Summary Book Clinical Psychology Chapters 1-35-911 1318

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Summary - book "Clinical Psychology" - Chapters

1-3,5-9,11-13,18
Introduction to Clinical Psychology (University of Texas at Austin)
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Chapter 1: Clinical Psychology Pages 3-30

What is Clinical Psychology?
 Clinical psychologists are individual trained in assessment and diagnosis, intervention or
treatment, consultation, research, and the application of ethical and professional principles
 Clinical psychologists work with a range of individuals, from infants to the elderly.
 They work in a large range of settings, including universities, hospitals, private practice
offices…
 Little medical training, extensive training in psychotherapy or talk therapy.
 Focus on client autonomy and collaboration with patient
 Only New Mexico and Louisiana allow trained clinical psychologists to prescribe medication
Closely Related Mental Health Professions
Psychiatrists
 A physician rooted in medicine

 Regards psychopathology as an “illness” that is biologically based and its causes can be
treated with medicine.
 Complete four years of medical school (M.D.), general medical internship, 4-year residency
training in psychiatry.
o Supervised work in clinical setting or outpatient facility (supervised by experienced
psychiatrist)
o May thus be better able to identify medical problems for psychological distress.
 Blurred lines between clinical psych and psychiatrists.
 Specialization is slowly declining—economic impact, competition from other specialties like
clinical psych.
 Brief quarter-hour sessions of medication management not long psychotherapy sessions.
 Prescription privileges are being allocated to other specialties as well and people no longer
rely on psychiatrists for advice on medication treatment.
 More authoritarian and focus on medication prescription.
Counseling Psychologists
 Work with moderately maladjusted individuals and use assessment methods, most commonly
interviews.
 Employed in educational settings, but also employed in hospitals, mental health centers.
 Focused on:
o Preventative treatment, consultation, development of outreach programs, vocational
counseling, short-term therapy.
 Counseling psychology is a small field (the file of clinical is bigger with 4x as many
graduates from doctoral programs).
 Most counseling psychology programs are in the School of Education.
 Counseling doctoral program acceptance rates are higher, greater focus on minority/cross-
cultural issues.
 Only 70 Ph.D. programs are there for counseling psych but there are 360 for clinical psych.

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Clinical Social Workers
 Work to improve social functioning of individuals, groups, or communities.

 In the past social workers focused on external or social factors contributing to patient’s
difficulties, while the psychiatrist prescribed medication and the clinical psychologist tested
them.
 Today social workers are more likely to deal with psychological factors that play a role in
individual and family difficulties (more focus on familial factors).
 Requires only master’s degree to practice (2 years).
 More likely to engage in home visits, workplace visits—active role
 The social work field is rapidly growing as a result of them being low-cost alternatives to
psychiatrists and psychologists.
School Psychologists
 Work with students, educators and administrators to promote social and emotional growth of
school age children and adolescents.
 School psychologists are in high-demand, as they conduct assessment for special educational
needs.
 Workplace include schools, nurseries, daycare, hospital, clinics…
 60 APA programs for doctoral degrees.
Health and Rehabilitation Psychologists
 May have a doctorate in clinical, but this is not required. This field is new and is rapidly
growing.
 Through research and practice contribute to the promotion of good health, involved with
prevention and treatment of illness.
o Ex: design prevention programs to help quit smoking, reduce weight.
 Most likely to engage in consultation with different organizations.
 Rehabilitation psychologists focus on physical or cognitive disability.
o Help with adjustment to physical, social, psychological barriers.
 Work at care facilities, medical centers, rehabilitation facilities, hospitals…
Psychiatric Nurses
 Working alongside psychiatrists and clinical psychologists

 They implement the therapeutic recommendations.
 Have prescriptive privileges in all but a few states.
Others

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 Include occupational therapists and recreational therapists, can help teach patients skills that
will help outside hospital settings.
 Can help patients deal with feelings via art, music, dance. Can help supplement work by
professionals.
 Those who are trained to help mental health professionals—Paraprofessionals
Professionals and Titles Not Regulated by the Government

 Clinical psychologists, counseling psychologists, school psychologists and so on all require
specific educational requirements to practice.
 Titles like psychotherapist and therapist can be used by anyone wishing to offer any service.
 The public is not aware of such distinctions and may seek to use services offered by someone
unregulated rather than a professional individual just because unregulated services use such
titles.
Activities of Clinical Psychologists
Activities include psychotherapy, research, diagnosis, teaching and administration.
Therapy or Intervention
 Client sit face-to-face across from the therapist and therapy involves either a one-to-one
relationship or couples, family, child therapy.
 Majority of therapists are women and not men
 Therapy involving specific skills is more useful to reduce problems (ex: CBT therapy).
Diagnosis/Assessment
 Used to better understand the individual so that a more informed decision can be made
 Gathering information through testing so that a problem can be solved.
Teaching
 May teach graduate courses in specific areas—advanced psychopathology, development
psychopathology, testing, personality theory…or even do undergraduate testing.
 Some clinicians may supervise doctoral students completing their degree (supervision).
 Clinicians may also conduct workshops and seminars to teach skills to nurses, aides,
probation officers and so on.
Clinical Supervision
 A form of teaching, more one-to-one teaching that is less formal.
 Involves supervising students and interns; people learn by doing under the guidance of a
supervisor-trainee relationship.
Research

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 Scientist-Practitioner model was adapted—thinking like a scientist.

 Clinical work is enhanced by knowledge of scientific methods and exposure to clinical
practice.
 Clinical psychologists have the ability to both consume and produce knowledge.
Consultation
 Consultation can occur on a case by case basis with another individual in the field or for an
organization looking for help in a particular domain (ex: drug addiction).
 Clinical psychologists also serve as consultants for advertising agencies.
 A large number of consultants work for primary care services.
Administration
 All clinical psychologists have to engage in administrative duties like maintaining client
record and filling out reports.
 Some are drafted by colleagues as a result of their skills to perform greater admin duties
 Ex: head of the psychology department, vice president of a consulting firm, program director
of a clinic.
Employment Sites
 Employment sites that are the biggest are: (1) private practice, (2) universities and (3)
medical schools.
 Other settings include: Psychiatric hospitals, outpatient facilities…
 Clinical psychologists tend to engage in a diversity of both private practice and research.
 Demographics—in 2005 only 34% of clinical psych doctoral majors were women and only
7% were racial minorities—this is slowly increasing.
Research and the Scientific Tradition
An Overview
 Clinical Psychology is based on research tradition and the quest to acquire new knowledge
 Typically, a clinical doctorate student engages in assessment, research, diagnosis and
therapeutic skill development with an internship.
 Psychology programs offer a two-year Master’s program that some students pursue before
doing the Ph.D.
 Master level students are viewed as less competent and can’t practice independently.
 Growing Master’s field with 3x as many Masters than Ph.D.’s being awarded.
Coursework and Practicum Work
 Students have to take a series of basic courses that help found their basic knowledge of
human behavior.
 Use scientist-practitioner model
 During the advance years of graduate school students are exposed to practica work, that
involves application of theories studied.

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o Acquisition of specific clinical skills

 Practicums can be in assessment, therapy, interviewing methods or even in consulting within
specific areas/agencies.
Research
 Competence needs to be developed in computer software, technology and research methods

by engaging in research projects.
 Different universities place different emphasis on research
o Completion of Master’s thesis by the end of second year
 A research project/dissertation is required by the end of 4th/5th year that adds new information
to the field.
 When entering grad school, a student joints a “team of faculty members”—team meets 2/3
hours per week.
Qualifying Exam
 Preliminary or comprehensive examination, it is three written exams each lasting 4-hours

over the span of one-week or 5-day examinations.
 Often taken during the 3rd year or students write an in-depth literature review or research
grant.
The Internship
 Provides experience to complete the scientist-practitioner role, required of all clinical

programs.
 Occurs at the end of graduate training, usually at an independent facility off campus or at
university counseling centers or medical schools.
 Allows the student to work full-time in a professional setting provides the students with skills
that will mirror that of a professional career.
 Women are increasingly growing in the field of clinical psych.
Training Models
 Professional clinical psych programs use the Ph.D. scientist-practitioner model focused on
research but the Psy.D. program is an alternative degree more focused on application.
 Professional schools award 60% of doctoral degrees for clinical psych.
 Combined Program—focuses on core of both knowledge and skills across applied
psychology areas—broad skills.
 Clinical-Science Model is focused on evidence-based approaches.
Clinical Practice
 Clinical psychologists are slowly going into private practice and para-professionals &
master’s level individuals are being employed more in mental-health settings.
 Clinical psychologists need to have a capacity to tolerate ambiguity

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Chapter 2: Historical Overview of Clinical Psychology pages 32-58

Historical Roots
 Individuals that altered the field of clinical psychology and began viewing mental illness
as treatable—Pinel, Tuke, Todd, Dix
 The development of clinical psychology slowly expanded in the fields of diagnosis,
assessment, intervention, research and professional matters.
Diagnosis and Assessment
The Beginnings (1850-1899)
 James Keen Cattell, a student of William Wundt believed that studying reaction time
differences would help to understand intelligence—mental tests.
 Witmer founded the current model of treatment by forming the first psychological clinic
& a journal called the Psychological Clinic.
 Initial emphasis focused on the youth population of children and adolescents who were
unable to functionally adapt to society.
The Advancement of the Modern Era (1900-1919)
 Binet and Simon developed the Binet-Simon Scale—measures intelligence.
 Carl Jung developed testing methods around word-associations and 1910 brought the
arrival of the Kent-Rosanoff Free Association Test.
 WWI brought the screening of individuals entering the military, marking the movement
away from children and youth towards adults.
Between the Wars (1920-1939)
 By the late 1920’s psychologists had individual and group testing tools at their disposal.
 The field of intelligence was being expanded with work by Spearman, Thorndike,
Thurstone
 Wechsler-Bellevue test—first adult intelligence test; created in 1939 and since then
modified & adapted.
 Rorschach—inkblot tests that attempted to bring people to reveal their real-life
experiences by looking at ambiguous stimuli. He published this in his book
Psychodiagnostik.
 Projective Techniques—Designed to allow a person to respond to ambiguous stimuli, and
reveal hidden emotions and internal conflicts projected by the person into the test.
 Thematic Appreciation Test (TAT)—Requires an individual to make up stories reflecting
activities, thoughts and feelings of the people in the picture.
World War II and Beyond (1940-Present)
 More complex tests began to develop. Minnesota Multiple Personality Inventory
(MMPI)-self-report test, and unique because no interpretation of scores was needed.

