Chapter 1 –

Introduction

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 The challenges facing mental
health workers

 It is often difficult to put a cut-off line

between normal distress and distress that
has clinical significance
 For example- many of us experience
anxiety, or sadness; when is still within the
normal range and when is it considered an
abnormality?
 Is it a matter of intensity? Duration?
Frequency?
 More Questions

 Do some mental disorders lend themselves to

treatment better than others?
 For example, schizophrenia is a chronic
condition, whereas anxiety disorders may be
more effectively treated.
 The expression of the same disorder might
take different forms in different people
 There is a high incidence of co-morbidity
(occurring together) of mental disorders
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 Assessment
 The first challenge facing a clinical
psychologist is the assessment of a
presenting problem
 Is the condition fully displayed or is it
still in the process of unfolding?
 To what extent is there a co-existence
of several clinical conditions in the
same person? (Co-morbidity).
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Importance of Clinical Psychology
as a Discipline

 About half of mental disorders begin

before age 14
 Worldwide 800,000 people commit
suicide every year
 1 in 4 adult Americans suffers from a
mental disorder in any given year
 Worldwide more than 450 million
people suffer from mental disorders
– Most undiagnosed or misdiagnosed
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 Defining Scope of Clinical
Psychology

 Early definitions stressed assessment,

evaluation and diagnosis
 More recent inclusion of intervention in
various forms as well as prevention
 Evidence-Based Practice
Active debate on the ‘science of clinical
psychology’
McFall’s Manifesto for a Science of Clinical
Psychology
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 McFall’s Manifesto
Toward research-based practice of
psychology
 Clinical psychology needs to be based on the results
of research
 The exact nature of the service needs to be described
 The claimed benefits of the service must be described
clearly
 These benefits must be validated scientifically
 Possible negtive side eefefcts must be ruled
out empirically

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The Shifting Nature of the Field of
Clinical Psychology

 From the focus on one individual the

focus has shifted to couples and
families, both directly as interventions
and indirectly as in prevention
activities, consultations, and research
 Increasing focus on pharmacological
treatment an decrease in traditional
activites
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 The APA Definition of Clinical
Psychology: Research-based

 “ 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, social and behavioral
aspects of human functioning across the life-
span, in varying cultures and Socio-economic
levels.
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 Elements of the APA Definition of
Clinical Psychology

1. Integration of theory and research –

bi-directional relationship: the theory is
an attempt to explain the symptoms; it
generates research to assess the
explanation, and the research results
may change the theory- that is –our
understanding of the causes of the
symptoms (as one example)
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 Elements of the APA definition
(cont-d)

 2. The goals are on the one hand to remove

distress and suffering, but also to promote
adaptation; that is- sometimes a conditions
may not go away, and the person needs to
learn to live with it and to adapt to it.
 3. The various aspects of human functioning
(e.g. biological, emotional, intelelctual etc
are inter-related and affect one another.
They cannot be viewed in isolation .
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 Importance of Clinical
Psychology as a Discipline
 Evidence-Based Practice (cont.)
 Importance of using only practices empirically
found to be effective
 Intuition should not be a part of assessment or
treatment
– Critics argue (among other points):
 Group-based data is not always sufficient in
working with individuals
 Research is not always available for all
problems
 Each person is unique in many different ways
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All rights reserved.
 Counseling vs. Counseling
Psychology

 Counseling is a generic term use d to describe

a range of mental health professions with
various training and licensure requirements.
 Counseling psychology has a great deal in
common with clinical psychology
 It started in he field of vocational counseling
in an attempt to match between traits and
aptitudes (skills) and the demands of a given
job.
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 Counseling Psychology (cont-d)

 Today, the focus of clinical psychology

is more in treating of more severe
conditions of psychopathology,
whereas counseling psychology
addressed less severe issues, such as
all types of life-transitions, and
relationships difficulties.

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Traditional distinctions between clinical
and counseling psychologists are fading

 Today counseling psychologists provide

services in more severe cases, such as
depression, panic, social phobia or eating
disorders
 Clinical psychologists have expanded their
services to conditions that do not
represent psychopathology such as
chronic illness or stress- related conditions

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 Cont-d

 It is difficult to mark professional

boundaries on the basis of what
constitutes normal vs. abnormal range
of distress
 Depending on the point in time in
which someone seeks help, the same
person may present clinical or
subclinical symptoms
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Other Related Mental Health
Professions (and Differences)

 School Psychology
– Training in both psychology and education
– Work in diverse education-related settings
– There is a natural overlap between school
psychology and child clinical-psychology
– Traditionally, school psychologists provided services
related to assessment of intellectual functioning,
learning difficulties, consultation to teachers on the
basis of the assessment of a given child- how to
translate the assessment into instructional
objectives, and parent consultation.
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 School Psychology (cont-d)

 Over time, the scope of school psychology

has expanded, to include attention to
parental psychopathology and stressful
family circumstances affecting the learning
of children
 The legal obligation to provide the most
appropriate education to any child, no matter what
is the level of the child’s disability, also affected the
role of the school-psychologist.

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 School Psychologists (cont-d)

 All these changes affected the role of

school psychologists, who today deal
with a wide range of disorders of
childhood as well as with developing
school-based and family-based
programs such as the promotion of
social skills, fighting bullying, conflict-
resolution and prevention of violence.
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 Psychiatrists: MD’s who specialize
in mental disorders

 Trained as physicians with an additional

training in mental disorders
 Require 5 years of residency after the
regular medical school
 Training focuses on biological functioning
 Interactions between the physical and the
emotional, also the results of medications
 Less training in psychological development
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 Psychiatrists (cont-d)

 More psychopharmacological (medication)

therapies
 Less trained in conducting psychological
assessment
 Traditionally leaning toward the
psychoanalytic (Freud), psychodynamic
models of therapy
 Shift toward evidence-based therapies e.g.
Cognitive–Behavioral and Interpersonal
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 Psychiatrists (con-d)

 Until recently an important distinction

between clinical psychologists and
psychiatrists has been that only psychiatrists
could prescribe medication
 This is in general still the case, though in some
jurisdictions clinical psychologists are being trained
to prescribe psychoactive medication
 There is a decline in the number of graduate
students wishing to specialize in psychiatry.

