qualities among people. Sometimes, case studies are qualitative in nature. Meta-Analysis A meta-analysis is a statistical method of combining results of separate studies (translated into effect sizes) to create a summation (or, statistically, an overall effect size) of the findings. As the name implies, meta-analysis is a study of studies, a quantitative analysis in which the full results of previous studies each represent a small part of a larger pool of data. Cross-Sectional Versus Longitudinal Designs Cross-sectional designs- assess or compare a participant or group of participants at one particular point in time. Longitudinal designs -emphasize changes across time, often making within-group comparisons from one point in time to another. Use of Technology in Research Use the technology to collect data \- For ex: they measured negative thoughts and mood by sending e-mails to the smartphones of participants at eight randomly selected times per day. Each e-mail provided a link to a website at which participants immediately completed a brief survey about either their negative thoughts or their mood. Sleep quality was measured by actigraphs (similar to a Fitbit tracker) worn on the participants' wrists each night. This high-tech method of data collection---often called experience sampling, for its ability to tap into participants' behavior in real time---produced results indicating that negative thoughts did in fact significantly correlate with reduced sleep quality and poorer mood the next day. Use of MTurk is an Internet-based crowdsourcing marketplace run by the Amazon corporation that matches researchers with willing participants. Clinical psychologists are increasingly turning to MTurk as an alternative to undergraduate psychology students or other available pools of participants. MTurk has been available since 2007. Additionally, clinical psychologists have involved technology in their research by focusing on the technology as a clinical intervention. They have examined how well a particular use of technology works as a component of therapy. \- For example, researchers studied the benefits of a smartphone app designed specifically for the treatment of alcohol use disorder (and found that it worked about as well as alternate treatments). Ethical Issues in Research PAP Code of Ethics X. RESEARCH A. Rights and Dignity of Participants B. \*Informed Consent to Research C. Informed Consent for Recording Voices and Images in Research D. Research Participation of Client, Students and Subordinates E. Dispensing with Informed Consent for Research F. Offering Inducements for Research Participation G. Deception in Research H. \*Debriefing I. Observational Research J. Humane Care and Use of Animals in Research K. \*Reporting Research Results L. Plagiarism M. Publication Credit N. Duplicate Publication of Data O. Sharing Research Data for Verification P. Reviewers Q. Limitations of the Study UNIT 4 CLINICAL ASSESSMENT Learning Objectives: 1\. Discuss the clinical interview and its components as part of assessment 2\. Distinguish behavioral assessment from traditional approaches to assessment. 3\. Examine the different observational methods and its relevance to behavioral assessment. ASSESSEMENT Any assessment technique used by a clinical psychologist should possess the qualities of validity, reliability, and clinical utility. An element common to all kinds of psychological assessment is feedback. In other words, clinical psychologists provide their clients with the results of tests or interviews that have been conducted and the feedback can come in the form of a face-to-face meeting, a written report, or other forms. Clinical psychologists conducting assessments can employ a wide variety of methods, including intelligence tests, achievement tests, neuropsychological tests, personality tests, and specialized measures for targeted variables. However, the vast majority of clinical psychologists use interviews, and few assessments are conducted without an interview of some kind. CLINICAL INTERVIEW A skilled interviewer only is not a master of the technical and practical aspects of the interview but also demonstrates broad-based wisdom about the human interaction it entails. The clinical interview is a core element of most assessments conducted by clinical psychologists. In a clinical interview, the investigator may utilize certain standard material but essentially determines which questions to ask based on the responses given by the patient to previous ones. This technique is largely spontaneous and enables the interviewer to adapt questions to the patient's comprehension and ask additional questions to clarify ambiguities and enhance understanding. Before conducting an interview, the interviewer should have acquired some general skills to serve as a foundation for interviewing in any context. The general skills will focus on the interviewer's own frame of mind rather than any particular set of techniques. Frame of mind \- quieting yourself- not simply mean that the interviewer shouldn't talk much during the interview, rather, what should be quieted is the interviewer's internal, self-directed thinking pattern. If clinicians are preoccupied by their own thoughts, they will struggle in the fundamental task of listening to their clients. \- self-awareness- self-awareness should not be confused with the excessive self- consciousness which should be minimized. The type of self-awareness that should be maximized is the interviewer's ability to know how he or she tends to affect others interpersonally and how others tend to relate to him or her. \- developing positive working relationships with clients- there is no formula for developing positive working relationships during an interview; however, attentive listening, appropriate empathy, genuine respect, and cultural sensitivity play significant roles. Positive working relationships are always a function of the interviewer's attitude as well as the interviewer's actions. \- Specific Behaviors Attentive listening vs. Eye Contact Body Language - culture can shape