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 Wechsler Intelligence Scale for Children—Alternative to Stanford-Binet scale.

 Clinical psychologists were viewed as experts of psychodiagnosis—use of interpretation
of test scores as a basis of diagnosis and treatment.
 Different approaches—objective nomothetic approach (empirically tested rules) vs.
projective idiographic approach (focused more on the individual and interpretations).
 Radical Behaviorism: Only overt behavior can be measured and psychological trait
measurement is not useful. It brought the era of behavioral assessment—behaviors were
understood in the context of the stimuli or situation in which they occurred.
 First DSM appeared in 1952, focused mostly on adult psychopathology and post-war
symptoms.
 Structured Diagnostic Interviews: Standard list of questions that are used as criteria to
assess different disorders.
 Health care insurers became more interested in managed health because it controlled and
reduced costs and required mental health professionals to be more efficient.
Interventions
 Jean Charcot focused on interventions for hysteria using hypnosis
 Freud and Breuer collaborated on a patient Anna O’s whose treatment was challenging
o Psychoanalysis (most influential theoretical and treatment development for
clinical psychology)
The Advent of the Modern Era (1900-1919)
 1900’s—psychoanalytic movement began with Freud’s publication of The Interpretation
of Dreams.
o Terms like Oedipus complex, ego, id began part of psychological terminology.
 Healey’s establishment of the child guidance center in Chicago in 1909 reflected a
movement towards looking at juvenile offenders and not simply learning problems of
children.
 Psychoanalytic therapy was viewed as being the sole right of a medical practitioner but
psychologists soon began to use it in their work with children (child guidance clinics).
 Adler’s emphasis on family relationships instead of sexuality grew prominent with
practitioners.
 Play Therapy: Release of anxiety or hostility through expressive play (Freudian Principle
based).
 Behavior Therapy: Encompassing the works of Watson, Jones, Levy and others it focused
on conditioning.

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World War II and Beyond (1940-Present)

 As psychiatrists and physicians were too few to help WWII men, psychologists began to
fill the role and aid with psychotherapy, assisting men to return to combat and help with
rehabilitation.
 Shifting away from intelligence and focusing on personality, psychoanalytic intervention
grew.
 Carl Rogers publication, Client-Centered Therapy was the first alternative to
psychoanalytic therapy.
 Therapy was a growing field with the introduction of rational-emotive therapy (RET),
cognitive-behavioral therapy (CBT), and behavioral therapy work by B.F. Skinner and
Joseph Walope
o Looked at desensitization, operant principles and conditioning.
Research
The Beginnings (1850-1899) and the Advent of the Modern Era (1900-1918)
 William Wundt and William James, both of whom formed research laboratories and
influenced the scientist-practitioner model.
 Ivan Pavlov’s classical conditioning theories became important
 1905-Binet-Simon improved their intelligence tests and in 1916 development of the
Army Alpha and Beta tests appeared.
Between the Wars (1920-1939) + World War II and Beyond (1940-Present)
 Behaviorism (power of conditioning) and Gestalt psychology (emphasized patient’s

unique perceptions) were prominent.
 By the 1960’s diagnosis and assessment were less important, but in the 1950’s it was
largely hyped up.
 Focus on effectiveness of psychotherapy (Carl Rogers and Dymond)
 Wolpe (1958)—developed systematic desensitization
 DSM-III published focused on reliability, validity of criteria used for mental disorders in
the DSM manual.
 Focus on etiological factors or causes for many mental disorders.
 Behavioral Genetics: Both environmental and genetic factors influence development of
behavior.
 Brain imaging: Allows us to view both the structure and function of the brain.

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The Profession
 1892—Founding of the American Psychological Association (APA)

o President: G. Stanley Hall
 1896—Lightner Witmer—first Psychological Clinic establishment at U of Pennsylvania.
He named the field clinical psychology
The Advent of the Modern Era (1900-1919)
 1909—Establishment of the Psychopathic Institute in Chicago (Healy)

 1910—222 APA members, $1 membership.
 Focus on APA was psychology as a science not a profession.
 1919—First Clinical Psychology Section was created within APA
 APA 1935 Clinical Psychology---art and technology that deals with adjustment &
problems of human beings.
 1937—Journal of Consulting Psychology was founded
World War II and Beyond (1940-1969)
 Psychologists experience in research and tools for testing differentiated them from
psychiatrists.
 With the end of WWII soldiers that were returning experienced extensive emotional
trauma/
 The Veterans Administration (VA) increased availability of mental health professionals
by providing financial support for training.
 VA’s needs to deal with the psychological problems of adults resulted in a shift from
children.
 1945—Connecticut first state to institute certification examination for psychologists.
 1949—Conference on graduate education in Clinical Psychology held at Boulder,
Colorado.
o Focused on the scientist-practitioner model for training
The Growth of the Profession (1970-Present)
 1960’s—shift towards focusing on conditioning and altered reinforcement contingencies.

 Key focus was looking at patient’s behaviors and not their thoughts. People began to
question this and turned towards cognitive-behavioral orientation.

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The 1988 Schism
 Many critics felt that the APA was being controlled by practitioners that were using it for
their own interests; no longer focused on scientific needs.
 Plan to reorganize APA so that it lessened the gap between the clinical wing and
academic-scientific wing failed by a 2-1 vote of membership.
 American Psychological Society (APS)/Association of Psychological Science—focused
on the scientific aspect of psychology. First conference held in June 1988.

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Chapter 3: Current Issues in Clinical Psychology pages 59-92

Models of Training in Clinical Psychology
The Scientific-Practitioner Model
 Boulder Model/Scientist-Practioner Model: Attempts to marry science and clinical

practice and is the most popular model to this day. Skilled practitioners that could
produce own research and learn from others research.
 In the past, training was not the focus of the field; clinical psychologists focused on
research.
 The model sought to aid students in thinking like a scientist in whatever activities they
engaged in.
 1987—Salt Lake City, Utah: Seeking a model that deemphasized research and placed
greater emphasis in clinical skills
The Doctorate of Psychology Degree (Psy.D.)
 Emphasis on the development of clinical competence, de-emphasis on research

competence.
 Dissertation is about professional subject and not research contribution.
 Increasing experience in therapeutic practice (3rd year divergence)
 Differences between Psy.D. and Ph.D.
o Great Psy.D. acceptance rate
o Lower percent receive full financial assistance
o Lower percent of faculty with a cognitive-behavioral orientation
o Lower percentage obtain internships at top-facilities
o Shorter period to complete degree (5.1 years).
Professional Schools
 No affiliation with universities and they have their own financial and organizational
framework.
 Free standing or free for profit schools, mostly offer Psy.D. degrees.
 There are 45 professional’s schools and they offer over 60% of the clinical psychology
doctorates. Greater proportion of doctorates given by professional schools today.
 Rely heavily on student-tuition (so expensive) as not fully-funded and have only part-
time faculty.
 Very rare that professional schools are APA accredited
Clinical Scientist-Model
 Scientific and clinical psychology is the only acceptable form of clinical psychology

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 Focused on building a science of clinical psychology, by integrating scientific principles

into their work.
 Academy of Psychological Science (1995)—graduate programs and internships focused
on empirical methods of research.
 Main goals:
o Training—clinical science research + scientific knowledge
o Research and Theory—advance clinical science research and theory and
integration with other sciences.
o Application—broad application to human problems
o Dissemination—to foster distribution of knowledge to public in a timely manner.
Combined Professional-Scientific Training Programs
 Combined specialty in counseling, clinical and school psychology; assumes a share core
knowledge based for all three areas.
 Graduates however may not develop a specific sub-specialty as an expertise for an area.
 Better suited to the future practitioner than the future clinical research scientist.
Graduate Programs: Past and Future
 1960’s: Shift from university based jobs to private practice work.

