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psc 165
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clinical psychology
was first used in 1907 by Lightner Witmer. Originally defined as similar to medicine, education, and sociology
- emphasize the study, assessment, and treatment of people with psychological problems
APA definition of Clinical Psychology
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.*
what are the education and training in clinical psychology?
Commonalities among most training programs
Doctoral degree
Most enter with bachelor’s, some with master’s degree
Required coursework
Predoctoral internship
Three models of training
-Scientist-practitioner model (or Boulder model)
*Balancing practice and science
- Practitioner-scholar model (or Vail model)
* Leaning toward practice
- Clinical scientist model
* Leaning toward science
boulder model
balancing practice and science
- Created in 1949 at a conference in Boulder, Colorado of directors of clinical psychology training programs
Scientist-practitioner model

Emphasizes both practice and research

Graduates should be able to competently practice (e.g., therapy, assessment) and conduct research
A balanced approach
Vail Model
Emphasizing Practice

Created in 1973 in a conference in Vail, Colorado

Also known as practitioner-scholar model

Emphasizes practice over research

Yields the Psy. D. degree (not the traditional Ph. D.)

Higher acceptance rates and larger classes

Proliferated in recent years
What is the difference between a Ph.D. and Psy.D.?
Emphasize practice and research

Smaller classes

Lower acceptance rate

Typically in university depts.

Offer more funding to students

- psy D.

Emphasize practice over research

Larger classes

Greater acceptance rate

Often in free-standing professional schools

Offer less funding to students
Clinical scientist model
Emphasizing Research

Emerged in 1990s, primarily as a reaction against the trend toward practice represented by Vail model

Richard McFall’s 1991 “Manifesto for a
Science of Clinical Psychology” sparked this movement

A subset of Ph. D. institutions who strongly endorse empiricism and science

Tend to train researchers rather than practitioners
sample grad program website self description
1. “Because we believe that the education of a sophisticated clinical psychologist requires systematic exposure to both the academic/research and clinical/applied areas of professional activity, our curriculum adheres to the ‘Boulder Model’ …  we labor to strike a vital balance between the scientist and practitioner facets of clinical psychology.” 

2. Boulder model example: U. of Kansas
“Because we believe that the education of a sophisticated clinical psychologist requires systematic exposure to both the *academic/research and clinical/applied areas* of professional activity, our curriculum adheres to the ‘Boulder Model’ …  we labor to strike a vital *balance between the scientist and practitioner* facets of clinical psychology.” 

3. As a professional school, our focus is not strictly on research and theory, but on preparing students to become outstanding practitioners, providing direct service to help individuals and organizations thrive.”

4. Vail model example: Chicago School of Professional Psychology
“As a professional school, our focus is not strictly on research and theory, but on preparing students to become *outstanding practitioners, providing direct service* to help individuals and organizations thrive.”

5. “Indiana University’s Clinical Training Program is designed with a special mission in mind: To train first-rate clinical scientists …applicants with primary interests in pursuing careers as service providers are not likely to thrive here….”

6. Clinical scientist model example: Indiana University
“Indiana University’s Clinical Training Program is designed with a special mission in mind: To train first-rate clinical scientists …applicants with primary interests in pursuing careers as service providers are not likely to thrive here….”
getting into graduate school in clinical psychology
Know your professional options
Take the appropriate undergraduate courses
Get to know your professors
Get research experience
Get clinically relevant experience
Maximize your GRE score
Select graduate programs wisely
Consider your long-term goals
internship: predoc
Predoctoral internship
Takes place at the end of doctoral training programs (before Ph. D. or Psy. D. is awarded)
A full year of supervised clinical experience in an applied setting
An apprenticeship of sorts, to transition from student to professional
internship: postdoc
Postdoctoral internship
Takes place after the doctoral degree is awarded
Typically lasts 1-2 years
Still supervised, but more independence
Often specialized training
Often required for state licensure
getting licensed
Licensure enables independent practice and identification as a member of the profession
Requires appropriate graduate coursework, postdoctoral internship, and licensing exams
Each state has its own licensing requirements
To stay licensed, most states require continuing education units (CEUs)
Where Do Clinical Psychologists Work?
A variety of settings, but private practice is most common
True since 1980s
Other common work settings include
Psychiatric and general hospitals
Community mental health centers
Other settings
What do Clinical Psychologists Do?
A variety of activities, but psychotherapy is most common
True since 1970s
Other common professional activities include:
Other activities
How Are Clinical Psychologists Different From Other Professionals?
-- Counseling Psychologists:
Tend to see less seriously disturbed clients
Tend to work less often in settings like inpatient hospitals or units
Tend to endorse humanism more and behaviorism less
Tend to be more interested in vocational and career counseling

