Clinical Psychology: Diagnostic and Statistical Manual of Mental Disorders
PSYC 3083- Exam 1
Seth Kunen
1) There are 5 clinical psychology/history overview questions
2) There are 4 questions involving specific theorists
3) There are about 14 questions about ethics/principles - nothing to memorize; mostly have to know/understand the principle/ethic in question (e.g., sexual intimacies, gift giving, torture, boundaries)
4) 2 questions about In-treatment
5) Probably 17 questions about issues in the practice of therapy and related concepts like therapeutic relationship, cultural sensitivity, transference, & cases I've presented in class and what the issues are in those cases.
6) Probably 8 questions about the DSM (know axes & meaning of GAF )
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* Clinical Psychology: the application of psychological knowledge and tecniques to alleviate distress and promote health.
- conducting and using scientific research
- assessment (interviews and testing)
- consultation
- application of various psychotherapeutic techniques
Lightner Witner: study of individuals by observation or experimentation with the intention of promoting change
Definition of Counseling
- to alleviate distress and maladjustment
- increase ability to function
Counseling Psychology is unique in its attention both to normal and abnormal human development
Psy.D // “Practitioner-Scholar Model”
// more clinical practice // less emphasis on research
Ph.D // “Scientist Practitioner Model”
Models of Therapeutic Intervention
Clinical psychologists use a variety of therapeutic techniques
- Psychodynamic
- Cognitive
- Behavioral
- Humanistic
- Systems (e.g. family or couples therapy),
- Gestalt
- Existential
- Transpersonal *
“eclectic” approach – combines two or more techniques or models
THE BIG THREE
Psychodynamic perspective
- developed out of the Psychoanalysis of Sigmund Freud.
Psychodynamic – see a patient once or twice a week
Psychoanalysis – see a patient four or five times a week, more in depth (expensive)
Modern day psychodynamic approach focuses on conflict
+ how has the patient resolved the conflict? healthy/unhealthy
(explore unconscious, what went on in childhood, free association, analysis of defenses and transferences).
Defenses: anything that you do that helps you cope with anxiety. Not a conscious decision.
Ex. Projection: project what’s in your unconscious on someone else
Denial: (ex. cigarette smoking) doesn’t believe they’re affected
Regression, Rationalization, Reaction Formation, Identification with Aggressor
There is an Infinite Number: anything can be a defense mechanism if it serves the purpose of defense and is unconscious ex. heterosexual male – “serial adventurer” defense mechanism – moves on from relationship to relationship to
- reduce anxiety of homosexuality
- avoid getting to close, past abuse/abandonment
Transferences
Take some relationship from your past and impose it on someone else.
Male client working with female therapist has issues with mother, begins to treat therapist as mother
Counter Transferences
Transferences therapists have to patients occur because of unresolved issues in your past or you’re reacting to something the patient does that upsets/disturbs you whenever the therapist is acting in a non-neutral way to the patient therapist giving personal opinion from personal experience, should allow patient to reach his/her own conclusion. Guide patient towards his/her own decision.
Friends can be biased, Therapist must be free to say what they truly believe about patient. Patients need to learn to solve problems on their own.
Therapy should be a process in which the therapist teaches the patient how to learn and think so they can solve their own problems.
Therapist: identify themes, transferences.
Suspend judgment
What is the meaning
“I would answer that question if I could figure out how would my answer help you?”
Help them discover why they are asking the question // What would they get out of the answer. anytime you can bring the unconscious to the conscious you solve the problem.
“What would it mean for you if I said I had/hadn’t used drugs?” do I have to have been an addict to be a good addiction therapist?
“What led you to wonder that in your thought process at this moment?”
Boundary Management
Feeling – Thought – Behavior
- mediate feelings
Many theorists built upon Freud’s fundamental ideas, including Anna Freud, Alfred Adler, Carl Jung, Heinz Hartmann, Karen horney….
Cognitive Behavioral Therapy _ Albert Ellis and Aaron Beck, developed in 50’s and 60’s (both had analytic training. looking for shortcut method of psychoanalytic approach)
The object of CBT is to help the patient become aware of “nonconscious” thoughts – discover the irrational thinking that leads to emotions that motivate problem behaviors.
- Rational Emotive Behavior Therapy
- Dialectic Behavior Therapy
* Particularly helpful with depression and anxiety disorders
*empirically designed to treat borderline personality (sexually promiscuous, acting out, motivated by extreme fear of rejection, unstable relationships in their lives, difficulty understanding that people exist along a dimension, borderline sees thing as either black or white: idealize you for a while, but then see you as a piece of shit the next day, have to walk on eggshells around them. 80% are female, borderline resembles bipolar
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treat bipolar with mood stabilizers, knock down hypomania
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Transference//Counter-Transference: (when a therapist responds in a non-neutral way to the patient) an inappropriate transfer of sentiments from the counselor to the patient. Must remain neutral. Neutral atmosphere helps in detecting transferences from patient to counselor.
Self-Disclosure: some legitimate, some not. Whatever is relevant to your credentials. (experience. Ex: what is your experience with couples? ever treated anyone with a sever mental illness? treated anyone with substance abuse?)
Being a good therapist means putting all your own issues aside and focusing on the patient.
Counter-Transferences can help if you are aware of them// Alert you to disturbances in the patient.
Ex: “If you spend an hour in a room with a true ADHD kid you will want to kill them by the end of it”
However, do not act on counter-transferences.
Cognitive Behavioral Therapy
- help to show the patient they’re thinking irrationally
- was developed in the 50’s and 60’s by Albert Ellis…
Humanistic
- developed in 1950’s
- reaction against behaviorism and psychoanalysis
- originated with Rogers, Rogerrian therapy
- help person become more integrated
Goal: Integration of the whole person
(called patients clients, humanizes them)
Rogers believed the client needed three things from the therapist:
1) Congruence – genuineness, honesty with the client
2) Empathy – the ability to feel what the client feels
3) Respect – acceptance, unconditional positive regard
unconditional positive regard: no matter what the client’s problems are you respect them as a person. Doesn’t matter what they’ve done they’re still human (Ex. Working with child molestors).
It is arguable that Humanistic psychology is more of an outlook than a set of techniques. Even so, there are several therapeutic approaches that could be called Humanistic, including Gestalt Therapy, Existential therapy, Experimental psychotherapy, Psychodrama, and Transpersonal therapy.
Practice Areas
Clinical psychologists often specialize in specific areas such as mood and/or anxiety disorders, eating disorders, psychosis, learning problems, neuropsychological disorders, or SUDS
85% of all disorders: mood, eating, anxiety.
Many clinical psychologists diagnose their patients (or clients) based on criteria described in the DSM or ICD, although some clinical psychologists do not use a medical or categorical approach.
Clinical psychologists in Guam, New Mexico and Louisiana now have the prescription privilege. (neuropsyc)
DSM: Diagnostic and Statistical Manual evolution of DSM has become very atheoretical (DSM III, explanations)
(epidemiology: mental disorders has gotten statistical in DSM IV)
Incidence Rate: Number of new cases in a specified period of time// NEW OCCURENCE
Prevalence Rate: What is the total number of people in the population
ICD: International Classification of Diseases Manual. Entire DSM fits inside ICD. Moving closer together; however some disorders are in one and not the other.
Misery & Unhappiness Disorder – In ICD but not DSM
(If you want to get paid by insurance companies you have to use one or the other).
Ethical Question: adjust diagnosis for what insurance company will pay for. shift diagnosis just slightly.
Related Areas
- School Psychology
- Developmental Psychology
- Neuropsychology
- Educational Psychology (Ph.D or Ed.D)
- Forensic Psychology: anything that has to due with legal issues, determining sanity or insanity, culpability in a criminal case.
- Industrial/Organization Psychology – work with big businesses to help people fit into a work environment.
- Health Psychology – growing area, what it means to have a disease and why you need to take medication.
Religions experiences: differentiate b/w Delusions, Auditory hallucinations
“If you hear a voice in your head and you can’t identify it as your voice, You’re crazy.”
Psychiatry vs. Clinical Psychology
•Psychiatrists have medical degree (MD)
•Psychologists earn Ph.D., Psy.D.
•Each has valuable training and experiences
•Psychiatrists train more in the “Disease-Medical Model”
•Psychologists train more in the Bio-Psycho-Social Model, research, psychometric assessment
According to Hubble et al. (see Archer, p.3) 40% of therapy outcome is related to factors in the client’s life that cause or facilitate change (getting a better job; faith; supportive social network).
Some theories actively encourage patients to better utilize their personal resources as part of the therapy.
30% of therapy outcome is related to therapist characteristics, such as empathy, warmth, acceptance, caring, etc.
15% expectancy accounts for outcome variance
15% due to specific therapeutic model or technique used
Therapeutic alliance – trust, safety, feel understood, etc.)
Therapist is a reliable fixture for the patient. Demonstrates integrity.