 Vail Training Conference (1973): Alternative training models to meet the needs of future
practitioners. Psy.D. degree and professional school model arose from this conference.
 As a result of the excessive number of applicants, many graduate students have been
unable to acquire an internship position (25%).
 Curriculum will place an emphasis on empirically supported psychological intervention
and focal assessment.
Professional Regulation
Certification
 Certification and licensure can vary from state to state; but it is a weak form of regulation
in most instances.
 People can’t call them “psychologists” unless they have been certified; attempts to
protect the public by restricting title use.
 Does not prevent anyone from offering psychological services to the public as long as the
non-certified people don’t use the same title.
Licensing
 Stronger than certification, provides the title of “psychologist” but also defines what
specific activities are offered for the public.
 APA developed a model act for licensure of psychologists.

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 Applicants for licensure are required to take an exam (can be oral + written)
 May require supervised experience beyond doctorate
 Licensing boards are starting to become increasing picky about the requirements and
restrictions placed on those that qualify and those that can obtain licensure.
 Some argue that both licensing and certification are invalid measures of competence,
others say that regulating licensing measures will ensure competence.
 Challenges include establishment of a national standard, deciding between oral or written
exams and licensing over the internet.
Requirements for Licensure
 Doctoral degree from APA accredited program (e.g. clinical)

 1-2 years of supervised clinical experience
 Must bass Examination for Professional Practice in Psychology (EPPP); sometimes oral
exam is needed.
 Must practice within the scope of the knowledge and competence, training
American Board of Professional Psychology (ABPP)
 ABPP offers certification in the field of clinical child and adolescent psychology, clinical
psychology, clinical health psychology and other fields.
 Candidates are required to submit practice sample (ex: videotape sessions), provide
written statement regarding professional expertise and complete a supervised oral exam.
 Provides increased mobility if one decides to move states, greater respect and more
reliability.
Private Practice
 Clinical Psychology moving in the direction of policies, legislation and greater

emphasis on practice than on research.
 A fee for private-practice service is now the past, and managed health care now
dominates.
The Costs of Health Care
 Predicted that from 2009 to 2019 proportion of GDP costs devoted to health care will rise
by 19.6%.
 Managed Care: Profit driven corporate approach to health care that attempts to contain
costs by controlling the length and frequency of service utilization and restricting the
types of services provided
o Shift in control from practitioners to those that pay the bills (employers)
 Three managed care types:

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1. Health Maintenance Organization (HMO’s): restricted number of providers and

serves those who enroll in the service plan at a fixed cost for all services.
2. Preferred Provider Organization (PPO’s): have contracts with outside providers at a
discounted rate for membership and in exchange providers get more referrals.
3. Point of Service Plan (PPO’s): managed members have more choices at their health
care choices but may more for non-managed features (incorporates HMO and PPO
features)
 Two Models of Health Care
o Consumer-Directed Health Care Plan: Shift cost and responsibility to consumer
o Performance Disease Management Models: Pay for performance incentives to
clinicians to provide high-quality effective services (fewer sessions).
 Self-help methods may increase—books, pamphlets, handouts, computer/internet
therapy.
Prescription Privileges
Background
 Argument that it will allow for autonomy of clinical psychologists as health service
providers
 Help with continuous care from one physician
 Argument of professional boundaries and bridging the gap between psychology &
psychiatry.
Pro Arguments for Prescription Privileges

 Enable practitioners to provide a wider variety of treatments to a wider number of people.
 Increase in efficiency and cost-effective of care for patients who need psychological
treatment and medication.
 Provide clinical psychologists an advantage in the marketplace (e.g. over social workers)
 May be more qualified to consider psychopharmacological treatment due to them
spending longer sessions with clients.
 Better able to offer combined treatment (psychosocial + psychopharmacological).
Con Arguments for Prescription Privileges

 De-emphasis on psychological forms of treatment as medication is faster and brings more
money.
 May result in conflict between members of the fields of psychology and psychiatry.
 May lead to more drug-company sponsored research.
Implications for Training

 Ad Hoc Task Force for Psychopharmacology—three levels of competence and training.

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 Level 1—Basic Pharmacology Training: knowledge of medication and substances that

may be addictive. Recommended: a course on psychopharmacology.
 Level 2—Collaborative Practice: Psychopharmacology consultant with knowledge as
well as diagnostic assessment skills. Recommended: coursework and practical exposure.
 Level 3—Prescription Privileges: Practice independently and prescribe medication.
Recommended: Intensive science based coursework, 2 years of graduate training in
psychopharmacology and postdoctoral residency in psychopharmacology.
 Only Level 3 individuals are qualified to prescribe.
 Additional course requirements would make it longer to complete graduate school;
prescription privilege programs may thus only be offered at the post-doctoral level.
Technological Innovations
Telehealth
 Delivery and oversight of health services using telecommunication technologies (ex:
websites, email, videoconferencing).
 Increased accessibility to services, efficiency, reducing stigma.
Ambulatory Assessment
 Involves assessing the emotions, behaviors and cognitions of individuals as they are
interacting with their environment in real time.
 Requires very little retrospection of the client (reflection).
 More ecologically valid (ex: tracking mood via phone throughout the day).
 Multiple assessments on the same client are possible; multiple forms of ambulatory
assessment focusing on different response across domains can also be done.
Computer-Assisted Therapy
 Clients who don’t have access to mental health professionals for face-to-face time or
embarrassment may choose to use this method.
 If mental health services are accessible through telephone, internet or videoconferencing
it could aid those that have lack of accessibility, inconvenience or fear treatment.
 Electronic health records can be maintained and clinicians can view clients Web-based
homework’s.
Culturally Sensitive Mental Health Services

 Given the plurality of U.S. culture, mental health services need to serve ethnically diverse
populations.
 Clinical psychologists must demonstrate cultural competence—knowledge and
appreciation of other cultural groups and the skills to deal with other cultures.
o Scientific-mindedness

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o Dynamic sizing; when to generalize vs. when to individualize

o Culture specific expertise; have knowledge of the groups that they work with
Ethical Standards
 1953: Publication of the Ethical Standards of Psychologists
 General principles of ethical standards:
o Beneficence and non-maleficence (strive to benefit others and do not harm)
o Fidelity and responsibility: professional and scientific responsibility to society
o Integrity: strive to accurate, honest and truthful
o Justice: all people are entitled to access and to benefit from knowledge generated
by psychology
o Respect for people’s rights and dignity: enact safeguards and protection measures.
 Specific ethical standards underlined under APA membership are enforceable rules, the
general principles are not.
Rule 1: Competence
 Clinicians must only provide services within the boundaries of their training.
 Clinicians should not provide treatment for assessment procedures of which they have no
knowledge.
 Tool kits to ensure competence: performance reviews, case presentation reviews, client
outcome data.
Privacy and Confidentiality

 Respect and protect confidentiality of their patients.
 Clinicians should be clear about confidentiality and the conditions under which it can be
broken.
 Tasaroff Case: A 1976 case in which California Supreme Court deemed that therapist
was remiss for not informing all parties of the clients intention to harm his girlfriend.
 Being aware that confidentiality may need to be broken in certain instances (e.g. child
abuse, potential suicide or murder).
 Jaffe vs. Redmond: 1996 Supreme Court case that permits communication between
licensed mental health professionals and individual adult patients in psychotherapy.
Human Relations
 Client-Welfare: The best interests of the client and as such this condones relations of a
sexual nature, relationships, sexual harassment.
 Most common ethical dilemma for psychologists—confidentiality (breach of potential
risk due to abuse or other reasons).

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Chapter 5—Diagnosis and Classification of Psychological Problems
What is Abnormal Behavior?
 Psychopathologist: Scientist that studies the cause of mental disorders and the factors that
influence its development.
 Hard to define abnormal behavior—a. no single descriptive feature is shared by all abnormal
behavior, no one criteria are sufficient to define abnormal behavior and b. there is no discrete
boundary between abnormal and normal behavior.
Definition 1 of Abnormal Psychology: Statistical Infrequency or Violation of Social Norms
 Person whose behavior is deviant or non-conforming is likely to be noted as “abnormal”.

 Statistical infrequency—difference from the norm in a very low IQ score (ex: score of 64)
 Violation of social norms—dressing different from typical girls or women
Definition 1: Advantages of the Statistical Infrequency or Violation of Social Norms Definition
1. Cutoff Points: Has cutoff marks that are quantitative (a low score can be compared to the cutoff
point). Ex: Used to compare psychological test-scores (above the cutoff is clinically significant).
2. Intuitive Appeal: Behaviors that we consider abnormal would be judged as abnormal by others.
Definition 1: Problems of the Statistical Infrequency or Violation of Social Norms Definition
1. Choice of Cutoff Point: Conformity criteria are limited as it is difficult to establish cutoff points.
Very few guidelines on how to form cutoff points. Shouldn’t categorize every abnormality as
deviant.
2. The Number of Deviations: How many deviant behaviors are needed to earn the label “deviant”?
3. Cultural and Developmental Relativity: What is classified as deviant for one group, is not deviant
for another. Also some behaviors that are appropriate at one developmental stage may be
inappropriate at another (focus on comparison to same-age peers and not all-peers).
a. Reducing cultural practices to the extreme (i.e. subcultures) is too much.
Definition 2 of Abnormal Psychology: Subjective Distress
 Subjective feelings and sense of well-being of the individual (ex: feeling happy, sad, troubled…).
Definition 2: Advantages and Problems of Subjective Distress Definition
 Individuals are aware of their emotional experiences and can express them; harder for children.
 Labeling someone as maladjusted only works if their behavior is specified and their behavioral
manifestations are stated.
 How much subjective distress is needed to be defined as “abnormal”?