the connotations of body language. Vocal Qualities- not just the words but how those words sound to the client's ears. Verbal Tracking- ability to repeat key words and phrases back to their clients to assure the clients that they have been accurately heard; monitor the train of thought implied by clients' patterns of statements. Referring to the Client by the Proper Name- the initial interview is an ideal opportunity to ask clients how they would prefer to be addressed and to confirm that it is being done correctly. Components of the Interview Rapport- engaging in small talk about harmless things; acknowledge the unique, unusual situation of the clinical interview; noticing how the client uses language and then following the client's lead. Technique- If rapport is how an interviewer is with clients, technique is what an interviewer does with clients. These are the tools in the interviewer's toolbox, including questions, responses, and other specific actions. \- Directive Versus Nondirective Styles (balance of both styles) \- Specific Interviewer Responses- Open- and Closed-Ended Questions \- Clarification (I want to make sure I'm understanding this correctly) \- Confrontation (focus on the discrepancies or inconsistencies in a client's comments) \- Paraphrasing (assurance of being heard) \- Reflection of Feeling (echoing the client's emotions) \- Summarizing (usually at the end of the interview) Conclusions- may consist of a specific diagnosis made by the interviewer on the basis of the client's response to questions about specific criteria or the conclusion may involve recommendations. Pragmatics of the Interview \- Note Taking (less vs. excessive) \- Audio and Video Recordings \- The Interview Room (strike a balance between professional formality and casual comfort) Types of Interviews Intake Interviews \- It determines whether the client needs treatment; if so, what form of treatment is needed (inpatient, outpatient, specialized provider, etc.); and whether the current facility can provide that treatment or the client should be referred to a more suitable facility. \- Detailed questioning about the presenting complaint. Diagnostic Interviews At the end of a diagnostic interview, the interviewer is able to confidently and accurately assign Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses to the client's problems. Some clinical psychologists believe that the questions should essentially replicate the DSM criteria. Other clinical psychologists believe that every question in a diagnostic interview need not be coupled with a specific DSM diagnostic criterion. These clinical psychologists prefer a more flexible interview style in which they choose or create questions as they move through the interview, and they use inference rather than absolute fact to make diagnostic decisions. In other words, some clinical psychologists prefer structured interviews, while others prefer unstructured interviews. Mental Status Exam Its primary purpose is to quickly assess how the client is functioning at the time of the evaluation. The mental status exam does not delve into the client's personal history, nor is it designed to determine a DSM diagnosis definitively. Instead, its yield is usually a brief paragraph that captures the psychological and cognitive processes of an individual "right now"---like a psychological snapshot. The format of the mental status exam is not completely standardized. It is intended for brief, flexible administration, primarily in hospitals and medical centers, requiring no manual or other accompanying materials. Crisis Interviews A special type of clinical interview designed not only to assess a problem demanding urgent attention (most often, clients actively considering suicide or another act of harm toward self or others) but also to provide immediate and effective intervention for that problem. Crisis interviews can be conducted in person but also take place often on the telephone via suicide hotlines, crisis lines, and similar services. Evidence-Based Assessment Clinical psychologists who practice evidence-based assessment select only those methods that have strong psychometrics, including reliability, validity, and clinical utility. Moreover, they select tests that have sufficient normative data and are sensitive to issues of diversity such as age, gender, race, and ethnicity. Contemporary clinical psychologists now face the challenge of integrating "what works" empirically with their own clinical judgment and their clients' needs as they make decisions about assessment. Reliability and Validity of Interviews The reliability of an interview is typically evaluated in terms of the level of agreement between at least two raters who evaluated the same patient or client. Agreement refers to consensus on diagnoses assigned, on ratings of levels of personality traits, or on any other type of summary information derived from an interview\-- interrater reliability. The use of test--retest reliability---the consistency of scores or diagnoses across time. We expect that, in general, individuals should receive similar scores or diagnoses when an interview is readministered. We expect the test--retest reliability of an interview to be quite high when the intervening time period between the initial testing and the retest is short (hours or a few days). However, when the intervening time period is long (months or years), test-- retest reliability typically suffers. Criterion-related validity refers to the ability of a measure to predict (correlate with) scores on other relevant measures. These measures may be administered concurrently with the interview (concurrent validity) or at some point in the future (predictive validity). As should be apparent, both the reliability and validity of a measure, such as an interview, are a matter of degree. Scores from interviews, like those from psychological tests, are neither perfectly reliable nor perfectly valid. But the higher the reliability and validity, the more confident we are in our conclusions. Whenever possible, use a structured