Demonstrates something to the patient, leading by example.
What else to patients get out of therapy? Someone who is working without a hidden agenda.
Therapy is not usually successful when a patient is forced to come to therapy. Prochaska et al. (2003) have developed a stage of change model for addiction but could be used to assess therapy readiness.
1) Precontemplative: Person does not think she has a problem; not considering change.
2) Contemplation: Person recognize a problem; not ready to do anything about it.
3) Preparation: Getting ready to do something
4) Action: Doing something
5) Maintenance stage: Avoiding relapse
Identify problems as Ego Syntonic or Ego Dystonic
Ego Syntonic: perfectly fine with problem, consistent with who they are as a person
Ego Dystonic: person has a problem that they recognize as a problem and are uncomfortable with it.
Managed Care
- Motivated by a need to reduce costs.
- If managed care (HMO, Medicaid, Medicare, Private Insurance, PPO, etc) permits a limited number of sessions this can dramatically affect the focus, goals, and choice of techniques
- Often puts non-professionals in charge of determining how many sessions or what services a patient will receive.
“you’re a garden variety neurotic. mildly interesting”
Multi-Cultural and Diversity Issues
- These issues can involve any group of persons who do not share the majority, point of view, values, customs, beliefs.
- Gays, racial minorities, different religious groups, non-English speaking ethnic groups, opposite gender?
- The problem is that almost any individual can claim to have unique experiences that the therapist has not had.
- The primary issue with diversity is the unknowing (and perhaps knowing) attempts to use one’s values, experiences, beliefs, to understand and treat the patient.
- Clinical psychologists must be able to sensitively provide services to persons from a variety of backgrounds
• Four states now have white minorities:
• California, Hawaii, New Mexico & Texas
• Cultural explanations of why one becomes ill will determine what the diagnosis is, what treatments are acceptable, and how well a patient complies with treatment recommendations.
• Major cultural differences in how patients talk to their therapists/doctors. Often say yes (out of respect) without meaning it (I’m getting better, I’m taking my medications)
• Numerous specific standards and principles in the most recent edition of the American Psychological Association (2003) ethical code compel psychologists to be culturally competent and sensitive.
• Their inclusion as standards makes it clear that awareness of diversity issues is an obligation rather than merely an ethical aspiration psychologists.
Idiographic vs. Nomothetic approaches to understanding people
- Idiographic emphasizes uniqueness and differences (sometimes called emics)
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- Nomethetics (sometimes called etics) emphasizes commonalities
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Culture bound / Specific Symptoms
- A “disease-like” condition (not voluntary)
- Widely recognized in that culture
- Other cultrues are unfamiliar with the condition
- No organic basis
- Usually recognized and treated by he folk medicine in that culture
- Individual not legally responsible for his behavior when afflicted by the syndrome
Recognized by the DSM:
Amok – is derived from the Malay/Indonesian/Tagalog workd “amuk” meaning “mad with uncontrollable rage”
- Example: a man who has shown no previous inclination to violence, will in a sudden frenzy, attempt to kill or injure anyone he encounters. Amok episodes often result in the death of the attacker (killed by bystanders or commits suicide).
Ataque de nervios (Latinos) – similar to but different from panic attack
Hwa-byung (Korean) – an anger syndrome with agitation but no depression
Pibloktoq (Eskimos) “Arctic Hysteria”
Includes hysteria (screaming, uncontrolled wild behavior), depression, coprophagia, insensitivity to extreme cold (such as running around in the snow naked), echolalia: due to Vitamin A toxicity? Sensory deprivation?
Sensory deprivation: disconnected from the environment
High Internal Arousal: People who talk to themselves in their heads. Many internal conversations. Huge amounts of stimulation that they provide from themselves. Enough activity going on in their heads that they want enviroment to be quiet, shut-out
Low Internal Arousal: Often bored, seek stimulation from the environment to feel comfortable. Lack of internal conversation.
Experiment: Dress people up in a wetsuit with blind goggles and earphones with white noise. Hang them upside down in a tank of water. They quite quickly go psychotic. Zero environmental stimulation
Cultural Experience of Depression
- depression has many symptoms, and these symptoms are expressed in different degrees among different cultures.
- Westerners complain of sadness and lack of enjoyment of life
- Among far eastern cultures, depression may be experienced somatically (weakenss, tiredness) rather than emotionally (e.g., sadness, guilt)
- Individuals from Middle Eastern cultures may complain of problems of the heart
* The following can greatly affect how the patient responds to medication
- Age (children and older people need smaller doses)
- Height and Weight (volume of distribution; fat stores)
- Diet (protein intake; grapefruit juice = inhibits enzymes that break down the medication; body gets toxic)
- Exercise
- Smoking and alcohol use (inducers: stimulates the liver to produce more of the enzyme that gets rid of the medication. makes the medication less effective over time).
Culture and Medication
- Asians and Hispanics need smaller doses of TCA’s (anti-depressants) b/c they metabolize TCA’s more slowly than Caucasians
Antipsychotics (AP’s)
Asians metabolize AP’s more slowly and thus need smaller doses
African Americans and Hispanics have a greater risk of developing Metabolic Syndrome (weight gain, increase blood pressure, prone to diabetes and heart attacks) for unknown reasons.
Benzodiazapine (BZD’s) – anxiety medication
Asians and African Americans experience greater sensitivity and thus need smaller doses
“one size therapy doesn’t fit all”
APA ETHICS: Guiding Principles
Preamble and general principles are not enforceable rules
The Ethical Standards set forth enforceable rules
The Ethics code only applies to professional life
“If psychologists’ responsibilities conflict with the law they may adhere to the requirements of the law…. in keeping with basic principles of human rights”
Subpoena
- patients will lie to you, omit stuff, highlight certain things, will put spin on events.
- even if they aren’t lying each patient has his or her own unique perspective.
- get as much background information as you can. Even though it might change your opinion it will make up for everything they will omit.
“I will take enough notes to remind me of what we were talking about, but not enough that might violate our confidentiality should I be subpoenaed.”
Principle A: Beneficence (the act of doing good) and Nonmaleficence (the principle of doing no harm, based on the Hippocratic maxim, primum non nocere, first do no harm).
Principle B: Fidelity and Responsibility
Principle C: Integrity
Principle D: Justice …provide services to people who can’t afford it
Principle E: Respect for People’s Rights and Dignity – Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination (right to choose what they wanna do). * Clinical psychology(informal) | Is the application of psychological knowledge and techniques to alleviate distress and promote health. This includes conducting and using scientific research, assessment, consultation, and application of various psychotherapeutic techniques | Clinical psychology(Lightner Witmer) | The study of individuals, by observation or experimentation, with the intention of promoting change | Clinical psychology(APA) | 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 | Counseling psychology | Facilitates personal and interpersonal functioning across the life span with a focus on emotional, social, vocational, educational, health-related, developmental, and organizational concerns *is unique in its attention both to normal and abnormal development |
Ph.D. | *Earned by psychologists *“scientists-practitioner model”*Training: -4 years of college-4-5 years grad school-1 year internship-1 year post-doc supervision -train more in bio-psycho-social model, research, psychometric assessment | Psy.D. | *Earned by psychologists *“practitioner-scholar model” (more emphasis on clinical practice and less on research)*Training: (same as Ph.D.)-4 years of college-4-5 years grad school-1 year internship-1 year post-doc supervision -train more in bio-psycho-social model, research, psychometric assessment | MD (medical degree) | Earned by psychiatristsTrain more in “disease-medical model” |
“Big 3” therapy approaches | 1. Psychodynamic perspective- Freud 2. Cognitive behavioral therapy- Albert Ellis and Aaron Beck 3. Humanistic approach- Rogers | Psychodynamic perspective(Sigmund Freud) | * Focuses on conflicts and whether the individuals resolution of the conflict is adaptive * attempts to uncover unconscious thoughts and childhood experiences that contribute to the conflict * uses free association and analysis of defenses and transferences | Cognitive Behavioral Therapy(Albert Ellis & Aaron Beck) | * object is to discover the irrational thinking that leads to emotions that motivate problem behaviors * helpful with depression and anxiety disorders | Humanistic(Rogers) | * developed as a reaction to behaviorism and psychoanalysis * goal: integration of the whole person * client needs 3 things from therapist: congruence, empathy, respect | Congruence | Genuineness, honesty with the client | Empathy | The ability to feel what the client feels | Respect | Acceptance, unconditional positive regard |
Stage of change model | Pre-contemplativeContemplationPreparationActionMaintenance | Pre-contemplative | Person does not think they have a problemNot considering change | Contemplation | Person recognizes problemNot ready to do anything about it | Preparation | Getting ready to do something | Action | Doing something | Maintenance | Avoiding relapse |