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Definition 3 of Abnormal Psychology: Disability, Dysfunction or Impairment
 Abnormal behavior must create a level of social (interpersonal) or occupational (educational)

problem. Dysfunction in either one of these two areas.
o Ex: Lack of friendships due to lack of social relationships (social dysfunction)
o Ex: loss of one’s job due to depression (occupational dysfunction)
Definition 3: Advantages and Problems of the Disability, Dysfunction or Impairment Definition
 Adv. Relatively little inference is needed; people seek treatment for social and work problems.
 Disadv. Judgements regarding social and occupational dysfunction is relative not absolute (no
standard).
o There are self-report inventories and interviews to assess work and social functioning.
What does this mean?
 No specific definition of 1,2 or 3 can be used as a standard to define abnormal behavior.

 Abnormal behavior does not equal mental illness
 Mental Illness: Frequently observed syndrome that are made up of certain abnormal behaviors.
Mental Illness Definition—What Does it Encompass?
 A. Behavioral or psychological syndrome (cluster of abnormal behaviors) must be linked to

distress, disability or a risk of problems.
 B. Represents a dysfunction within an individual
 C. Not all deviant behavior or conflicts in society are indicative of a mental disorder (ex: cultural,
religious, sexual deviance).
The Importance of Diagnosis
 Diagnosis is a type of categorization; categorization allows us to make distinctions for survival.

 Advantages of Diagnosis:
1. Communication—conveyed through a diagnostic term (“verbal shorthand”)
o Standardized criteria allow for comparison across states (ex: California vs. Texas) and clinicians.
o DSM criteria for mental disorders are useful for communication as they are descriptive (no
specific theoretical focus).
2. Diagnosis promotes empirical research in psychopathology
o Comparison between groups (ex: psychological test performance or personality).
3. Standard diagnostic criteria allow for research into the etiology/causes of abnormal behavior
o Placing individuals in groups with individuals that share the same diagnostic features.
4. Diagnosis allows/suggests which model of treatment is most likely to be effective

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Early Classification Systems
*Emil Kraepelin—father of modern systems of psychiatric diagnostic criteria
 1889—Congress of Mental Science adopted a classification system in Paris.

 1948—World Health Organization developed a classification system.
 1952—American Psychiatric Association developed Diagnostic and Statistical Manual (DSM-I)
 1968—DSM-II
 1980—DSM-III (Major change in diagnostic criteria)
o Explicit diagnostic criteria for mental disorders was introduced
o Use of a multi-axial system of diagnosis
o Descriptive diagnostic approach (neutral to etiology theories)
o Greater focus on clinical utility of diagnostic system
 1987—DSM-III-R
 1994—DSM-IV; published an additional DSM for children aged 0-31.
 2000—DSM-IV-TR
 2013—DSM-V
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
 Changes made in DSM-IV-TR was based far more on empirical data than was previous versions.
 Multiaxial Assessment: Complete diagnostic evaluation; clients are evaluated on 5 domains.
 Principal Diagnosis: Main diagnosis or condition for which patient seeks treatment
1. Axis I: Clinical Disorders or Other Conditions (except personality disorder & mental retardation)
2. Axis II: Personality Disorders and Mental Retardation
3. Axis III: Medical Condition that are relevant to the treatment of Axis I and II
4. Axis IV: Psychosocial and Environmental Problems
5. Axis V: Global Assessment of Functioning (GAF) score on scale 1-100
General Issues in Classification
8 Main Issues: Categories versus Dimensions, Bases of Categorization, Pragmatics of Classification,

Description, Reliability, Validity, Bias and Coverage.
1 This is called the Diagnostic Classification System (DC 0-3)

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Categories Versus Dimensions—Is present vs. absent appropriate or is a dimensional model better?
 Based on symptoms a patient is placed within a category.

 Easy to confuse categorization with explanation
 Abnormal behavior is not different from normal behavior but it falls along a dimension (degree).
 Category implies an all-or-nothing approach (present vs. absent) instead of using a dimension.
Bases of Categorization—Should there be multiple ways to make a diagnosis? Does this create too
much heterogeneity within the diagnostic category?
 Diagnostic measures may be complicated requiring the clinician to know a wide variety of
techniques.
 Membership in any one area is most likely going to be heterogeneous because there is multiple
basis for diagnosis.
Pragmatics of Categorization—How do we decide if a condition is included in the diagnostic manual?
 Homosexuality was dropped from the DSM and regarded as a lifestyle (dropping from DSM was
done through a psychiatric membership vote).
 DSM is crafted by committees. Members are from different backgrounds and constituencies.
Description—Are diagnostic category features properly described? Are diagnostic criteria specific and
objective?
 DSM-IV provides detailed information for Axis I and II. Also provides information about each
diagnosis including age of onset, course, prevalence, complications, family patterns…these
features enhance reliability and validity.
Reliability—Are diagnostic judgements reliable & can different clinicians agree on a diagnosis?
 Refers to the consistency of diagnosis across raters; DSM III—specific criteria attempted to
increase reliability of diagnosis.
 Developed structured diagnostic interviews that push clinicians to use specific DSM criteria; this
had led to greater reliability.
 Even with structured interviews, reliability is not guaranteed (e.g. generalized anxiety disorder).
Validity—Can we make meaningful predictions based on our knowledge of an individual’s diagnosis?
 If clinicians fail to agree on proper classification of patients then it can’t be demonstrated that
the classification system has meaningful correlates or has validity.
 Establishing validity of a diagnostic criteria involves 5 steps (Robbins & Guze):
o Clinical description and features beyond the disorders symptoms (ex: demographic).
o Laboratory studies—identify meaningful correlates of the diagnosis (ex: psych tests)
o Delimitation from other disorders—homogeneity among clinicians
o Follow-up studies—assess test-retest validity of diagnosis
o Family studies—determine if the disorder runs in the family.

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Bias—Are DSM features biased due to gender, race, SES background? Are clinicians biased in their
interpretations or application of the diagnostic criteria?
 The DSM system would be called into question if the same cluster of behaviors resulted in a
diagnosis for one individual but not for another.
 Two areas of most bias—sex bias and race bias
 DSM has been regarded as a male centered system that overestimates pathology in females.
 For some diagnosis biological/cultural factors may influence which gender is diagnosed more
(ex: antisocial personality disorder is more common in men).
 Clinicians may however be biased in the way they apply the diagnosis; but it does not indicate
sex bias within the diagnostic criteria.
 Culture may influence diagnosis & treatment factors, “culture bound syndromes” (ex: koro,
voodoo death) and if a patient decides to seek treatment or not.
Coverage—Does the DSM criteria apply to people that present with psychological or psychiatric
treatment? Is the DSM too narrow or too broad in coverage?
 DSM-IV-TR has very descriptive and detailed diagnosis, but some feel that it may be too broad.
o Ex: childhood developmental disorders (i.e. dyslexia…) being labelled as mental disorder
 Other diagnosis: “premenstrual dysphoric disorder”—may be used against women.
Additional Concerns
 Mental disorders use terms like disorder, symptom, condition, and suffers from make it seem
like the person has a disease.
 Diagnosis can be stigmatizing to the labeled individual and it is also why people do not seek
treatment.
 Observers see the label not the person (ex: can damage relations, employment opportunity).
The Diathesis-Stress Model
 Diathesis: Vulnerability or predisposition to develop a disorder (can be biological or

psychological).
o Necessary but not sufficient for a disorder; added component is stress.
 Stress can be environmental (ex: abuse), biological (ex: poor nutrition), interpersonal (ex: bad
marriage) or psychological (ex: bad family environment).
 Diathesis can influence perception of stress (one event can be more stressful for someone than
another).
 Diathesis also influences person’s own life course and choice experiences.
 Both Diathesis + Stress is needed disorder
o High diathesis and high-moderate stress level greater likelihood of disorder.
Value of Classification
 Categorization allow us to generalize and predict

 DSM has been accused of being used more by clinical research than clinical practice.

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Chapter 6: The Assessment Interview pages 160-188

Assessment in Clinical Psychology
 1960’s and 1970’s—Decline in assessment measures and focus more on therapy.

 Clinical Assessment: Evaluation of an individual or family’s strengths and weaknesses,
conceptualization of the problem and prescription for alleviating it.
 Our capacity to understand a problem is based on our skill to diagnose it (diagnose before
treatment).
 Referral Question: Take into consideration what question was asked by the referral
source and what the referral source is seeking. (e.g. from parent, teacher, psychologist).
What Influences How the Clinician Addresses the Referral Question?
 The type of information asked is often based on the clinician’s theoretical approach (ex:
psychodynamic clinician may ask about childhood experiences but a behavioral clinician
may ask about daily life).
 Assessment Interview: Most basic and serviceable data gathering tools. It has a wide
range of application and adaptability, but this again depends on the clinician’s skills.
General Characteristics of Interview

An Interaction
 Interaction between at least 2 people in which each person contributes to the process and
influences the other’s response.
 Involves face-to-face interaction but the conversation is based on a specific set of goals in
mind.
 One characteristic that interviews have that conversation does not—the interexchange is
not based on personal satisfaction or prestige (used to gather data and information).
Interviews Versus Tests
 More purposeful but less formalized than standardized psychological tests.