-- Psychiatrists:
Go to medical school and are physicians
Have prescription privileges (this is changing for clinical psychologists—see Chapter 3)
Increasingly emphasize biological/pharmaceutical rather than “talk therapy” intervention

-- Social Workers
Tend to emphasize social factors in client’s problems
Earn a master’s degree rather than a doctorate
Training emphasizes treatment and fieldwork over research or formalized assessment

-- School Psychologists:
Tend to work in schools
Tend to have a more limited professional focus than clinical psychologists (student wellness and learning)
Frequently conduct school-related testing and determine LD and ADHD diagnoses
Consult with adults in children’s lives (e.g., teachers, staff, parents)
Origins of the Field
The emergence of clinical psychology around the turn of the 20th century was preceded by numerous important historical events
These events “set the stage” for clinical psychology
Some pioneers in the treatment of the mentally ill made important contributions in the 1700s and 1800s
Past views of the mentally ill
Early Pioneers
- William Tuke
Lived in England
Appalled by deplorable conditions in “asylums” where mentally ill lived
Devoted much of his life to improving their treatment
Raised funds to open the York Retreat(people cared for with kindness, dignity, and decency), a model of humane treatment

- Phillippe Pinel
Lived in France
Advocated for more humane and compassionate treatment of the mentally ill in France

- Also introduced ideas of a case history, treatment notes, and illness classification, indicating care about their well-being

- Eli Todd
A physician in Connecticut
At the time, there were very few hospitals for the mentally ill
Burden for their care fell on families
Using Pinel’s efforts as a model, he opened humane treatment centers in US
Connecticut Retreat for the Insane

- Dorothea Dix
Prison reform
Persuaded leaders to build facilities for humane treatment of mentally ill
Resulted in over 30 state institutions in US and other countries

- The efforts of Tuke, Pinel, Todd, and Dix helped to alter the view of the public
Contempt, fear, and punishment --> respect, understanding, and help
Lightner Witmer and the Creation of Clinical Psychology
- Lightner Witmer
--Received doctorate in 1892 in Germany
--Psychology was essentially academic; no practice, just study
--In 1896, Witmer founded the first psychological clinic at the U. of Pennsylvania

- Received doctorate under Wilhelm Wundt (father of experimental psychology)
-- At the 1896 convention of the APA, Witmer spoke to his colleagues about his clinic and encouraged them to open their own, but they were largely unenthusiastic.

- By 1914, there were about 20 clinics in US
-- By 1935, there were over 150
-- Witmer also founded the first scholarly clinical psychology journal, The Psychological Clinic, in 1907
Evolution of Assessment: Diagnostic Issues
- Diagnosis and categorization of mental illness has been central to clinical psychology from the start
- Neuroses
-- Psychiatric symptoms
- Psychosis
-- Break from reality

- Emil Kraepelin (1855-1926) is considered a pioneer of diagnosis
-- Coined some of the earliest terms to categorize mental illness

-Currently, numerous disorders are under consideration for inclusion in next DSM
-- Premenstrual dysphoric disorder
-- Minor depressive disorder
-- Recurrent brief depressive disorder
-- Binge eating disorder
-- Parental alienation disorder
Parental Alienation Disorder
- (A) The child – usually one whose parents are engaged in a high-conflict divorce – allies himself or herself strongly with one parent and rejects a relationship with the other, alienated parent without legitimate justification. The child resists of refuses contact or parenting time with the alienated parent.