APA | American Psychological Association | Ethics Code | * formal name: Ethical Principles of Psychologists and Code of Conduct * consists of introduction, preamble, 5 general principles, ethical principles * applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists | General principles | * aspirational in nature * intent is to guide and inspire psychologists toward the very highest ethical ideals of the profession * they do not represent obligations and should not form the basis for imposing sanctions | Principle A | * beneficence: the act of doing good * nonmaleficence: the principle of doing no harm | Principle B | * fidelity and responsibility | Principle C | * integrity | Principle D | * justice | Principle E | * respect for people’s rights and dignity | Ethical standards | * set forth enforceable rules for conduct as psychologist * broadly written- in order to apply to psychologist in varied roles * the fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical * | 1.04 | Resolving Ethical Issues: Informal Resolution of Ethical Violations-attempt to resolve the issue by bringing it to the attention of that individual | 1.05 | Resolving Ethical Issues: Reporting Ethical Violations- if informal resolution not appropriate, take further action such as conferring with state licensing board | 2.01 | Competence: Boundaries of Competence-provide services, teach and do research with populations and in areas only within the boundaries of their competence | 3.0 | Human Relations-do not discriminate, do not engage in sexual harassment | 3.05 | Human Relations: Multiple Relationships-do not engage in multiple relationships | 3.07 | Human Relations: Third-Party Requests for Services-at request of a 3rd party, attempt to clarify at the outset of service the nature of the relationship with all individuals involved | 3.10 | Human Relations: Informed Consent -obtain informed consent except when conducting activities without consent is mandated by law or government regulation | 4.01 | Privacy and Confidentiality: Maintaining Confidentiality-have an obligation to protect confidential information-HIPPA | 6.05 | Record Keeping and Fees: Barter with Clients/Patients | 9.0 | Assessment | 10.01 | Therapy: Informed Consent to Therapy-inform patients ASAP about nature and course of therapy, fees, 3rd party involvement, limits of confidentiality and Q&A session | 10.05 | Therapy: Sexual Intimacies With Current Therapy Clients/Patients-no sex for 2 years after therapy with patient ends | 10.10 | Therapy: Terminating Therapy-terminate therapy when it becomes clear that patient no longer needs the service, not likely to benefit or is being harmed by continued service | Harassment | Sexual solicitation, physical advances, or verbal/nonverbal conduct that Is sexual in nature, that occurs in connection with the psychologists activities, and is unwelcome or offensive | Barter | Is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services |
5 most frequent ethical issues | Confidentiality, blurred roles, payment issues, academic issues, forensic issues | Confidentiality | Ethical responsibility of psychologist to safeguard personal information disclosed in therapy | Jaffe vs. Redmond | Ruled that licensed therapists cannot be forced to testify about confidential communication from their patients | Tarasoff case | Exception to Jaffe vs. Redmond: “private privilege ends where public peril begins” | Insanity | A person is insane, and is not responsible for criminal conduct if, at the time of such conduct, as a result of a severe mental disease or defect, he was unable to appreciate the nature and quality of the wrongfulness of his acts | Middle ages | Believed that mental illness was caused by demons | 18th century reform | Demonstrated that releasing patients with mental illness from restraints and treating them humanely produced dramatic improvements | Dorothy Dix | American mental health reformer- got 32 new mental health hospitals built | Emile Kraepelin | Physician- developed the first diagnostic system for mental disorders: divided psychosis into 2 different clinical forms: manic depression (including bipolar disorders and dementia praecox ( now called schizophrenia) | Signs | * objective findings that can be observed and described by the health care professional * found in the “physical exam” section of a medical record * or found in “psychiatric interview” of a psychological evaluation * do not rely on the subjective reporting of sensations by the affected individual | Symptoms | * any subjective evidence of a disease or a condition as perceived and reported by the patient * found in “history” section of a medical record | Lightner Witmer | * first to popularize the term clinical psychology * first to call for involvement of psychologist in community clinics * opened the first psychological clinic in the US in 1896 * emphasized the intellectually subnormal populations, others focused on mentally ill populations * founded the Orthogenic School at the University of Pennsylvania Hospital * founded the journal “Psychological Clinic” | Orthogenic | Concerned with dx & tx of mentally retarded or seriously disturbed children | Mental retardation | Defined as an IQ 2 standard deviations below the mean, appearance in developmental period, and adaptive behavior deficits | David Shakow | Developed the scientists/practitioner model known today as the Boulder model | Scientists/ practitioner model- Boulder model | Called for clinical psychologists to train as scientific psychologist first rather than focus only on clinical skills |
DSM | * APA’s Diagnostic and Statistical Manual of Mental Disorders * developed to give more objective terms for psychiatric research * before DSM: communication was not uniform * establishment of specific criteria: attempt to facilitate mental health research * recognizes that 2 patients with the same diagnostic label can be different: especially in terms of severity, symptom profile and co morbidity * multi-axial system of diagnosing attempts to yield a more complete picture of the patient rather than just a simple diagnosis * does not reflect all opinions on the subject of psychopathology, emotional distress and social functioning * there are no objective biological standards to which it adheres * the criteria and the way they’re applied are variable and may reflect a particular theoretical orientation * what is considered a mental disorder changes over time | Psychosis | Severe mental disorder characterized by a disconnection from reality*typically involve hallucinations, delusions, illogical thinking*Early editions of DSM were rooted in a distinction between 2 poles of mental disorders: psychosis and neurosis | Neuroses | Midler mental disorder as compared to psychosis characterized by distortions of reality (but not a complete break with reality)*involve anxiety and depression* Early editions of DSM were rooted in a distinction between 2 poles of mental disorders: psychosis and neurosis | DSM-I | * published in 1952 * about 106 different disorders * DSM-I and DSM-II both strongly influenced by psychodynamic approach | DSM-II | * published in 1968 * 140 disorders * DSM-I and DSM-II both strongly influenced by psychodynamic approach | DSM-III | * biomedical model became the primary approach (as opposed to psychodynamic view) * 1986: DSM-III-R appeared as a revision of DSM-III: many criteria were changed | DSM-IV | * Published in 1994 * 2000: DSM-IV-TR published: majority of the criteria were not changed from DSM-IV | DSM-V | * 2011: tentative publication date for DSM-V | Homosexuality | * Considered a mental illness before 1973 * Now considered a disorder only if ego-dystonic and if it causes disruption of functioning * If individual is comfortable with his/her sexual orientation, then not a disorder (ego-syntonic) | Ego-dystonic | of or pertaining to aspects of one's behavior or attitudes viewed as inconsistent with one's fundamental beliefs and personality | Ego-syntonic | of or pertaining to aspects of one's behavior or attitudes viewed as acceptable and consistent with one's fundamental personality and beliefs | Criticisms of diagnosis and assessment | Criticisms include: Bias, overlap in diagnosis, use of diagnosis as social control, stigmatizing, self-fulfilling prophecies, categorizes or pigeon- holes people | Axis I | Major mental disorders (such as depression, schizophrenia, anxiety)Developmental disordersLearning disabilities | Axis II | Personality disordersMental retardation | Axis III | Non-psychiatric medical conditions | Axis IV | Stress Social functioning | Axis V | Global Assessment of Functioning (on a scale from 1- 100) * 61-100: generally doing well (includes more neurotic disorders) * 50-60: moderate social, educational, work, family problems * 40-49: serious impairment * <40: very serious, inability to function or care for self, psychotic, MR | Diagnosis of Major Depressive Disorder from DSM | 1. 5 or more of following symptoms present during 2 week period and represent a change from previous functioning (depressed mood; anhedonia-loss of interest or pleasure ; significant weigth loss; insomnia or hypersomnia; psychomotor agitation or retardation; anergia-fatigue or loss of energy; feelings of worthlessness or guilt; problems with attention, memory, and concentration; recurrent thoughts of death 2. Symptoms don’t meet other criteria 3. Symptoms cause clinically significant distress or impairment 4. Not due to SUDS or medical disease 5. No better explanation for bereavement |
Projective testing | * Tries to get at “unconscious” thoughts * Tests include: Rorschach, TAT, Drawing tests: Draw-A-Person or House-Tree-Person * Criticized for having inadequate reliability and validity | Rorschach | * 10 inkblots * Point: asked to describe what the inkblot might be * Exner developed a system of scoring responses based on shape, content, color, location, movement * Good for picking up severe pathology | TAT | * 31 cards- select about 10 * Point: asked to tell a story that has a beginning, middle, end (pictures are vague) * Psychodynamic interpretations look for conflicts, aggression, sexuality, early childhood themes of attachment and bonding, fears and anxieties | Drawing tests | * Draw-A-Person or House-Tree-Person * Drawings are interpreted based on features and details * House with few windows or shades: indicate desire to hide something * Smoke from chimney: indicate emotional tensions * Tree floating above ground with no roots: feeling of disconnection |
MMPI-II | * Most widely used personality test in the world * Has several validity and inconsistency scales, 10 clinical scales, content area scales | Validity scales (MMPI-II) | * L scale (fake good) * F scale (fake bad) * K scale (defensive) | 10 clinical scales (MMPI-II) | 1. (Hs) hypochondriasis (physical complaints) 2. (D) depression 3. (Hy) hysteria 4. (Pd) psychopathic deviate (family conflict, antisocial, authority problems) 5. (Mf) masculinity-femininity (traditional vs. non-traditional interests) 6. (Pa) paranoia 7. (Pt) psychasthenia (OCD, phobia, anxious) 8. (Sc) schizophrenia (unconventional, unusual thoughts) 9. (Ma) hypomania 10. (Si) introversion |