 Psychological tests—collection of data under standardized conditions using structured
procedures.
 Interviews can use an individualized approach and are more flexible.
The Art of Interviewing
 Except for diagnostic interviews have a degree of freedom to their structure.

 Clinician slowly learns to respond to patients cues over time.

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Computer Interviewing
 Asks all the questions that are assigned and has 100% reliability.
 May be less uncomfortable for patient to answer in private (dehumanizing to an extent).
 Clarification of interview questions is not possible and there is no flexibility room.
 Computers can’t assess non-verbal cues (ex: facial expression), can’t assess free-form
responses, can’t apply clinical judgment to patients.
Interview Essentials and Techniques

The Physical Arrangements
 The setting needs to consider privacy and protection from interruptions.

 Soundproofing may be necessary to ensure privacy (ex: remove hallway noise).
 Most clinicians prefer a neutral office setting.
Note Taking and Recording
 Few key note phrases will aid the clinician in recalling client’s responses.
 Most patients assume that some form of note-taking will occur, but may request note-
taking not occur for certain sensitive topics of discussion
 Verbatim notes; except during a structured interview as it prevents from noticing non-
verbal or subtle cues.
 Audio or videotaped interviews must be done with patient’s full consent.
Rapport
Definition and Functions
 Rapport: Characterize the relationship between patient and clinician, involving

comfortable atmosphere and mutual understanding of the purpose and goals of interview.
 Establishing a positive relationship will determine the type and amount of information the
clinician will acquire from the patient.
Characteristics
 Requires attitude of acceptance, understanding, respect for patient’s integrity.

 Does not require the clinician to like or be friends with the patient.
 Allows for probing and confrontation once rapport has been established.

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Special Considerations
 Difficult in establishing rapport with multiple individuals during family or marriage

counseling.
 Similar situations may occur with child and adolescents where rapport must be
established with both patient and parent(s).
Communication
Beginning a Session
 Using general topics like the weather or difficulty about finding a parking space are good
starters.
 Establishes the clinician as a real person and removes them from being related to as a
“shrink”. Helps relax the patient.
Language
 Initial estimation of patients age, background and educational level to determine what
language to use.
 Using proper language to establish oneself as a professional but also being cognizant of
the client’s needs “not using teenager language like LOL”.
The Use of Questions + Silence
 Questions may become more structured over time—open ended, facilitative, confronting.
 Assess meaning and functions of the silence—organizing thought, deciding what to say.
Listening
 Listen and appreciate the emotions that the patient is conveying.

 If the clinician is concerned about impressing the client, or guided by other motivations
therapy will not be effective.
Gratification of Self
 Clinicians must resist temptations to think about their own problems and concerns; but
instead focus on the patient.
 Clinicians should avoid discussing their personal lives with the patient.
The Impact of the Clinician
 The type of therapist that a patient has—tall, thin and muscular vs. very feminine female
will elicit different responses from their patients.
 The clinician must thus have a degree of self-insight to consider the possible impact they
can have.

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The Clinician’s Values and Background
 Clinicians must examine their own assumptions before making judgements about others;
some misconceptions may essentially be a part of the other person’s culture.
 Gender differences or different frame-of-references can sometimes elicit the same
response of disconnect from the patient.
The Patients and Clinicians Frame of Reference
 Being sensitive to the patient’s initial perceptions and expectations in necessary to

establish rapport.
 The clinician needs to be prepared and should know everything there is to know about
that patient before the first meeting.
o The clinicians should also be clear about the purpose of the interview, and clear
about the nature of what is required if it is for a referral.
Varieties of Interviews
 Interviews first differ in terms of purpose, and second in terms of whether it is

unstructured (clinical interview) or structured.
 Unstructured Interview: Clinicians are allowed to ask any questions that come to mind in
any order.
 Structured Interview: Verbatim set of standardized questions in a specific sequence.
The Intake-Admission Interview
 Helps determine why the patient has come to the hospital or clinic and judge whether the
facilities resources will meet the patients’ needs and expectations.
 Conducted by a psychiatric social worker.
 Can be done face to face or via phone.
 Informs patients of clinicians fees, policies, procedures.
The Case-History Interview
 A complete personal and social history is taken—concrete facts and dates and a patient’s
feelings about them.
 Broad history and context in which the patient and problem can be placed.
 Gathering historical-developmental context so that diagnostic significance and
implications can be determined.
 Can also use outside sources (e.g. parents, teachers, peers).

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The Mental Status Examination Interview
 Conducted to assess cognitive, emotional and behavioral problems.

 Very unreliable because they are unstructured in nature.
 One of the primary modes of assessment for a variety of mental health issues.
The Crisis Interview
 Hotline interviews for people fearful of abusing their children or abusing drugs.
 Rules of interviewing are blurred but the basics remain.
 Purpose is to meet the problem as it occurs and provide immediate resource of relief.
The Diagnostic Interview
 Evaluation against DSM-IV criteria; historically it used a free form unstructured

interview.
 Structured diagnostic interviews: Standard set of questions and follow up questions in a
specific sequence. Allows for greater inter-rater reliability.
 Very few clinicians used these structured interviews in daily life (only 15%).
Reliability and Validity of Interviews
 Interrater Reliability: Level of agreement between two raters who evaluate the same
patient. Quantified using the kappa coefficient or the intraclass correlation coefficient.
 Kappa Coefficient: To determine how reliable rater judge the presence or absence of a
feature of a diagnosis. Between .75 and 1.00 *best inter-rater agreement level.
 Validity concerns how well an interview measures what it intends to measure.
 Predictive validity: Scores from a measure, correlated (“predicted”) future events
relevant to that construct.
Reliability
 Structured interviews are more reliable than unstructured (reduce information and
criterion variance)
 Information Variance: Variation in the questions that clinicians ask, observations made
and the method integrating that information.
 Criterion Variance: Variation in the scoring threshold among clinicians. Clear cut
scoring criteria is better.
 DSM-III and structured interviews to assess DSM criteria made diagnostic interviews
more reliable.
 Test-Retest Reliability: Consistency of scores or diagnosis across time (retaken).
o Goes down over longer time periods—years or months.

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Validity
 Content Validity: Measures comprehensiveness in assessing the variable of interest (does

it measure all areas of the construct of interest).
 Criterion-Related Validity: Ability of a measure to predict (correlate with) scores on
other relevant measures.
 Concurrent Validity: Type of criterion-related validity. Extent to which interview scores
correlate with scores on other relevant measures given at the same time.
 Predictive Validity: Type of criterion-related validity. Extent to which interview scores
correlate with scores on other relevant measures, at some point in the future.
 Discriminant Validity: Extent to which interview scores do not correlate with measures
that are not theoretically related to the construct being measured. E.g. no reason phobia of
spiders should relate to intelligence.
 Construct Validity: Extent to which interview scores demonstrates all aspects of validity.
Suggestions for Improving Reliability and Validity
 Use a structured interview, or consider developing one.

 Interview skills that are essential: establish rapport, being a good communicator, listener,
knowing when to remain silent and ask questions, observe verbal and non-verbal cues.
 Be aware of patients motives and expectations for the interview.
 Be aware of your own (clinicians) expectations, biases and cultural values.

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Chapter 7—The Assessment of Intelligence (pg. 191-215)
Intelligence Testing: Yesterday and Today
 Due to under-education, and to measure mental abilities, intellectual tests were developed.
 Binet-Simon test looked at individual differences in mental functioning (focus academic ability).
 1971: Court Case Larry P. vs. Wilson Riles—California supreme court in 1975 placed a
moratorium on using IQ tests on African-Americans.
Review of Reliability
 Reliability—consistency with which individuals respond to test stimuli. The types are:
 Test-Retest: Consistency of responses to the same test stimuli on repeated occasions.
o May lead to “test-wiseness” that influences their scores the second time or
clients may show practice effects.
 Equivalent-Forms: Equivalent or parallel forms of a test are developed (ex: test forms A,
B, C with different colors for an exam).
 Split-Half: Test is divided into halves (or odd numbered items vs. even numbered items)
& participant’s scores on the two halves are compared (allows for internal-consistency
reliability).
 Internal Consistency: Do the items on a test measure the same thing? Index of internal
consistency, average of split half correlations is made (Cronbach’s alpha).
 Inter-Rater: Independent observers agree about their ratings of an aspect of someone’s
behavior.
 Reliability needs to be consistent in all forms, otherwise it won’t be valid at all; and
reliability does not automatically equal validity.
Measures for Reliability
1. Test-Retest reliability: Pearson’s r and Interclass correlation

2. Equivalent forms reliability: Person’s r
3. Split-half reliability: Pearson’s r
4. Internal consistency reliability: Cronbach’s alpha and Kuder-Richardson-20
5. Inter-rater reliability: Person’s r and Interclass correlation Kappa
Review of Validity
 Validity: An assessment technique measures what it is supposed to measure

 Content Validity: Measures comprehensiveness in assessing the variable of interest (does it
measure all areas of the construct of interest).
 Predictive Validity: Type of criterion-related validity. Extent to which test scores indicate some
behavior or event in the future.
 Concurrent Validity: Type of criterion-related validity. Extent to which test scores correlate with
scores on other relevant measures given at the same time.