- (B) The child manifests the following behaviors:
--(1) a persistent rejection or denigration of a parent that reaches the level of a campaign
--(2) weak, frivolous, and absurd rationalizations for the child’s persistent criticism of the rejected parent

-(C) The child manifests two or more of the following six attitudes and behaviors:
--(1) lack of ambivalence
-- (2) independent-thinker phenomenon
--(3) reflexive support of one parent against the other
--(4) absence of guilt over exploitation of the rejected parent
--(5) presence of borrowed scenarios
--(6) spread of the animosity to the extended family of the rejected parent

- (D) Duration of the disturbance is at least 2 months.
-(E) The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning
- (F) The child’s refusal to have contact with the rejected parent is without legitimate justification. That is, parental alienation disorder is not diagnosed if the rejected parent maltreated the child.
Evolution of Assessment: Assessment of Intelligence
- Assessment of intelligence characterized the profession in early years
- Early debates about the definition of intelligence focused on “g” (a single, general intelligence) vs. ”s” (specific intelligences)
- Alfred Binet’s early intelligence test (1905) later became the Stanford-- - Binet Intelligence Scales, which is still widely used today
Binet’s test was intended for children

- David Wechsler published the Wechsler-Bellevue in 1939, which was designed for adults
- Wechsler later created tests for school-age and preschool children
- Revisions of Wechsler’s tests are among the most commonly used today
Evolution of Assessment: Assessment of Personality
Projective tests were among the first to emerge
- Rorschach Inkblot Method—1921
-- Clients respond to ambiguous inkblot
- Thematic Apperception Test (TAT)—1935
-- Clients respond to ambiguous interpersonal scenes

- Objective tests soon followed projectives
-- Typically paper-and-pencil, self-report, and more scientifically sound
-- MMPI (1943)—comprehensive personality test measuring various pathologies
-- MMPI-2 (1989)—revised and restandardized
-- MMPI-A (1992)—for adolescents
Evolution of Psychotherapy
- Psychotherapy is the most common activity of clinical psychologists today, but before the 1940s/1950s, it was not a significant professional activity
-- Treatment was by medical doctors, not psychologists

- World War II created a demand for treatment of psychologically affected soldiers
-- Wars have had many other influences on the evolution of assessment and psychotherapy
-- For soldiers involved in direct combat, how might clinical psychologists be most helpful?

- When psychotherapy became a more common activity in the mid 1900s, the psychodynamic approach dominated
- In the decades that followed, numerous other approaches arose:
--Family Therapy
- Most recently, cognitive therapy has risen to become the most widely endorsed singular orientation

- Wechsler’s creation of the Wechsler-Bellevue emerged from his clinical experienced in WWI measuring intellectual capacities of military personnel.
- In response to the mental health needs of soldiers returning from WWII with PTSD, the US government responded by requesting that the APA formalize training of clinical psychologists and provided funding for training opportunities.
Development of the Profession
- At the historic Boulder conference in 1949, directors of graduate training programs agreed on a dual emphasis on practice and research
- In the 1950s, 1960s, and 1970s,
-- Therapy approaches proliferated
-- More minorities entered the field
--Psy. D./Vail model programs emerged

- In the 1980s,
-- Psychotherapy thrived, in part due to increasing respect from medical professionals and insurance companies
-- The number of training programs and new clinical psychologists increased

- In the 1990s and 2000s,
-- The size and scope of the field continues to grow
-- Multiple training model options are available
-- Empirical support of clinical techniques, prescription privileges, and new technologies are among major contemporary issues
Prescription Privileges
- Historically, prescribing has distinguished psychiatrists from psychologists
- However, in recent decades, clinical psychologists have actively pursued prescription privileges
\Since 2002, two states have agreed to grant prescription privileges to appropriately trained psychologists
-- New Mexico
-- Louisiana
- Other states have considered similar legislation, and may pass it soon
Why psychologists should prescribe?
- Shortage of psychiatrists
- Especially in rural areas
- Important factor in NM and LA decisions
-Other non-physicians have privileges
Dentists, podiatrists, optometrists, and some nurses, among others
- “one-stop” shopping for clients
(Tied together by one profession)
- Professional autonomy
- Professional identification
- Evolution of the profession
- Revenue for the profession
Why psychologists should not prescribe
- Training issues
-- Which courses? When? Taught by whom?
- Threats to psychotherapy
--Would medications replace talk therapy?
-Identity confusion
-- Especially when only some prescribe
- Influence of pharmaceutical industry
(A lot of money for pharmaceutical – they want their doctor to prescribe the medication. Prescribing psychotropic medication – people with serious mental illness – limiting to one appointment would be better. Help people in both aspect – prescribing and talk therapy – how are they adhering to their therapy and are they complimenting each other? There are strong argument for both sides.)
Payment Methods
- Early in the history of clinical psychology, clients paid for services directly out of pocket
- With time, health insurance companies began covering mental health
- Today, many clients use health insurance/managed care benefits to pay for services
-- Often called “third-party payers”
(salary comes in by how many clients you bring in. no insurance coverage – that person pays out of their own pocket.)
Effect of Third-Party Payment on Therapy
- Surveys of psychologists suggest that third-party payment can result in
-- Negative impact on quality
-- Too little control over clinical decisions
-- Ethical problems, including confidentiality
-- Confusion about informed consent (what to tell clients about payment method)
-- Greater affordability for many clients