interview; a wide variety of structured interviews exist for conducting intake-admission, case-history, mental status examination, crisis, and diagnostic interviews. If a structured interview does not exist for your purpose, consider developing one. BEHAVIORAL ASSESSMENT Behavioral assessment in a clinical context (like most good assessment) is NOT a one-shot evaluation performed before treatment is initiated. It is an ongoing process that occurs before, during, and after treatment. Behavioral assessment is important because it: 1\. Informs the initial selection of treatment strategies, 2\. Provides a means of feedback regarding the efficacy of the treatment strategies employed as they are enacted in the treatment process, 3\. Allows evaluation of the overall effectiveness of treatment once completed, and 4\. Highlights situational factors that may lead to recurrence of the problematic behavior(s). Functional Analysis Central feature of behavioral assessment is traceable to B. F. Skinner's (1953) notion of functional analysis. This means that exact analyses are made of the stimuli that precede a behavior and the consequences that follow it. Assessing the manner in which variations in stimulus conditions and outcomes are related to behavior changes makes possible a more precise understanding of the causes of behavior. The major thesis is that behaviors are learned and maintained because of consequences that follow them. Thus, to change an undesirable behavior, the clinician must (a) identify the stimulus conditions that precipitate it and (b) determine the reinforcements that follow. Once these two sets of factors are assessed, the clinician is in a position to modify the behavior by manipulating the stimuli and/or reinforcements involved. Crucial to a functional analysis is careful and precise description. The behavior of concern must be described in observable, measurable terms so that its rate of occurrence can be recorded reliably. With equal precision, the conditions that control it must also be specified. Both antecedent conditions and consequent events are thus carefully elaborated. Such events as time, place, and people present when the behavior occurs are recorded, along with the specific outcomes that follow the behavior of concern. Most behavioral therapists have broadened the method of functional analysis to include "organismic" variables as well. Organismic variables include physical, physiological, or cognitive characteristics of the individual that are important for both the conceptualization of the client's problem and the ultimate treatment that is administered. A useful model for conceptualizing a clinical problem from a behavioral perspective is the SORC model (Kanfer & Phillips, 1970): S = stimulus or antecedent conditions that bring on the problematic behavior O = organismic variables related to the problematic behavior R = response or problematic behavior C = consequences of the problematic behavior Behavioral clinicians use this model to guide and inform them regarding the information needed to fully describe the problem and, ultimately, the interventions that may be prescribed. Behavioral Interview The basic goal of the behavioral interview is to identify specific problem behaviors, situational factors that maintain the problem behavior, and the consequences that result from the problem behavior. During behavioral interviews, the clinician attempts to gain a general impression of the presenting problem and of the variables that seem to be maintaining the problem behavior. Other information sought includes relevant historical data and an assessment of the patient's strengths and of past attempts to cope with the problem. Also of interest are the patient's expectations regarding therapy. Finally, when feasible, some initial establishment and communication of therapeutic goals by the clinician can be helpful. This interview will result in a chain of behavior changes and results or consequences that can then inform the therapist about how short-term consequences of behavior change may be tied to long-term consequences or "ultimate outcomes." Typically, ultimate outcomes involve consequences like happiness, life satisfaction, or making the world a better place. By going through such an exercise, the client's priorities for behavior therapy become clearer, and the therapist can identify his or her own skills and expertise that can be helpful as well as map out short-term obstacles to achieving these end goals. Stages of Treatment in Behavioral Assessment 1\. Diagnostic formulations provide descriptions of maladaptive behaviors, or potential targets for intervention. 2\. The patient's context or environment (social support system, physical environment) is important to assess because of the relevance to treatment planning and the setting of realistic treatment goals. 3\. An evaluation of client resources, such as skills, level of motivation, beliefs, and expectations, is also important. As noted by Peterson and Sobell (1994), the initial assessments of diagnosis/maladaptive behaviors, treatment context, and client resources will naturally lead to a data- based initial treatment plan. 4\. This plan involves collaborative (patient and therapist) goal setting as well as mutually agreed-upon criteria to indicate improvement. 5\. Formal assessments of treatment progress serve as ongoing feedback as well as avenues for building the patient's self-efficacy as progress is made. 6\. Assessment following completion of treatment provides objective data regarding the patient's end-state functioning, which can then be compared to data from the pretreatment assessment. 