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 Construct Validity: Extent to which test scores demonstrates all aspects of validity in a consistent
manner (involves both convergence and discriminant validity demonstration).
Definitions of Intelligence—3 Classes Emphasize (are not mutually exclusive definitions):
1. Adjustment or adaptation to the environment—adapting to situations or dealing with situations.

2. Ability to learn—educability in the broad sense of the term
3. Abstract thinking—ability to use a wide range of symbols and concepts, ability to use verbal and
numerical symbols.
Theories of Intelligence
Factor Analytic Approaches
 Spearman—general intelligence g (general tests) and specific intelligence s (unique test

aspects).
 Spearman viewed intelligence as a broad generalized entity. Used principal components.
 Thrustone—viewed intelligence as a series of “group factors” not the basic g. Used principal
factors.
o 7 factors (Thurstone’s Primary Mental Abilities)
 Spearman and Thurstone also used different data sets (broad range vs. academic institutions).
Cattell’s Theory (Hierarchical Model of Intelligence)
 Emphasized g. He developed 17 ability concepts. Divided Spearman’s g into 2 components:

o Fluid Ability: Genetically based intellectual capacity
o Crystallized Ability: Capacities that are tapped by intelligence tests, (culture based
learning).
Guilford’s Classification (Viewed as a classification or taxonomy; not really a theory)
 Structure of Intellect Model (SOI)—used model as a guide in generating data.

 Intelligence components can be divided into 3 areas: operations, contents and products.
 Operations: Cognition, memory, constructing logic alternatives, arguments, evaluation.
 Content: Areas of information in which the operations are performed (figural, symbolic,
semantic and behavioral).
 Products: When a mental operation is applied to a context there are 6 types of products.
o Units, classes, systems, relations, transformations and implications.
Gardner’s Theory of Multiple Intelligences (Viewed as “Talents” not intelligences)
 Gardner—theory of multiple intelligences (8 intelligences):

o Linguistic, Musical, Logical-Mathematical, Spatial, Bodily-Kinesthetic, Naturalistic,
Interpersonal and Intrapersonal.

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Sternberg’s Triarchic Theory of Intelligence
 People function on the basis of three aspects of intelligence: componential, experiential and
contextual.
 Emphasis on planning responses and monitoring them and de-emphasis on speed & accuracy.
 Componential: Analytical thinking (good test-taker)
 Experiential: Creative thinking (combine separate elements of experience
 Contextual: “street smart”—practical, can play the game and manipulate the environment.
Today’s Focus—More on Spearman + Thurstone Contributions
 Focus is largely still on a single IQ or Spearman’s g.

 Current intelligence tests are made up of subtest scores (Thurstone factors).
The IQ: It’s Meaning and It’s Correlates—The Intelligence Quotient (IQ)
Ratio IQ
 Mental Age (MA): Index of mental performance (X items passed)

 Chronological Age (CA): Individual’s given age
 IQ: Used to overcome differences cause by CA and MA to express deviance
 IQ= MA/CA x 100
 IQ measurement is not one of equal-interval measurement and we can’t add & subtract (so IQ
of 100 is not twice IQ of 50).
Deviation IQ
 Ratio IQ is limited and not fully applicable to older age groups.

 Compares an individual’s performance on IQ test with his/her same age peers .
 Same IQ has a different meaning for different ages (ex: same IQ for 22 year vs. 80 year old).
Correlates of the IQ: School Success, Occupational Status and Success, Demographic Group Differences
 School
o General IQ shows success in school and specific tests measure what area.
o IQ scores + grades correlation—.50
 Occupation
o Based on educational level acquired (income, race, prestige…)
o IQ also good predictors of job performance
 Demographic Group
o Differences between sexes for specific abilities; males on spatial and quantitative ability
and females on verbal ability.
o Hispanic & African Americans have lower IQ scores than North or European Americans.

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Heredity and Stability of Intelligence
 Intelligence is influenced by genetic factors (behavioral genetics)

 Similarity in intelligence is a result of the amount of genetic material shared (monozygotic more
similar than dizygotic twins or siblings).
 IQ variance associated with genetics varies from 30% to 80%.
 Environment plays a role—biological relatives raised together are more similar.
 Heritability of intelligence is not stable; 20% in infancy and 60% in young adults, 80% in old age.
Stability of IQ Scores and the Flynn Effect
 IQ Scores tend to be less stable for children and more stable for adults and more influenced at a
younger age for children than for adults (i.e. environment).
 Flynn Effect: From 1972 onwards Americans IQ scores on average have increased 3 points each
decade.
The Clinical Assessment of Intelligence Scale 1: The Stanford-Binet Scales
Stanford-Binet 1972 revised test kit version followed a fourth revision in 1986 and the most recent
revision in 2003—Stanford-Binet Fifth Edition (SB-5)
Description:
 Hierarchical Model of Intelligence; 5 factors that tap non-verbal & verbal abilities.
1. Fluid Reasoning: Ability to solve new problems. Measured by sub-tests
a. Quantitative Reasoning, Visual-Spatial Processing, Working Memory and Knowledge
 Each sub-test is made up of items of varying difficulty (age 2-adulthood)
 Multistage Testing: Two routing subtests the Object-Series Matrices and Vocabulary subtest
o Routing: Examinee’s performance on these two sub-tests determine which item to start
with for each remaining subtest.
Standardization and Reliability and Validity:
 Included 4,800 participants aged 2-96 years old; participants were tested using various areas.
 SB-5 administered to individuals with disability, mental retardation to ensure utility of scores.
 Comparing Stanford-Binet to other scales like Wechsler Scales; the scale has strong validity.
The Clinical Assessment of Intelligence Scale 2: The Wechsler Scales
 Wechsler-Bellevue Intelligence Scale; developed to correct flaws in Stanford-Binet Scale.

 Test was designed for adults and items were groups into subtests not according to age level.
 Used a deviation IQ concept; intelligence is normally distributed, compare with same-age peers.

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The WAIS-IV
Description:
 1955—Wechsler-Adult Intelligence Scale (WAIS); revised version 1981 (WAIS-R).

 1997—(WAIS-III); and most recent version 2008 (WAIS-IV)
 Inclusion of reversal items in the subtests introduced first in WAIS-III
o Two examinee’s both begin with the same base items then based on performance
subsequent items are presented in reverse sequence until a perfect score on two
consecutive items is obtained.
 WAIS-IV—provided Index scores in addition to the Full Scale IQ Scores.
Obtaining the Full Scale IQ Score and Index Scores + Standardization:
 Raw scores converted to standardized scores for a given age group.

 Full IQ Score and Index score—adding scale scores of each subtest and converting sums to IQ
equivalents.
Reliability and Validity
 Scores from previous WAIS-III and WISC-IV are strongly correlated with WAIS-IV scores (good).
 Over relying on global IQ scores can thus be misleading (Full Scale IQ)
The Wechsler Intelligence Scale for Children (WISC-IV)—Description and Standardization
 1949—WIC; multiple revisions since then and the latest version WISC-IV was published in 2003.
 Used to test children age 6-16 years old; has 10 core and 5 sub-tests. A reduced version of WAIS.
 Individual subtests define 4 major indices and make up the Full Scale IQ (*see pg. 212).
o Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PCI), Working Memory
Index (WCI), The Processing Speed Index (PSI)
The Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III)
 1967—WPPSCI developed; a revised version since then and the latest WPPSI-III in 2002.
 Similar to the WISC-IV but targeted towards youth; so children below the age of 6.
 Only 3 indices—Full Scale IQ, Verbal IQ and Performance IQ; addition of PSI for age 4+; but also
has several subset scales specific for children only.

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Clinical Use of Intelligence Tests
Estimating General Intelligence Level
 Determining the person’s g level—what is the patient’s intellectual potential?

 Intellectual ability level can also assist with helping individuals recover cognitive abilities
following head trauma, injury.
 IQ scores need to be interpreted and placed in an appropriate context.
Prediction of Academic Success and Appraisal of Style
 Intelligent tests should predict academic success in school.

 Intelligence tests allow us to observe patient at work (observations; help with interpretation).
 Some clinicians made diagnosis of mental disorders from intelligence tests (intertest scatter) but
this is not at all reliable.
Final Observations and Conclusions—IQ is an Abstraction
 Look at IQ as “present functioning” not innate potential; it is an abstraction that allows us to

predict specific behaviors.
 Most believe that there is a “true IQ” and intelligence tests assess these.
Final Observations and Conclusions—Generality Versus Specificity of Measurement
 Intelligence tests can provide broad general index of intellectual functioning across a range of
situations. Can thus be used to compare similar individuals in same situations.

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Chapter 8—Personality Assessment (pg. 218-251)
Objective Tests
Objective Personality Measures: Administer standard set of questions and the examinee responds using
a fixed set of option choices (ex: T/F or Y/N response).
Advantages of Objective Tests or Self-Report Inventories
 Economical—large groups can be tested after only brief instructions.