(Negative impact on the quality of treatment – limited to certain amount of session when you have insurance. Reality – impact on the quality. Confidentiality- what can they tell to the insurance (can be talk openly to the client – limit of confidentiality. Health insurance – how many session have you already have) insurance company ask for specific information – so you have to ask you client to see if its ok for them to release the information – what the insurance company need from you.)
Effect of Third-Party Payment on Diagnosis
- Surveys of psychologists suggest that third-party payment can result in
-- Increased likelihood of being diagnosed with a mental disorder
-- Certain diagnostic categories being used more or less often
Effect of Third-Party Payment on Psychologists’ Experience
- Lower pay
- Time required for paperwork, phone calls, etc.
- Frustration due to denial of care psychologist believes to be necessary
The Influence of Technology
- In recent years, clinical psychologists have increasingly used technology in the direct delivery of psychological services
-- Assessment
-- Treatment
- Telehealth can replace or supplement face-to-face meetings
- Benefits can include accessibility, affordability, and anonymity, and more
Applications of Technology in Clinical Psychology--Examples
- Videoconferencing to interview or treat
- Email psychotherapy
- Interactive Internet sites
- Online psychotherapy programs
- Virtual reality therapeutic experiences
- Computer-based self-instruction
- Therapist/client interaction via hand-held devices (e.g., iPhones, cell phones, Blackberries)
Technology—Suggestions for Emerging Professional Issues
- Obtain informed consent about the technology
- Follow relevant telehealth laws
- Follow APA ethical code
- Ensure confidentiality via encryption
- Make efforts to appreciate culture
- Obtain relevant training
- Know client’s local emergency resources
Technology—Additional Potential Problems
- Confirming the identity of the client
- Confidentiality across electronic transmission
- Making interpretations in the absence of nonverbal cues that would be present face-to-face
- Competence in technical as well as clinical skills
Technology—Effectiveness of Treatment
- Early research is beginning to demonstrate that it can work
- Success depends on many factors:
-- Which treatment, disorder, device?
-- What setting?
-- How clients found or were referred to treatment?
-- Live support available?
Evidence-Based Treatments/Manualized Therapy
- When researchers measure therapy outcome, they often use therapy manuals
-- To ensure uniformity across therapists
-- To minimize variability
- When outcome data supports the use of a manualized therapy, the treatment is known as “evidence based”
- Example – Parent-Child Interaction Therapy
(To evaluate the treatment for the clients to see if its working.)
Parent-Child Interaction Therapy
- Developed by Dr. Sheila Eyberg for families of children ages 2-7 with disruptive behavior disorders
- Combines elements of attachment and learning theories, systems theory, and behavior modification
(Don’t have to remember the specific for the midterms)
- Short-term – avg. 14-16 weekly sessions
- Direct coaching of parent with child
- Strong research support
- Gives parent responsibility, not blame
PCIT 2 distinct phases
1. Child Direction Interaction (Relationship Enhancement)
Increase positive attention
Decrease negative attention

2. Parent Directed Interaction (Consistent Limit Setting)
(Increase the positive energy and decrease negative energy. Kids with oppositional defiance disorder- attention seeking behavior – a child craves attention and they don’t care if its positive or negative behavior – the only they get attention is when they engage in a negative behavior. The function of the disruptive behavior is attention seeking. The quality of the relationship becomes bad.