Reliability | Repeatability Must consider time frameLook at test-retest (use correlation) or internal reliability (using KR20 or coefficient alpha) | Validity | General issue of whether test is measuring what it purports to measure Many types of validity (predictive, face, concurrent, factorial) | Mental status exam | Covers a # of areas 1. Level of consciousness 2. Appearance and behavior 3. Speech and language 4. Thought disorder symptoms 5. Mood and affect 6. General knowledge 7. Assess IQ 8. Concrete vs. abstract thinking 9. Social judgment tests | Neuropsychological assessment | * Associated with brain damage problems * Helps identify areas affected * Characterize and assess extent of disability in specific areas * Useful in designing rehabilitation plans * Used to estimate premorbid levels | Efficacy studies | * Efficacy def: Power to produce a desired effect * Confined to a small number of techniques and manualized to be delivered in a fixed order | Effectiveness studies | * Studies what is actually done in real world * Include treatments of mixed duration |
Freudian Theory | * Goal of classic ego Freudian therapy: identify conflicts and unconscious drives and bring them under the control of the conscious * Structure of mind: unconscious, conscious, pre-conscious * Structure of personality: id, ego, superego * Conflict- central idea in modern thought * Defenses help protect against anxieties generated by conflicts * Origin of neuroses: drives that create conflicts (sexual and aggression) * Fixated: stuck at a developmental stage that has been unsatisfied * Oral fixation: failure to orally satisfy the infant leads to investment of emotional energy in oral behaviors and “oral” personality * Anal fixation: conflict/struggle over toileting * Freudian slips (parapraxisms): reflect the breakthrough of repressed thoughts | History of Freud/ Freudian Theory | * First problem dealt with: Conversion Hysteria now called Conversion Disorder * Tried hypnotism * Early work conducted in Victorian and repressed time * Originally formulated “seduction” theory as origin of neurosis * Distressed about WWI: formulated Death Instinct Aggression Instinct | ID | * At birth, we are all ID * Concerned with need to survive * Invest energy in oral stage which lasts 1.5-2 years * Governed by pleasure principle | Pleasure principle | Drives one to seek pleasure and to avoid pain | EGO | * Emerges during oral stage * Continues to develop during anal stage ages 1-3 * Concerned with perception, cognition, memory, problem solving, judgment, decision making * Socialization becomes the principle issue of concern * Executive function * Governed by reality principle | Reality principle | Learn to defer gratification and endure pain | SUPEREGO | * Incorporates the values and standards of parents or caregivers through a process labeled identification * Often in conflict with ID * Begins to emerge during phallic stage | Freud’s psychosexual stages | Oral, anal, phallic, latent, genital | Oral | * Birth- 18 months * Oral-incorporative: libidinal gratification comes from bodily sensations associated with feeding * Oral-aggressiveness: gratification appears through biting | Anal | * 18 months- 3 to 4 years * Pleasure comes from holding in and letting go | Phallic | * Between ages 3-4 * Focus is on genital pleasure * Children beign to experience masturbation pleasure * Oedipus complex: boy desires mom, fears dad but identifies with dad to avoid castration and to gain vicarious satisfaction from mom * Electra complex: girl desires father but not afraid of castration, perhaps penis envy | Latent | * 6 years- puberty (approximately 12) * Corresponds to elementary school * Libido submerges allowing cognition to flourish * Developing social relationships | Genital | * Begins at puberty * In adolescence, libido and aggression re-emerge * 2 prominent defense mechanisms: asceticism and promiscuity | Erikson’s psychosexual stages | Infancy: trust vs. mistrustEarly childhood: autonomy vs. shame and doubtPreschool age: initiative vs. guiltSchool age: industry vs. inferiority Adolescence: identity vs. role confusionYoung adulthood: intimacy vs. isolationMiddle age: generativity vs. stagnationLater life: integrity vs. despair | Expressive therapy | More active listening and formulating interpretations Aimed at insightRequires a good deal of ego strength | Supportive therapy | Neutral and empathic listening Shores up weak defensesDefenses need to be respected | Dream analysis | Royal road to unconsciousDreams contain unconscious content disguised in dream symbols | Narcissism | Complete over-evaluation of self and de-valuation of others | Interpretation | Summarize a good deal of clinical information as an observation | Ego strength | Term used by counselors to describe how well a client is able to handle the struggles between what we want to do and what we think we should do |
Object relations theory | * Emphasizes internal representations of others * Therapy centers around our relationship with others * Term “object” to mean anything that an infant uses to satisfy drives * Term “object-relations” refers to the self-structure wee internalize in early childhood which functions as blueprint for establishing and maintaining future relationships * Theorists believe that we have an innate drive to form relationships and that this is the fundamental human need * Theory encompases the idea: ego exists only in relation to other objects which may be external or internal. The internal objects are internalized versions of external objects * 3 “affects” that exists between self and object: attachment, frustration, rejection * Theorists believe we are relationship seeking rather than pleasure seeking * Defense mechanism: projective identification | Projective identification | People unconsciously project aspects of themselves onto others and get others to respond to this projection *different from projection | Margaret Mahler’s separation-individuation theory | * Normal autistic phase: first few weeks of life- infant is detached and self absorbed- Mahler eventually abandoned this phase * Normal symbiotic phase: last until 5 months- child is aware of mother but not a sense of individuality- mother/child are one * Separation-individuation phase: separation refers to infants ability to differentiate from mother and individuation refers to the development of the infants ego- divided into subphases (hatching, practicing, rapprochement) * Important aspect: Winnicott’s “good enough mother” |
Attachment theory | * John Bowlby assumed that babies are biologically programmed to attach to parents * Good attachment with the parent helps create “secure base” |
Self psychology | * Developed by Heinz Kohut * Believed overriding factor in human development is what is called healthy narcissism * Theorized that developing child has a poorly developed and fragmented sense of self and that parents support the development of the sense of self through empathy and positive feedback * Concept of selfobject: is an experience of the functions of anoter (idealized) object that supports us * Twinship: people have a need to feel that they belong and have a basic connection with others * Most fundamental fear: disintegration or fragmentation * Kohut believed the primary issues in Oedipal stage were affection and assertiveness rather than sex and aggression (freud) | Interpersonal psychiatry theory | * Harry Stack Sullivan * Focus on depression * Argues that good quality contemporary relationships are healing * 4 types of interpersonal problems: grief/loss, role disputes, role transitions, interpersonal deficits | Splitting | Primitive psychoanalytic defense mechanism in which object representations of others are split into that which is “all good” or “all bad” | Anxiety | * Freud saw it was an inevitable consequence of life * Basic * mechanism by which the ego recognizes and attempts to deal with threats to the well-being of society * Reality anxiety: produced by reality of real threats in society * Neurotic anxiety: threats of unleashed instinctual drives * Moral anxiety: caused by concern that one will violate societal rules and expectations | Defense mechanisms | * Ego uses various methods to help defend against anxiety and keep a person functional * They are unconscious * Rely on defense mechanism for 4 reasons: our constitutional temperament, types of stress we experience in early childhood, defenses that were modeled by caregivers or other significant figures, types of defense mechanisms that have worked for us in the past * 2 types | Primary defenses | Show no evidence of the attainment of the reality principle and lack of awareness of the separateness of people outside of oneself | Denial | Person does not allow themselves to experience a particular eventInvolves little thought or introspect | Projection | Process in which what is inside is misunderstood as coming from the outside | Dissociation | When confronted with traumatic experience, dissociate by mentally shutting out some awful event and having an out of body experience | Higher-order defenses | More sophisticated way of coping with anxiety that ego experiences | Repression | Memories that are pushed out of conscious awareness | Displacement | Channeling a particular feeling or frustration to a person, object or animal often when one cannot target the real object of frustration | Sublimation | Changing a basic impulse thought by the person to be unacceptable in societal context into something acceptable | Regression | When a person cannot handle a current situation and reverts back to an earlier time when she felt more secure and in control | Reaction formation | Unacceptable feelings and impulses are turned into their exact opposite | Intellectualization | Isolation of affect from ones intellectAllows person to think rationally in situations where her emotions threaten to overload her intellectual capacities | Triangles of conflict | * Model containing 2 triangles: triangle of conflict, triangle of person * Help explain the dynamics within the client and also within the relationship with therapist * Helpful ways of understanding the process of short-term psychodynamic therapy |
*
Seth Kunen
1) There are 5 clinical psychology/history overview questions
2) There are 4 questions involving specific theorists
3) There are about 14 questions about ethics/principles - nothing to memorize; mostly have to know/understand the principle/ethic in question (e.g., sexual intimacies, gift giving, torture, boundaries)
4) 2 questions about In-treatment
5) Probably 17 questions about issues in the practice of therapy and related concepts like therapeutic relationship, cultural sensitivity, transference, & cases I've presented in class and what the issues are in those cases.