 Administration and scoring is also very simple thus making interpretation easier (e.g. functional-
dysfunctional). But it is very objective and reliable.
Disadvantages of Objective Tests or Self-Report Inventories
 Questions are behavioral in nature and so may not characterize the respondent (can’t tell why
different people gave same response).
 A single score is provided to look at both cognitions and emotions, but individuals who receive
the same overall score may have different cognitions and emotions.
 Option choice prevents respondents from providing answer reasons, so information may be lost.
Methods of Construction for Objective Tests
Content Validation
 Best for clinicians to decide what they wish to test and then ask the patient that information.
 Content validation focuses on:
o A. defining relevant aspects of the variable looking to be measured
o B. consulting experts before generating items
o C. Using judges to assess each potential items relevance to the variable of interest
o D. Using psychometric analysis to assess each item before it is included in the measure.
Empirical Criterion Keying
 No assumption is made as to whether a patient is really telling the truth about feelings.
 Assumes that members of a certain diagnostic group will respond in the same way
 Utility of an item is based on its ability to discriminate between groups.
 Difficulty with interpreting the meaning of a score.
Factor Analysis or Internal Consistency Approach
 Seeks to reduce or “purify” the scales to reflect basic personality dimensions.

 Exploratory Approach: Taking various items and then reducing these items to basic elements—
(ex: personality, adjustment) to arrive at core traits of personality.
 Confirmatory Factor Approach: Seek to confirm a hypothesized factor structure (based on
predictions) for test items. Largely used by clinicians because it is empirical.

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Construct Validity Approach
 Scales are developed to measure specific constructs from a theory (personality). Validation is
obtained when the scale measures the theoretical construct.
 The most desirable and labor-intensive approach
Description of MMPI
 Uses the Keying Approach; Hathaway & McKinley wanted to identify psychiatric diagnoses of
individuals. Originally designed for ages 16+, but was also used with younger individuals.
 Given to both clinical and non-clinical population.
 550 items that were answered T/F or “can’t say”. Only items that differentiated clinical from
non-clinical individuals (ex: depressed individuals vs. non-clinical individuals) were included.
Description of MMPI-2
 MMPI originally overemphasized the U.S. population and lacked diversity; this was changed.
 Language was changed to be modern, & 154 new items were added bringing total to 704 items.
 Lower age range—can be used with at least 13 year olds or those with 8th grade education level.
 Versions in multiple languages are available & an adolescent version MMPI-A is also available.
Validity Scales
 As MMPI & MMPI-2 as self-report measures they are susceptible to distortion due to attitudes.
 To detect “faking-bad” behavior the MMPI & MMPI-2 incorporates 4 validity scales:
o Cannot Say Scale—items left unanswered
o F(Infrequency) Scale—tendency to exaggerate one’s problems/ symptoms
o L (Lie) Scale—attempts to present oneself favorably
o K (Defensiveness) Scale—attempts to present oneself favorably
 “Added” MMPI-2:
o Fb (Back-page Infrequency) Scale—tendency to exaggerate one’s problem’s/symptoms
o VRIN (Variable Response Inconsistency) Scale—random responding or T/F to most items
o TRIN (True Response Inconsistency) Scale—random responding or T/F to most items
Short Forms and Interpretation Through Patterns (Profile Analysis)
 Shortened versions of the MMPI & MMPI-2; but loss of interpretation is present and intense
scrutiny should be present in terms of whether these and reliable and valid measures.
 MMPI—interpretation on elevated scale scores (ex: high Sc score schizophrenia).
 MMPI-2—interpretation of “pattern or profile” test scores
Interpretation Through Content and Supplementary Scales
 Shift from clinical use of MMPI & MMPI-2—away from use of differential psychiatric diagnosis
based on a single score to a more sophisticated profile analysis of scale scores.
 MMPI-2: Content scales have been developed (ex: identify health concerns, identity fears…)
 Supplementary Scales: 450 MMPI scales ranging from Dominance to Success in Basketball!
MMPI-2 there are 20 supplementary scales (ex: Anxiety, Strength, Social Responsibility).

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A Summary Evaluation of the MMPI and MMPI-2
Screening and The Question of Personality Traits
 MMPI-2 useful for information about mental disorder diagnosis in terms of severity and
hypothesis generator.
 Not useful for a screening specific disorders (ex: depression) as very long + time intensive.
 Atheoretical: MMPI measures symptoms of psychopathology. Not useful for understanding
general personality traits and situational determinants.
Reliability and Validity of MMPI-2
 Lacks internal consistency but do show good test-retest reliability.

 Strong validity with external correlates—emotional states, stress reactivity.
 2 aspects of validity for MMPI-2 (Butcher et al., 1995)—incremental validity & cut-off scores.
o Incremental Validity: If a scale’s score provides information about a person’s personality
features, behavior or psychopathology that is not provided by other measures
 All psychological tests including MMPI-2 lack incremental validity.
o Cut-off scores validity: Varies on the nature of the sample population (which patients
have or don’t have the disorder).
 MMPI-2 cut off T score of 65+ may or may not be appropriate.
Personnel Selection and Bias
 Empirical Criterion Keying approach limits usage of MMPI-2 to those that understand it.
 May not be appropriate to use MMPI-2 to screen candidates for employment hiring (invasion of
privacy into religious beliefs, sexual orientation).
 MMPI original—may be biased against ethnic groups. Test Bias means that different predictions
are made for two groups even when they receive the same score.
Concerns about the MMPI-2
 The normative sample is too education; individuals without college degrees not represented.
 Criteria for inclusion of “normal respondents” is confusing.
 Those who are administered both versions of the MMPI show different results on each version.
 Scores on MMPI-2 are lower than the MMPI
 Internal consistency of the MMPI-2 Scale is low

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The Revised NEO-Personality Inventory (NEO-PI-R)
Description
 Self-report personality inventory that is made up of the Five-Factor Model (FFM)

 OCEAN (Openness to Experience, Consciousness, Extraversion, Agreeableness, Neuroticism).
o There are 6 subscales/facet scales for each FFM
 The 240 items are rated on a scale (strongly disagree, disagree, neural, agree, strongly agree)
 Original Version (Costa & McCrae) looked at only Neuroticism, Extraversion and Openness.
 Half of the items are reverse scored—lower scores are more indicative of a trait.
Norms and Reliability & Stability, Factor Structure
 U.S. Census for distribution of age and racial groups as well as college students.
 Excellent internal consistency and test-retest reliability (for periods as long as 6 years later).
 Factor analysis have supported the NEO-PI-R five-factor-model structure.
Clinical Applications, Alternative Forms of the NEO-PI-R
 Axis II (Personality Problems), application to the NEO-PI-R makes sense.

 The NEO-PI-R and related FFM can be used for clinical assessment related to Axis I & II disorders.
 60 question NEO Five Factor Inventory (NEO-FFI); but has no facet scales. There is also Form R.
Limitations of the NEO-PI-R
 Lack of validity scales, has no items to assess response patterns and test taking approach.
 May not be good for clinical diagnosis because it was based of a “normal” personality
Nature of Projective Tests
 Projective techniques: First developed by Rorschach in 1921, uses inkblots as a method of

differential diagnosis for psychopathology. Characterized as a person’s modes of behavior by
observing their behavior in response to a situation that does not elicit a particular response.
 Characteristics include:
1. Examinees are forced to impose their own structure and reveal something of themselves when
responding to ambiguous stimuli
2. Stimulus material is unstructured (supposed to be ambiguous without a clear answer).
3. Method is indirect—examinees are not aware of the purpose of the test.
4. There is freedom in response—allows a range of responses
5. Response interpretation deals with more variables—allows for interpretation along multiple
dimensions.
Standardization of Projective Tests, Reliability and Validity
 If they were standardized it would allow for communication & checks against biases.
 Other’s ague that project tests can’t be standardized because each person is unique.
 Test-retest reliability may change with participants over time, but even split-half reliability is
difficult to demonstrate in projective tests.
 Validity needs to ask specific questions: Does the TAT predict aggression in situation A?

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The Rorschach Inkblot Test
Description and Administration of Rorschach
 Consists of 10 cards on which inkblot images are printed. 5 black & white and 5 colored
 “Tell me what you see, there are no right or wrong answers, tell me what it looks like to you”
 Cards are administered in order and clinician notes down patient’s responses word for word.
 Other recorded aspects: lengths of time to make response, total time spent on card, position of
the card, all spontaneous remarks (um, uh…).
 Inquiry: At the end patient is reminded of their responses to each card and asked what
prompted that response.
Scoring
 Location: Area of the card that the patient responds to (whole, blot, large detail, white space…)
 Content: What is the object that is being viewed (animal, rock, clothing, person…)
 Determinants: What aspect of the card prompted patient’s response (form of the blot, color,
texture, shading…)
o Some tests also score Popular responses and Original responses
o Exner’s Comprehensive System of scoring is the most used.
 Most clinicians do not formally score the Rorschach but simply rely on determinants.
 Exner’s Scoring System—strong for test-retest reliability and construct validity.
Reliability and Validity of Rorschach
 Many argue that reliability across time or test conditions does not exist for the Rorschach, while
others counter-argue this statement.
 Clinicians who haven’t been trained together & that use free-wheeling interpretation of the
Rorschach makes interpreting the test difficult.
 Rorschach may be valid only under certain conditions; with the average validity being .41 (this
has not been steady as another clinician found a value of .29).
Rorschach Inkblot Method
 Best viewed as a method of data collection and not a “test”, as it is subject to interpretation.
 Viewing it as a method allows clinicians to use all aspects of the data output.