The parents going to respond the same way – parents respond to discipline so they can be consistence – predictability – learn consequences for their behavior – say what they mean and mean what they say instead of having empty threats. – put structure around it.)
PCIT is Assessment Driven
- Tells us where to start
- Guides course of each session
- Guides progress through phases
- Tells us when to end
- Shows overall outcome
- Shows where change needed
Measures for PCIT
- Eyberg Child Behavior Inventory
- Sutter-Eyberg School Behavior Inventory
- Child Behavior Checklist or BASC
- Parenting Stress Inventory
- Child Abuse Potential Inventory
- Other measures relevant to particular case
Dyadic Parent-Child Interaction Coding System (DPICS)
- Purpose of Coding
-- To assess the type and quality of interactions between the parent and child
-- Permits the therapist to determine coaching goals for each session
-- Allows therapist to easily give feedback to parents on progress
- Pre-treatment, during treatment, post-treatment
Relationship Enhancement
-- Enhance relationship between parent and child
-- Reduce frustration/anger
-- Improve social skills
-- Improve self-esteem
-- Improve organization and attention
- Teach and coach
- Criteria for completion
Relationship Enhancement Skills dos and don't
do: Praise



**IGNORE annoying, obnoxious behavior
STOP THE PLAY for dangerous or destructive behavior
CDI Mastery
- 10 Behavioral descriptions
- 10 Reflections
- 10 Labeled praises
- Less than Three:
-- Questions
-- Commands
-- Criticisms
- Ignore annoying/obnoxious behavior

(Critical role – how do we know the parents know how to do these roles – 5 min interaction)
Daily Special Time in CDI
- 5 minute 1:1 play time each day
- Structured to maximize success:
-- A time and place without distractions
-- Appropriate toys
-- Trouble shooting with parent
- Practicing CDI skills
Guidelines for Coaching a Parent in CDI
- Can be done with earpiece or live
- Be brief (rarely more than 5 words at a time)
- Be quick (comment on behavior immediately)
- Be positive (focus on the half-full glass)
- Be supportive (when needed)
- Control tempo (conducting a symphony)
- Be one step ahead...

Supportive - Difficult decision – feeling of guilt – for a parent to ask another for help. the therapist need to talk to the parents – so they don’t have to do it alone
Tempo – feed back
- Be prepared
-- Teaching Positive Discipline Program
-- Generalizing Discipline Program to Home Environment
-- Generalizing Discipline Program to Public Settings
-- Managing Future Behavior Problems
- Teach and coach
- Criteria for treatment termination
(Discipline at home
Public setting discipline – how to generalize those skills)
Elements of the Discipline Phase of PCIT (PDI)
- Command training
- Contingent praise or timeout
- Gradual generalization from clinic minding exercises to “real life” discipline
- Planned responses to
--Refusal to stay in timeout
--Behavior disruptions in public settings
(When ask the child a question – giving a command and not a question
Shape the listening behavior – ex. Thank you for listening
Time out – the child get out of their own.
No difficult commands – have them do the small things before they can do the difficult commands)
PDI Mastery

- 4 Commands - 75% Effective

-- Direct

-- Single

-- Positive (do)

-75% Correct follow-through

--Labeled praise after comply

--Warning after noncomply

- If TO, correct follow-through

(- Specific command – can’t say “clean up your room” – break it down to smaller pieces to see if they would comply or not.)


Treatment Outcome Research and Controlled Trials


- Significant reductions in noncompliance and behavior problems

- Generalization to home and school

- Maintenance of gains up to six years (maximum follow up time to date)

- Generalization to untreated siblings

New Directions
- Children with History of Physical Abuse - Children with FASD and Substance Abuse Exposure - Group PCIT Format – SHAPE video - Native American Families - Mexican-American Families - Older Children (7-12) from abusive families - Children with Developmental Disabilities - Children with Separation Anxiety Disorder (Feudal alcohol SD - To teach them – meet the cultural value – be culturally sensitive. Bottom line – give the positive feed back but still meet cultural aspects)
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