6) Probably 8 questions about the DSM (know axes & meaning of GAF )
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* Clinical Psychology: the application of psychological knowledge and tecniques to alleviate distress and promote health.
- conducting and using scientific research
- assessment (interviews and testing)
- consultation
- application of various psychotherapeutic techniques
Lightner Witner: study of individuals by observation or experimentation with the intention of promoting change
Definition of Counseling
- to alleviate distress and maladjustment
- increase ability to function
Counseling Psychology is unique in its attention both to normal and abnormal human development
Psy.D // “Practitioner-Scholar Model”
// more clinical practice // less emphasis on research
Ph.D // “Scientist Practitioner Model”
Models of Therapeutic Intervention
Clinical psychologists use a variety of therapeutic techniques
- Psychodynamic
- Cognitive
- Behavioral
- Humanistic
- Systems (e.g. family or couples therapy),
- Gestalt
- Existential
- Transpersonal *
“eclectic” approach – combines two or more techniques or models
THE BIG THREE
Psychodynamic perspective
- developed out of the Psychoanalysis of Sigmund Freud.
Psychodynamic – see a patient once or twice a week
Psychoanalysis – see a patient four or five times a week, more in depth (expensive)
Modern day psychodynamic approach focuses on conflict
+ how has the patient resolved the conflict? healthy/unhealthy
(explore unconscious, what went on in childhood, free association, analysis of defenses and transferences).
Defenses: anything that you do that helps you cope with anxiety. Not a conscious decision.
Ex. Projection: project what’s in your unconscious on someone else
Denial: (ex. cigarette smoking) doesn’t believe they’re affected
Regression, Rationalization, Reaction Formation, Identification with Aggressor
There is an Infinite Number: anything can be a defense mechanism if it serves the purpose of defense and is unconscious ex. heterosexual male – “serial adventurer” defense mechanism – moves on from relationship to relationship to
- reduce anxiety of homosexuality
- avoid getting to close, past abuse/abandonment
Transferences
Take some relationship from your past and impose it on someone else.
Male client working with female therapist has issues with mother, begins to treat therapist as mother
Counter Transferences
Transferences therapists have to patients occur because of unresolved issues in your past or you’re reacting to something the patient does that upsets/disturbs you whenever the therapist is acting in a non-neutral way to the patient therapist giving personal opinion from personal experience, should allow patient to reach his/her own conclusion. Guide patient towards his/her own decision.
Friends can be biased, Therapist must be free to say what they truly believe about patient. Patients need to learn to solve problems on their own.
Therapy should be a process in which the therapist teaches the patient how to learn and think so they can solve their own problems.
Therapist: identify themes, transferences.
Suspend judgment
What is the meaning
“I would answer that question if I could figure out how would my answer help you?”
Help them discover why they are asking the question // What would they get out of the answer. anytime you can bring the unconscious to the conscious you solve the problem.
“What would it mean for you if I said I had/hadn’t used drugs?” do I have to have been an addict to be a good addiction therapist?
“What led you to wonder that in your thought process at this moment?”
Boundary Management
Feeling – Thought – Behavior
- mediate feelings
Many theorists built upon Freud’s fundamental ideas, including Anna Freud, Alfred Adler, Carl Jung, Heinz Hartmann, Karen horney….
Cognitive Behavioral Therapy _ Albert Ellis and Aaron Beck, developed in 50’s and 60’s (both had analytic training. looking for shortcut method of psychoanalytic approach)
The object of CBT is to help the patient become aware of “nonconscious” thoughts – discover the irrational thinking that leads to emotions that motivate problem behaviors.
- Rational Emotive Behavior Therapy
- Dialectic Behavior Therapy
* Particularly helpful with depression and anxiety disorders
*empirically designed to treat borderline personality (sexually promiscuous, acting out, motivated by extreme fear of rejection, unstable relationships in their lives, difficulty understanding that people exist along a dimension, borderline sees thing as either black or white: idealize you for a while, but then see you as a piece of shit the next day, have to walk on eggshells around them. 80% are female, borderline resembles bipolar
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treat bipolar with mood stabilizers, knock down hypomania
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*
Transference//Counter-Transference: (when a therapist responds in a non-neutral way to the patient) an inappropriate transfer of sentiments from the counselor to the patient. Must remain neutral. Neutral atmosphere helps in detecting transferences from patient to counselor.
Self-Disclosure: some legitimate, some not. Whatever is relevant to your credentials. (experience. Ex: what is your experience with couples? ever treated anyone with a sever mental illness? treated anyone with substance abuse?)
Being a good therapist means putting all your own issues aside and focusing on the patient.
Counter-Transferences can help if you are aware of them// Alert you to disturbances in the patient.
Ex: “If you spend an hour in a room with a true ADHD kid you will want to kill them by the end of it”
However, do not act on counter-transferences.
Cognitive Behavioral Therapy
- help to show the patient they’re thinking irrationally
- was developed in the 50’s and 60’s by Albert Ellis…
Humanistic
- developed in 1950’s
- reaction against behaviorism and psychoanalysis
- originated with Rogers, Rogerrian therapy
- help person become more integrated
Goal: Integration of the whole person
(called patients clients, humanizes them)
Rogers believed the client needed three things from the therapist:
1) Congruence – genuineness, honesty with the client
2) Empathy – the ability to feel what the client feels
3) Respect – acceptance, unconditional positive regard
unconditional positive regard: no matter what the client’s problems are you respect them as a person. Doesn’t matter what they’ve done they’re still human (Ex. Working with child molestors).
It is arguable that Humanistic psychology is more of an outlook than a set of techniques. Even so, there are several therapeutic approaches that could be called Humanistic, including Gestalt Therapy, Existential therapy, Experimental psychotherapy, Psychodrama, and Transpersonal therapy.
Practice Areas
Clinical psychologists often specialize in specific areas such as mood and/or anxiety disorders, eating disorders, psychosis, learning problems, neuropsychological disorders, or SUDS
85% of all disorders: mood, eating, anxiety.
Many clinical psychologists diagnose their patients (or clients) based on criteria described in the DSM or ICD, although some clinical psychologists do not use a medical or categorical approach.
Clinical psychologists in Guam, New Mexico and Louisiana now have the prescription privilege. (neuropsyc)
DSM: Diagnostic and Statistical Manual evolution of DSM has become very atheoretical (DSM III, explanations)
(epidemiology: mental disorders has gotten statistical in DSM IV)
Incidence Rate: Number of new cases in a specified period of time// NEW OCCURENCE
Prevalence Rate: What is the total number of people in the population
ICD: International Classification of Diseases Manual. Entire DSM fits inside ICD. Moving closer together; however some disorders are in one and not the other.
Misery & Unhappiness Disorder – In ICD but not DSM
(If you want to get paid by insurance companies you have to use one or the other).
Ethical Question: adjust diagnosis for what insurance company will pay for. shift diagnosis just slightly.
Related Areas
- School Psychology
- Developmental Psychology
- Neuropsychology
- Educational Psychology (Ph.D or Ed.D)
- Forensic Psychology: anything that has to due with legal issues, determining sanity or insanity, culpability in a criminal case.
- Industrial/Organization Psychology – work with big businesses to help people fit into a work environment.
- Health Psychology – growing area, what it means to have a disease and why you need to take medication.
Religions experiences: differentiate b/w Delusions, Auditory hallucinations
“If you hear a voice in your head and you can’t identify it as your voice, You’re crazy.”
Psychiatry vs. Clinical Psychology
•Psychiatrists have medical degree (MD)
•Psychologists earn Ph.D., Psy.D.
•Each has valuable training and experiences
•Psychiatrists train more in the “Disease-Medical Model”
•Psychologists train more in the Bio-Psycho-Social Model, research, psychometric assessment
According to Hubble et al. (see Archer, p.3) 40% of therapy outcome is related to factors in the client’s life that cause or facilitate change (getting a better job; faith; supportive social network).
Some theories actively encourage patients to better utilize their personal resources as part of the therapy.
30% of therapy outcome is related to therapist characteristics, such as empathy, warmth, acceptance, caring, etc.
15% expectancy accounts for outcome variance
15% due to specific therapeutic model or technique used
Therapeutic alliance – trust, safety, feel understood, etc.)
Therapist is a reliable fixture for the patient. Demonstrates integrity.
Demonstrates something to the patient, leading by example.