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 Other Related Mental Health
Professions (and Differences)

 Social Work
– Emphasis on social/community conditions
– Different settings than clinical psychologists
(especially community agencies)
– Social conditions that facilitate optimal
development
– Program planning and management
– Diversity of settings
– Many function as part of mental-health team
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 Social Work (cont-d)

 Case-workers and coordinators of

services
 Help patients navigate in a maze of
mental-health services
 Need to have either a BSW or MSW
and supervise training progarm

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 History of Clinical Psychology

 Early views that did not include demonic

possession or evil spirits causing mental
illness were rare
 Hippocrates may be first to consider a
“biopsychosocial approach”
– Biological, psychological and social factors
all need to be considered.
– S t. Vincent de Paul (late 1500’s)
emphasized natural forces and not
witchcraft
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Other Mental Health Professionals

 Psychiatric nurses: Managing

administrative matters in inpatient settings;
psychoeducation and counseling.
 Child and Youth Care-Workers: Two-
year college training in child development
and behavior management
 Applied Behavior Analysis: Using behavior
modification strategies with autistic children

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 History of Clinical Psychology

 Enlightenment period (later 1700’s)

– Philippe Pinel – French reformer: humane
treatment of the mentally ill
– William Tuke – English reformer: hospitals
based on appropriate care
– Benjamin Rush – U.S.: moral therapy
 1800’s – neurology as a discipline
recognizing hysteria could not be
recognized as biological: Charcot, Janet
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 History of Assessment in Clinical
Psychology

 Early Clinical Psychology was almost

entirely an assessment field

 Late 1800’s – Francis Galton: differences in

reaction time as intelligence differences
 Wilhelm Wundt (Germany) first psychology
laboratory, studied sensation and perception
 James McKeen Cattell: studied connection
between reaction time and intelligence
– Coined termCopyright
“mental tests”
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 History of Assessment in Clinical
Psychology

 Emil Kraepelin (Germany)

– Believed in biological causes to mental illness
– Worked on classifications of syndromes – much
of his work formed basis for DSM and ICD (chp 3)
 Alfred Binet (France)
– French government asked Binet and collaborator
Theodore Simon to design a measure to assess
children with cognitive deficits
– 1908 Binet-Simon scale measured 50 tests of
mental skills
– 1916 Lewis Terman (US) modified it, first widely
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available test of cognitive rights reserved.
ability
 History of Assessment in Clinical
Psychology

 WWI – APA asked to develop a scale to

measure mental functioning of recruits
– Army Alpha Test (verbal abilities)
– Army Beta Test (non-verbal abilities – for those
who could not read or spoke limited English)
– These tests and the value they gave recognized
clinical psychology as a sub-discipline of psych
 Testing began to flourish
– Wechsler-Bellevue intelligence test 1939
(considered the gold standard in IQ tests)
– Projective tests – Rorschach Inkblot 1921,
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Thematic Apperception Test (TAT) etc.
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 History of Assessment in Clinical
Psychology

 WWII – Psychologists again active in tests for

armed forces
– MMPI – (personality test) 1943
 Heavy use of statistics and test development
 Criticisms of Early Assessment
– Paul Meehl – importance of using statistics to
testing viability of hypotheses
– Walter Mischel’s work showing personality traits as
having problems with validity
– Behavioral assessment as a field grew in part from
these criticisms
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 History of Assessment in Clinical
Psychology

 1980’s – Diagnostic and Statistical Manual for

Mental Disorders (DSM-III) published
– DSM-III more focused on observable symptoms
– Focus on reliability

 Several changes in psychological assessment

have recently occurred
– Clinical utility – does the assessment help with
treatment
– Service evaluation – do treatments work
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 History of Intervention in Clinical
Psychology

 Sigmund Freud
– First elaborated treatment of mental health issues
– Early connection to neurology and work of Charcot
– Focus on role of unconscious
– Many subsequent followers elaborating related
psychodynamic theories (e.g., Jung, Adler, etc.)
 Lightner Witmer – coined term ‘clinical
psychology’ – opened a clinic (1904) to
assess and remediate learning difficulities
 Demand for therapy increases in 1940’s and
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 History of Intervention in Clinical
Psychology

 WWII
– Soldiers needing therapy when returning from war
– Members of public affected by loss
– VA hired many clinical psychologists
 Many therapy approaches developed in
1940’s – 60’s
– Carl Rogers Client-centered approach
– Several adaptations to Freud’s model
– Fritz Perls – Gestalt therapy
– Joseph Wolpe – Systematic desensitization
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History of Intervention in
Clinical Psychology
 Criticisms of Psychotherapy
– Hans Eysenck 1952
– Levitt, 1957
– Resulting in enormous amount of research on
whether psychotherapy works
 Efficacy studies – focus on studies that
emphasize internal validity of the study
 Effectiveness studies – focus on studies that look
at real world conditions
– Meta-analysis – statistical technique combining
several studies, showed psychotherapy effective
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 History of Intervention in Clinical
Psychology

 Contemporary approaches
– Albert Ellis – Rational Emotive Therapy
– Aaron Beck – Cognitive Therapy
– Cognitive Behavioral Therapy
– Short-term Dynamic Therapy
 Prevention in Clinical Psychology
– A growing area of Clinical Psychology

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