7\. Thorough assessment throughout all these stages will provide information regarding the likelihood of symptom recurrence, including identification of "high-risk" environments that may lead to relapse. According to behavioral assessment, client behaviors are not signs of underlying issues or problems; instead, those behaviors are the problems. The behavior a client demonstrates is a sample of the problem itself, not a sign of some deeper, underlying problem. OBSERVATION METHODS Naturalistic Observation The most essential technique in behavioral assessment is behavioral observation or the direct, systematic observation of a client's behavior in the natural environment (Bakeman & Haynes, 2015; Ollendick et al., 2004). This practice involves taking a direct sample of the problem at the site where it occurs (home, work, school, public places, etc.). The first step in behavioral observation involves identifying and operationally defining the problem behavior. This takes place via interviews, behavioral checklists, consultation with those who have observed the client (family members, coworkers, teachers, etc.), or self-monitoring by the client. Examples of Naturalistic Observation Over the years, many forms of naturalistic observation have been used for specific settings. These settings have included classrooms, playgrounds, general and psychiatric hospitals, home environments, institutions for those with mental retardation, and therapy sessions in outpatient clinics. Again, it is important to note that many of the systems employed in these settings have been most widely used for research purposes. But most of them are adaptable for clinical use. Home Observation Because experiences in the family or home have such pervasive effects on adjustment, it is not surprising that a number of assessment procedures have been developed for behaviors occurring in this setting. e.g. Mealtime Family Interaction Coding System (MICS; Dickstein, Hayden, Schiller, Seifer, & San Antonio, 1994), which is based on the McMaster Model of Family Functioning (Epstein, Bishop, & Levin, 1978). This observational system involves the use of a videotaped interaction of the entire family eating at mealtime, without the presence of a clinician or researcher. Trained coders watch the videotape and rate the family on several domains, including: Task Accomplishment (meeting and balancing of family members' needs in the context of the meal) Affect Management (expression and management of feelings expressed by family members) Interpersonal Involvement (the degree to which family members show concern for one anothers' needs) Behavior Control (use of discipline and consistency) Communication (appropriateness and directness of verbal and non-verbal communication Roles (how family members divide tasks and responsibilities) (Hayden et al., 1998) School Observation Clinical child psychologists must often deal with behavior problems that take place in the school setting; some children are disruptive in class, overly aggressive on the playground, generally fearful, cling to the teacher, will not concentrate, and so on. Although the verbal reports of parents and teachers are useful, the most direct assessment procedure is to observe the problem behavior in its natural habitat. e.g. Achenbach's revised Direct Observation Form (DOF; McConaughy & Achenbach, 2009) of the Child Behavior checklist. The DOF is used to assess problem behaviors that may be observed in school classrooms or other settings (McConaughy & Achenbach, 2009). It consists of 88 problem items as well as an open-ended item that allows assessors to indicate problem behaviors not covered by these items. Assessors are instructed to rate each item according to its frequency, duration, and intensity within a 10-minute observation period. It is recommended that three to six 10-minute observation periods be completed over at least two days, preferably in both the morning and afternoon. In this way, a more reliable and stable estimate of the child's level of behavior problems in the classroom can be obtained. Hospital Observation Observation techniques have long been used in such settings as psychiatric hospitals and institutions for those with mental retardation. The sheltered characteristics of these settings have made careful observation of behavior much more feasible than in more open, uncontrolled environments. e.g. Time Sample Behavior Checklist (TSBC) developed by Gordon Paul and his associates (Mariotto& Paul, 1974). It is a time-sample behavioral checklist that can be used with chronic psychiatric patients. Time-sample means that observations are made at regular intervals for a given patient. Observers can make a single 2-second observation of the patient once every waking hour. Thus, a daily behavioral profile can be constructed on each patient. Controlled Observation Controlled observation is sometimes referred to as analogue behavioral observation (Haynes, 2001). Such observation can occur in a clinic setting or in the natural environment. The important feature is that the environment is "designed" such that it is likely that the assessor will observe the targeted behavior or interactions---for example, asking couples to discuss relationship problems in the laboratory to observe couple interaction patterns (Heyman, 2001). For many years, researchers have used techniques to elicit controlled samples of behavior. These are really situational tests that put individuals in situations more or less similar to those of real life. Direct observations are then made of how the individuals react. In a sense, this is a kind of work sample approach in which the behavioral test situation and the criterion behavior to be predicted are quite similar. This should reduce errors in prediction, as contrasted, for example, to psychological tests whose stimuli are far removed from the predictive situations. e.g. Parent--Adolescent Conflict. To more accurately assess the nature and degree of parent--adolescent conflict, Prinz and Kent (1978) developed the Interaction Behavior Code (IBC) system. Using the IBC, several raters review and rate audiotaped discussions of families attempting to resolve a problem about which they disagree. Items are rated separately for each family member according to the behavior's presence or absence during the discussion (or for some items, the degree to which they are present). Summary scores are calculated by averaging scores (across raters) for negative behaviors and positive behaviors.