What else to patients get out of therapy? Someone who is working without a hidden agenda.
Therapy is not usually successful when a patient is forced to come to therapy. Prochaska et al. (2003) have developed a stage of change model for addiction but could be used to assess therapy readiness.
1) Precontemplative: Person does not think she has a problem; not considering change.
2) Contemplation: Person recognize a problem; not ready to do anything about it.
3) Preparation: Getting ready to do something
4) Action: Doing something
5) Maintenance stage: Avoiding relapse
Identify problems as Ego Syntonic or Ego Dystonic
Ego Syntonic: perfectly fine with problem, consistent with who they are as a person
Ego Dystonic: person has a problem that they recognize as a problem and are uncomfortable with it.
Managed Care
- Motivated by a need to reduce costs.
- If managed care (HMO, Medicaid, Medicare, Private Insurance, PPO, etc) permits a limited number of sessions this can dramatically affect the focus, goals, and choice of techniques
- Often puts non-professionals in charge of determining how many sessions or what services a patient will receive.
“you’re a garden variety neurotic. mildly interesting”
Multi-Cultural and Diversity Issues
- These issues can involve any group of persons who do not share the majority, point of view, values, customs, beliefs.
- Gays, racial minorities, different religious groups, non-English speaking ethnic groups, opposite gender?
- The problem is that almost any individual can claim to have unique experiences that the therapist has not had.
- The primary issue with diversity is the unknowing (and perhaps knowing) attempts to use one’s values, experiences, beliefs, to understand and treat the patient.
- Clinical psychologists must be able to sensitively provide services to persons from a variety of backgrounds
• Four states now have white minorities:
• California, Hawaii, New Mexico & Texas
• Cultural explanations of why one becomes ill will determine what the diagnosis is, what treatments are acceptable, and how well a patient complies with treatment recommendations.
• Major cultural differences in how patients talk to their therapists/doctors. Often say yes (out of respect) without meaning it (I’m getting better, I’m taking my medications)
• Numerous specific standards and principles in the most recent edition of the American Psychological Association (2003) ethical code compel psychologists to be culturally competent and sensitive.
• Their inclusion as standards makes it clear that awareness of diversity issues is an obligation rather than merely an ethical aspiration psychologists.
Idiographic vs. Nomothetic approaches to understanding people
- Idiographic emphasizes uniqueness and differences (sometimes called emics)
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- Nomethetics (sometimes called etics) emphasizes commonalities
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* *
Culture bound / Specific Symptoms
- A “disease-like” condition (not voluntary)
- Widely recognized in that culture
- Other cultrues are unfamiliar with the condition
- No organic basis
- Usually recognized and treated by he folk medicine in that culture
- Individual not legally responsible for his behavior when afflicted by the syndrome
Recognized by the DSM:
Amok – is derived from the Malay/Indonesian/Tagalog workd “amuk” meaning “mad with uncontrollable rage”
- Example: a man who has shown no previous inclination to violence, will in a sudden frenzy, attempt to kill or injure anyone he encounters. Amok episodes often result in the death of the attacker (killed by bystanders or commits suicide).
Ataque de nervios (Latinos) – similar to but different from panic attack
Hwa-byung (Korean) – an anger syndrome with agitation but no depression
Pibloktoq (Eskimos) “Arctic Hysteria”
Includes hysteria (screaming, uncontrolled wild behavior), depression, coprophagia, insensitivity to extreme cold (such as running around in the snow naked), echolalia: due to Vitamin A toxicity? Sensory deprivation?
Sensory deprivation: disconnected from the environment
High Internal Arousal: People who talk to themselves in their heads. Many internal conversations. Huge amounts of stimulation that they provide from themselves. Enough activity going on in their heads that they want enviroment to be quiet, shut-out
Low Internal Arousal: Often bored, seek stimulation from the environment to feel comfortable. Lack of internal conversation.
Experiment: Dress people up in a wetsuit with blind goggles and earphones with white noise. Hang them upside down in a tank of water. They quite quickly go psychotic. Zero environmental stimulation
Cultural Experience of Depression
- depression has many symptoms, and these symptoms are expressed in different degrees among different cultures.
- Westerners complain of sadness and lack of enjoyment of life
- Among far eastern cultures, depression may be experienced somatically (weakenss, tiredness) rather than emotionally (e.g., sadness, guilt)
- Individuals from Middle Eastern cultures may complain of problems of the heart
* The following can greatly affect how the patient responds to medication
- Age (children and older people need smaller doses)
- Height and Weight (volume of distribution; fat stores)
- Diet (protein intake; grapefruit juice = inhibits enzymes that break down the medication; body gets toxic)
- Exercise
- Smoking and alcohol use (inducers: stimulates the liver to produce more of the enzyme that gets rid of the medication. makes the medication less effective over time).
Culture and Medication
- Asians and Hispanics need smaller doses of TCA’s (anti-depressants) b/c they metabolize TCA’s more slowly than Caucasians
Antipsychotics (AP’s)
Asians metabolize AP’s more slowly and thus need smaller doses
African Americans and Hispanics have a greater risk of developing Metabolic Syndrome (weight gain, increase blood pressure, prone to diabetes and heart attacks) for unknown reasons.
Benzodiazapine (BZD’s) – anxiety medication
Asians and African Americans experience greater sensitivity and thus need smaller doses
“one size therapy doesn’t fit all”
APA ETHICS: Guiding Principles
Preamble and general principles are not enforceable rules
The Ethical Standards set forth enforceable rules
The Ethics code only applies to professional life
“If psychologists’ responsibilities conflict with the law they may adhere to the requirements of the law…. in keeping with basic principles of human rights”
Subpoena
- patients will lie to you, omit stuff, highlight certain things, will put spin on events.
- even if they aren’t lying each patient has his or her own unique perspective.
- get as much background information as you can. Even though it might change your opinion it will make up for everything they will omit.
“I will take enough notes to remind me of what we were talking about, but not enough that might violate our confidentiality should I be subpoenaed.”
Principle A: Beneficence (the act of doing good) and Nonmaleficence (the principle of doing no harm, based on the Hippocratic maxim, primum non nocere, first do no harm).
Principle B: Fidelity and Responsibility
Principle C: Integrity
Principle D: Justice …provide services to people who can’t afford it
Principle E: Respect for People’s Rights and Dignity – Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination (right to choose what they wanna do). * Clinical psychology(informal) | Is the application of psychological knowledge and techniques to alleviate distress and promote health. This includes conducting and using scientific research, assessment, consultation, and application of various psychotherapeutic techniques | Clinical psychology(Lightner Witmer) | The study of individuals, by observation or experimentation, with the intention of promoting change | Clinical psychology(APA) | 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 | Counseling psychology | Facilitates personal and interpersonal functioning across the life span with a focus on emotional, social, vocational, educational, health-related, developmental, and organizational concerns *is unique in its attention both to normal and abnormal development |
Ph.D. | *Earned by psychologists *“scientists-practitioner model”*Training: -4 years of college-4-5 years grad school-1 year internship-1 year post-doc supervision -train more in bio-psycho-social model, research, psychometric assessment | Psy.D. | *Earned by psychologists *“practitioner-scholar model” (more emphasis on clinical practice and less on research)*Training: (same as Ph.D.)-4 years of college-4-5 years grad school-1 year internship-1 year post-doc supervision -train more in bio-psycho-social model, research, psychometric assessment | MD (medical degree) | Earned by psychiatristsTrain more in “disease-medical model” |
“Big 3” therapy approaches | 1. Psychodynamic perspective- Freud 2. Cognitive behavioral therapy- Albert Ellis and Aaron Beck 3. Humanistic approach- Rogers | Psychodynamic perspective(Sigmund Freud) | * Focuses on conflicts and whether the individuals resolution of the conflict is adaptive * attempts to uncover unconscious thoughts and childhood experiences that contribute to the conflict * uses free association and analysis of defenses and transferences | Cognitive Behavioral Therapy(Albert Ellis & Aaron Beck) | * object is to discover the irrational thinking that leads to emotions that motivate problem behaviors * helpful with depression and anxiety disorders | Humanistic(Rogers) | * developed as a reaction to behaviorism and psychoanalysis * goal: integration of the whole person * client needs 3 things from therapist: congruence, empathy, respect | Congruence | Genuineness, honesty with the client | Empathy | The ability to feel what the client feels | Respect | Acceptance, unconditional positive regard |
Stage of change model | Pre-contemplativeContemplationPreparationActionMaintenance | Pre-contemplative | Person does not think they have a problemNot considering change | Contemplation | Person recognizes problemNot ready to do anything about it | Preparation | Getting ready to do something | Action | Doing something | Maintenance | Avoiding relapse |
APA | American Psychological Association | Ethics Code | * formal name: Ethical Principles of Psychologists and Code of Conduct * consists of introduction, preamble, 5 general principles, ethical principles * applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists | General principles | * aspirational in nature * intent is to guide and inspire psychologists toward the very highest ethical ideals of the profession * they do not represent obligations and should not form the basis for imposing sanctions | Principle A | * beneficence: the act of doing good * nonmaleficence: the principle of doing no harm | Principle B | * fidelity and responsibility | Principle C | * integrity | Principle D | * justice | Principle E | * respect for people’s rights and dignity | Ethical standards | * set forth enforceable rules for conduct as psychologist * broadly written- in order to apply to psychologist in varied roles * the fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical * | 1.04 | Resolving Ethical Issues: Informal Resolution of Ethical Violations-attempt to resolve the issue by bringing it to the attention of that individual | 1.05 | Resolving Ethical Issues: Reporting Ethical Violations- if informal resolution not appropriate, take further action such as conferring with state licensing board | 2.01 | Competence: Boundaries of Competence-provide services, teach and do research with populations and in areas only within the boundaries of their competence | 3.0 | Human Relations-do not discriminate, do not engage in sexual harassment | 3.05 | Human Relations: Multiple Relationships-do not engage in multiple relationships | 3.07 | Human Relations: Third-Party Requests for Services-at request of a 3rd party, attempt to clarify at the outset of service the nature of the relationship with all individuals involved | 3.10 | Human Relations: Informed Consent -obtain informed consent except when conducting activities without consent is mandated by law or government regulation | 4.01 | Privacy and Confidentiality: Maintaining Confidentiality-have an obligation to protect confidential information-HIPPA | 6.05 | Record Keeping and Fees: Barter with Clients/Patients | 9.0 | Assessment | 10.01 | Therapy: Informed Consent to Therapy-inform patients ASAP about nature and course of therapy, fees, 3rd party involvement, limits of confidentiality and Q&A session | 10.05 | Therapy: Sexual Intimacies With Current Therapy Clients/Patients-no sex for 2 years after therapy with patient ends | 10.10 | Therapy: Terminating Therapy-terminate therapy when it becomes clear that patient no longer needs the service, not likely to benefit or is being harmed by continued service | Harassment | Sexual solicitation, physical advances, or verbal/nonverbal conduct that Is sexual in nature, that occurs in connection with the psychologists activities, and is unwelcome or offensive | Barter | Is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services |
5 most frequent ethical issues | Confidentiality, blurred roles, payment issues, academic issues, forensic issues | Confidentiality | Ethical responsibility of psychologist to safeguard personal information disclosed in therapy | Jaffe vs. Redmond | Ruled that licensed therapists cannot be forced to testify about confidential communication from their patients | Tarasoff case | Exception to Jaffe vs. Redmond: “private privilege ends where public peril begins” | Insanity | A person is insane, and is not responsible for criminal conduct if, at the time of such conduct, as a result of a severe mental disease or defect, he was unable to appreciate the nature and quality of the wrongfulness of his acts | Middle ages | Believed that mental illness was caused by demons | 18th century reform | Demonstrated that releasing patients with mental illness from restraints and treating them humanely produced dramatic improvements | Dorothy Dix | American mental health reformer- got 32 new mental health hospitals built | Emile Kraepelin | Physician- developed the first diagnostic system for mental disorders: divided psychosis into 2 different clinical forms: manic depression (including bipolar disorders and dementia praecox ( now called schizophrenia) | Signs | * objective findings that can be observed and described by the health care professional * found in the “physical exam” section of a medical record * or found in “psychiatric interview” of a psychological evaluation * do not rely on the subjective reporting of sensations by the affected individual | Symptoms | * any subjective evidence of a disease or a condition as perceived and reported by the patient * found in “history” section of a medical record | Lightner Witmer | * first to popularize the term clinical psychology * first to call for involvement of psychologist in community clinics * opened the first psychological clinic in the US in 1896 * emphasized the intellectually subnormal populations, others focused on mentally ill populations * founded the Orthogenic School at the University of Pennsylvania Hospital * founded the journal “Psychological Clinic” | Orthogenic | Concerned with dx & tx of mentally retarded or seriously disturbed children | Mental retardation | Defined as an IQ 2 standard deviations below the mean, appearance in developmental period, and adaptive behavior deficits | David Shakow | Developed the scientists/practitioner model known today as the Boulder model | Scientists/ practitioner model- Boulder model | Called for clinical psychologists to train as scientific psychologist first rather than focus only on clinical skills |
DSM | * APA’s Diagnostic and Statistical Manual of Mental Disorders * developed to give more objective terms for psychiatric research * before DSM: communication was not uniform * establishment of specific criteria: attempt to facilitate mental health research * recognizes that 2 patients with the same diagnostic label can be different: especially in terms of severity, symptom profile and co morbidity * multi-axial system of diagnosing attempts to yield a more complete picture of the patient rather than just a simple diagnosis * does not reflect all opinions on the subject of psychopathology, emotional distress and social functioning * there are no objective biological standards to which it adheres * the criteria and the way they’re applied are variable and may reflect a particular theoretical orientation * what is considered a mental disorder changes over time | Psychosis | Severe mental disorder characterized by a disconnection from reality*typically involve hallucinations, delusions, illogical thinking*Early editions of DSM were rooted in a distinction between 2 poles of mental disorders: psychosis and neurosis | Neuroses | Midler mental disorder as compared to psychosis characterized by distortions of reality (but not a complete break with reality)*involve anxiety and depression* Early editions of DSM were rooted in a distinction between 2 poles of mental disorders: psychosis and neurosis | DSM-I | * published in 1952 * about 106 different disorders * DSM-I and DSM-II both strongly influenced by psychodynamic approach | DSM-II | * published in 1968 * 140 disorders * DSM-I and DSM-II both strongly influenced by psychodynamic approach | DSM-III | * biomedical model became the primary approach (as opposed to psychodynamic view) * 1986: DSM-III-R appeared as a revision of DSM-III: many criteria were changed | DSM-IV | * Published in 1994 * 2000: DSM-IV-TR published: majority of the criteria were not changed from DSM-IV | DSM-V | * 2011: tentative publication date for DSM-V | Homosexuality | * Considered a mental illness before 1973 * Now considered a disorder only if ego-dystonic and if it causes disruption of functioning * If individual is comfortable with his/her sexual orientation, then not a disorder (ego-syntonic) | Ego-dystonic | of or pertaining to aspects of one's behavior or attitudes viewed as inconsistent with one's fundamental beliefs and personality | Ego-syntonic | of or pertaining to aspects of one's behavior or attitudes viewed as acceptable and consistent with one's fundamental personality and beliefs | Criticisms of diagnosis and assessment | Criticisms include: Bias, overlap in diagnosis, use of diagnosis as social control, stigmatizing, self-fulfilling prophecies, categorizes or pigeon- holes people | Axis I | Major mental disorders (such as depression, schizophrenia, anxiety)Developmental disordersLearning disabilities | Axis II | Personality disordersMental retardation | Axis III | Non-psychiatric medical conditions | Axis IV | Stress Social functioning | Axis V | Global Assessment of Functioning (on a scale from 1- 100) * 61-100: generally doing well (includes more neurotic disorders) * 50-60: moderate social, educational, work, family problems * 40-49: serious impairment * <40: very serious, inability to function or care for self, psychotic, MR | Diagnosis of Major Depressive Disorder from DSM | 1. 5 or more of following symptoms present during 2 week period and represent a change from previous functioning (depressed mood; anhedonia-loss of interest or pleasure ; significant weigth loss; insomnia or hypersomnia; psychomotor agitation or retardation; anergia-fatigue or loss of energy; feelings of worthlessness or guilt; problems with attention, memory, and concentration; recurrent thoughts of death 2. Symptoms don’t meet other criteria 3. Symptoms cause clinically significant distress or impairment 4. Not due to SUDS or medical disease 5. No better explanation for bereavement |
Projective testing | * Tries to get at “unconscious” thoughts * Tests include: Rorschach, TAT, Drawing tests: Draw-A-Person or House-Tree-Person * Criticized for having inadequate reliability and validity | Rorschach | * 10 inkblots * Point: asked to describe what the inkblot might be * Exner developed a system of scoring responses based on shape, content, color, location, movement * Good for picking up severe pathology | TAT | * 31 cards- select about 10 * Point: asked to tell a story that has a beginning, middle, end (pictures are vague) * Psychodynamic interpretations look for conflicts, aggression, sexuality, early childhood themes of attachment and bonding, fears and anxieties | Drawing tests | * Draw-A-Person or House-Tree-Person * Drawings are interpreted based on features and details * House with few windows or shades: indicate desire to hide something * Smoke from chimney: indicate emotional tensions * Tree floating above ground with no roots: feeling of disconnection |
MMPI-II | * Most widely used personality test in the world * Has several validity and inconsistency scales, 10 clinical scales, content area scales | Validity scales (MMPI-II) | * L scale (fake good) * F scale (fake bad) * K scale (defensive) | 10 clinical scales (MMPI-II) | 1. (Hs) hypochondriasis (physical complaints) 2. (D) depression 3. (Hy) hysteria 4. (Pd) psychopathic deviate (family conflict, antisocial, authority problems) 5. (Mf) masculinity-femininity (traditional vs. non-traditional interests) 6. (Pa) paranoia 7. (Pt) psychasthenia (OCD, phobia, anxious) 8. (Sc) schizophrenia (unconventional, unusual thoughts) 9. (Ma) hypomania 10. (Si) introversion |
Reliability | Repeatability Must consider time frameLook at test-retest (use correlation) or internal reliability (using KR20 or coefficient alpha) | Validity | General issue of whether test is measuring what it purports to measure Many types of validity (predictive, face, concurrent, factorial) | Mental status exam | Covers a # of areas 1. Level of consciousness 2. Appearance and behavior 3. Speech and language 4. Thought disorder symptoms 5. Mood and affect 6. General knowledge 7. Assess IQ 8. Concrete vs. abstract thinking 9. Social judgment tests | Neuropsychological assessment | * Associated with brain damage problems * Helps identify areas affected * Characterize and assess extent of disability in specific areas * Useful in designing rehabilitation plans * Used to estimate premorbid levels | Efficacy studies | * Efficacy def: Power to produce a desired effect * Confined to a small number of techniques and manualized to be delivered in a fixed order | Effectiveness studies | * Studies what is actually done in real world * Include treatments of mixed duration |
Freudian Theory | * Goal of classic ego Freudian therapy: identify conflicts and unconscious drives and bring them under the control of the conscious * Structure of mind: unconscious, conscious, pre-conscious * Structure of personality: id, ego, superego * Conflict- central idea in modern thought * Defenses help protect against anxieties generated by conflicts * Origin of neuroses: drives that create conflicts (sexual and aggression) * Fixated: stuck at a developmental stage that has been unsatisfied * Oral fixation: failure to orally satisfy the infant leads to investment of emotional energy in oral behaviors and “oral” personality * Anal fixation: conflict/struggle over toileting * Freudian slips (parapraxisms): reflect the breakthrough of repressed thoughts | History of Freud/ Freudian Theory | * First problem dealt with: Conversion Hysteria now called Conversion Disorder * Tried hypnotism * Early work conducted in Victorian and repressed time * Originally formulated “seduction” theory as origin of neurosis * Distressed about WWI: formulated Death Instinct Aggression Instinct | ID | * At birth, we are all ID * Concerned with need to survive * Invest energy in oral stage which lasts 1.5-2 years * Governed by pleasure principle | Pleasure principle | Drives one to seek pleasure and to avoid pain | EGO | * Emerges during oral stage * Continues to develop during anal stage ages 1-3 * Concerned with perception, cognition, memory, problem solving, judgment, decision making * Socialization becomes the principle issue of concern * Executive function * Governed by reality principle | Reality principle | Learn to defer gratification and endure pain | SUPEREGO | * Incorporates the values and standards of parents or caregivers through a process labeled identification * Often in conflict with ID * Begins to emerge during phallic stage | Freud’s psychosexual stages | Oral, anal, phallic, latent, genital | Oral | * Birth- 18 months * Oral-incorporative: libidinal gratification comes from bodily sensations associated with feeding * Oral-aggressiveness: gratification appears through biting | Anal | * 18 months- 3 to 4 years * Pleasure comes from holding in and letting go | Phallic | * Between ages 3-4 * Focus is on genital pleasure * Children beign to experience masturbation pleasure * Oedipus complex: boy desires mom, fears dad but identifies with dad to avoid castration and to gain vicarious satisfaction from mom * Electra complex: girl desires father but not afraid of castration, perhaps penis envy | Latent | * 6 years- puberty (approximately 12) * Corresponds to elementary school * Libido submerges allowing cognition to flourish * Developing social relationships | Genital | * Begins at puberty * In adolescence, libido and aggression re-emerge * 2 prominent defense mechanisms: asceticism and promiscuity | Erikson’s psychosexual stages | Infancy: trust vs. mistrustEarly childhood: autonomy vs. shame and doubtPreschool age: initiative vs. guiltSchool age: industry vs. inferiority Adolescence: identity vs. role confusionYoung adulthood: intimacy vs. isolationMiddle age: generativity vs. stagnationLater life: integrity vs. despair | Expressive therapy | More active listening and formulating interpretations Aimed at insightRequires a good deal of ego strength | Supportive therapy | Neutral and empathic listening Shores up weak defensesDefenses need to be respected | Dream analysis | Royal road to unconsciousDreams contain unconscious content disguised in dream symbols | Narcissism | Complete over-evaluation of self and de-valuation of others | Interpretation | Summarize a good deal of clinical information as an observation | Ego strength | Term used by counselors to describe how well a client is able to handle the struggles between what we want to do and what we think we should do |
Object relations theory | * Emphasizes internal representations of others * Therapy centers around our relationship with others * Term “object” to mean anything that an infant uses to satisfy drives * Term “object-relations” refers to the self-structure wee internalize in early childhood which functions as blueprint for establishing and maintaining future relationships * Theorists believe that we have an innate drive to form relationships and that this is the fundamental human need * Theory encompases the idea: ego exists only in relation to other objects which may be external or internal. The internal objects are internalized versions of external objects * 3 “affects” that exists between self and object: attachment, frustration, rejection * Theorists believe we are relationship seeking rather than pleasure seeking * Defense mechanism: projective identification | Projective identification | People unconsciously project aspects of themselves onto others and get others to respond to this projection *different from projection | Margaret Mahler’s separation-individuation theory | * Normal autistic phase: first few weeks of life- infant is detached and self absorbed- Mahler eventually abandoned this phase * Normal symbiotic phase: last until 5 months- child is aware of mother but not a sense of individuality- mother/child are one * Separation-individuation phase: separation refers to infants ability to differentiate from mother and individuation refers to the development of the infants ego- divided into subphases (hatching, practicing, rapprochement) * Important aspect: Winnicott’s “good enough mother” |
Attachment theory | * John Bowlby assumed that babies are biologically programmed to attach to parents * Good attachment with the parent helps create “secure base” |
Self psychology | * Developed by Heinz Kohut * Believed overriding factor in human development is what is called healthy narcissism * Theorized that developing child has a poorly developed and fragmented sense of self and that parents support the development of the sense of self through empathy and positive feedback * Concept of selfobject: is an experience of the functions of anoter (idealized) object that supports us * Twinship: people have a need to feel that they belong and have a basic connection with others * Most fundamental fear: disintegration or fragmentation * Kohut believed the primary issues in Oedipal stage were affection and assertiveness rather than sex and aggression (freud) | Interpersonal psychiatry theory | * Harry Stack Sullivan * Focus on depression * Argues that good quality contemporary relationships are healing * 4 types of interpersonal problems: grief/loss, role disputes, role transitions, interpersonal deficits | Splitting | Primitive psychoanalytic defense mechanism in which object representations of others are split into that which is “all good” or “all bad” | Anxiety | * Freud saw it was an inevitable consequence of life * Basic * mechanism by which the ego recognizes and attempts to deal with threats to the well-being of society * Reality anxiety: produced by reality of real threats in society * Neurotic anxiety: threats of unleashed instinctual drives * Moral anxiety: caused by concern that one will violate societal rules and expectations | Defense mechanisms | * Ego uses various methods to help defend against anxiety and keep a person functional * They are unconscious * Rely on defense mechanism for 4 reasons: our constitutional temperament, types of stress we experience in early childhood, defenses that were modeled by caregivers or other significant figures, types of defense mechanisms that have worked for us in the past * 2 types | Primary defenses | Show no evidence of the attainment of the reality principle and lack of awareness of the separateness of people outside of oneself | Denial | Person does not allow themselves to experience a particular eventInvolves little thought or introspect | Projection | Process in which what is inside is misunderstood as coming from the outside | Dissociation | When confronted with traumatic experience, dissociate by mentally shutting out some awful event and having an out of body experience | Higher-order defenses | More sophisticated way of coping with anxiety that ego experiences | Repression | Memories that are pushed out of conscious awareness | Displacement | Channeling a particular feeling or frustration to a person, object or animal often when one cannot target the real object of frustration | Sublimation | Changing a basic impulse thought by the person to be unacceptable in societal context into something acceptable | Regression | When a person cannot handle a current situation and reverts back to an earlier time when she felt more secure and in control | Reaction formation | Unacceptable feelings and impulses are turned into their exact opposite | Intellectualization | Isolation of affect from ones intellectAllows person to think rationally in situations where her emotions threaten to overload her intellectual capacities | Triangles of conflict | * Model containing 2 triangles: triangle of conflict, triangle of person * Help explain the dynamics within the client and also within the relationship with therapist * Helpful ways of understanding the process of short-term psychodynamic therapy |
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