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The Thematic Apperception Test (TAT)
Description
 31 TAT cards (of that 20 is recommended to be given to an examinee). Not as ambiguous as the
Rorschach but not clear cut either.
o Other versions: Roberts Apperception Test and Children’s Apperception Test]
 Reveal patient’s basic personality characteristics by their interpretation of their responses to a
series of pictures.
 Used as a method inferring psychological needs (ex: for achievement, sex, power…) and how the
patient interacts with the environment. Used to infer content of personality & mode of social
interaction.
Administration and Scoring
 6-12 cards are administered and patient’s responses and noted down word-for-word.
 “Make up a story for each of these pictures, who are these people, what are they doing…”
 Not much emphasis is placed on scoring TAT’s as the types of responses are so varied.
Reliability and Validity
 Very difficult to assess validity and reliability (as a result of personality changes—test-retest).
 Broadly looks at reliability of interpretations—when there is explicit scoring instructs interjudge
reliability can be achieved.
 Comparing TAT data with case data and patient evaluations, matching techniques with no prior
patient knowledge and general principles interpretation include ways of establishing validity.
 There are no adequate norms for TAT and typically clinicians interpret responses (no scores).
Sentence Completion Techniques
 Most used is the Rotter Incomplete Sentences Blank.

 Incomplete Sentences Blank—uses 40 sentence stems (ex: I like…., What annoys me….)
 Completions are scored along a 7-point scale for adjustment-maladjustment.
 Very versatile and has a strong scoring system that is objective and reliable (but also has
freedom of response), it can be used economically and is a good screening device.
Illusory Correlation
 Not a lot of evidence backing these “signs” associated with certain personalities.
 Poor correlation between making valid statement about patients on the basis of their
responses—illusory correlation can lead to error.
Incremental Validity and Utility
 Refers to the degree to which a procedure adds to the prediction obtainable from other sources.
 Assessment must inform the clinicians of something that the base rate/prevalence rate can’t.

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Use and Abuse of Testing: Protections, The Question of Privacy
 Clinicians should use only assessments that lie within their competence (only then can they
acquire tests).
 The examinee or individual has a right to full explanation of how their responses & results will
be used. Informed consent must thus be obtained.
 Must only be given tests relevant to the evaluation and reason for test must be provided.
Use and Abuse of Testing: The Question of Confidentiality & The Question of Discrimination
 There are cases in which confidential matters must be disclosed (i.e. Tarasoff case). If the person
is going to harm themselves or others, then information can’t be privileged.
 Tests might discriminate against minorities (only include White-middle class populations) or
include only certain population members (ex: TAT only white members in cards)
Use and Abuse of Testing: Test Bias
 This is a validity issue (i.e. criterion or performance varies significantly across groups). That it is
more accurate for one group than another.
o Using traits characteristic for one group (ex: men) but not the other group (ex: women).
 Differences in mean scores does not mean bias, and bias can be overcome.
The Use and Abuse of Testing: Computer-Based Assessment
 Used to standardize tests, interpret responses, cut costs, increase clients attention.
 Internet based psychological testing may lack qualities of traditional testing—less reliable, valid,
lack of control over testing situation, technological issues, cultural differences in test
interpretation.
 Computer Based Test Interpretation (CBTI’s): Generate quick responses and processing complex
scores, but they must result in inaccurate interpretations of results.
 CBTI’s must be clinically useful (should aid in clinical understanding and treatment), valid
(accurate interpretations) and reliable (interpretations should be similar for similar scores).

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Chapter 9: Behavioral Assessment pages 255-282

The Behavioral Tradition
Sample vs. Sign
 Behavioral Assessment: Assessment that focuses on the interaction between situations

and behaviors for the purposes of creating behavioral change.
 Focus on how well assessment device samples the behaviors and situations
 Sample orientation: Parallels how a person behaves in a situation; as in a test.
 Sign orientation: Inference about performance is indicative of some other characteristic.
 Traditional research has used a sign as opposed to sample orientation. But behavioral
research sample approach is used.
Functional Analysis
 Exact analysis is made of the stimuli that precede a behavior and the consequences that
occur from it.
 Behaviors are learnt and maintained as a result of consequences that follow them.
Identify stimulus that occurs beforehand and determine reinforcements that follow, to
elicit change.
 Behaviors that are monitored must be recorded in observable, measurable terms.
 Antecedent Conditions: Stimulus conditions that lead up to the behavior of interest.
 Consequent Events: Outcomes or events that follow the behavior of interest
o E.g. lack of attention (stimulus) taking pencil from another child (behavior)
attention (consequence).
 Organismic Variables: Physical, physiological or cognitive factors of the individual that
are important to determine the client’s problem.
 SORC Model—Used to conceptualize a client’s problem
o S—Stimulus or antecedent conditions that bring on a problem
o O—organic variables related to the problem
o R—response or problematic behavior
o C—consequences of the problematic behavior
Behavioral Assessment as an Ongoing Process
 Behavioral assessment is an ongoing process that occurs before, during and after
treatment.
 Diagnostic formulations—potential targets for intervention
 Patients context or environment—social support, physical environment, evaluation of
skills.
 Initial understand of client’s behaviors, resources will lead to a treatment plan.

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 Treatment includes collaboration between therapist and client and feedback will lead to
adjustment of treatment.
Behavioral Interviews
Behavioral interview allows therapist to assess the client’s “hope” for end results.
 Ultimate Outcomes: Happiness, life satisfaction, making the world better.

 Behavioral Interviews: Clinician attempts to make sense of the problem and of the
variables that seem to maintain the problem.
 Basic goal is to identify the problem behaviors, situational factors that maintain those
behaviors and consequences that result from the problem.
Naturalistic Observation
 Observing individuals in their natural environment, will enable a clinician to better

understand the problem.
 Observation in a natural environment has limitations and is easier for children than adults
who may be outpatients.
 Clinicians need to ensure that clients are not observed without their knowledge or that
family members are not drawn into the observation net—do not compromise privacy.
 Due to the cumbersome nature of it, clinicians prefer to use traditional assessment.
 Examples:
o Home Observation (Family mealtime routines)
o School Observation (school classroom, playground). Rate frequency, duration and
intensity.
o Hospital Observation (mental retardation; open environments)
 Unfiltered observation not contaminated by extraneous variables.
Controlled Observation or Analogue Behavioral Observation
 Clinicians can exert certain amount of control over the events being observed, may be
better in situations where behavior does not occur very often on its own.
 The environment is “designed” for the clinician to observe the behavior occurring.
 Situational Tests: Place individuals in situations similar to real life and observe how
people behave.
Controlled Performance Techniques
 Assessment procedure in which the clinician palces individuals in a controlled

performance situation and collects data on their reaction, performance and behavior.
 Approaches include:
o Behavioral Avoidance Tasks (Total number of steps/tasks completed)
o Fear Arousal Accompanying Responses (Total fear or distress ratings)

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 Behavior in this type of situation may not reflect real-life behavior.

 Psychophysiological measures: To assess CNS, autonomic nervous system, skeletal
motor activity.
o Complement other traditional assessments, can assess a process (e.g. emotional
response). E.g.—Event Related Potentials (ERP’s), Electroencephalographic
activity (EEG).
Self-Monitoring
 Individuals observe and record their own behaviors, thoughts and emotions.
 Keep diaries, logs for some period of time—usually in terms of how often the behavior
occurs (frequency, duration and intensity).
 May lead to distortion or wrongful recordings, resistance.
 Most effective in relation to other larger forms of therapy.
 Other monitoring devices include personal digital assistants (PDA’s), palmtop computers,
phones
Variables Affecting Reliability of Observation

Complexity of Target Behavior
 More complex behaviors, greater unreliability of observation so focus is usually on less-

complex behaviors.
Training Observers
 Training observer by bringing them into an inpatient facility and training them to look for
specific signs of a disorder is most helpful. The goal should not be to please the
supervisor or agree.
 Observer Drift: Observers that work closely with each other began to subtly drift away
from other observers in their ratings. To prevent this regularly scheduled reliability
checks by an independent rater should be performed.
Variables Affecting Validity of Observations
 Content Validity—Behavioral observation schema should include behaviors that are

important/pertaining to the research or clinical purpose being measured.
 Concurrent Validity—Whether one’s obtained results of rating correspond to that found
by other people (teachers, spouse, friends).
 Construct Validity—Degree to which a test measures what it claims to measure.
 Mechanics of Rating:
o Unit of Analysis: Length of time observations will be made along with the type
and number of responses made.

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o Scoring procedures must also be developed (ex: checklist, timers, laptop

computers).
 Observer Error: Observers need to be monitored and double checked to ensure that their
work is not subject to bias, flattering or misidentification/attribution.
 Reactivity: Patients or participants react to the fact that they are being observed and may
change the way they behave. Can impact the validity of a study; and prevents the data
from being generalizable.
 Ecological Validity: In the context of behavior assessment, the extent to which behavior
analyzed or observed are representative of a person’s typical behavior. Is the sample large
enough for the behavior to be truly representative?
Contemporary Trends in Data Acquisition
 The use of laptops and handheld devices can be used to code observational data.
 Devices like audio-recordings, diaries and logs can assist patients in self-monitoring by
providing them questions at specific time-points.
 Ecological Momentary Assessment (EMA): Devices for data collection in an individual’s
natural environment. E.g. electronic diaries.
 EMA’s have the potential to be ecological and moods of patients can be studied in their
“natural habitat”.
 Completing data entries using paper diaries—subjects neglect, threat to validity,
forgetting, self-presentation bias.
Role Playing or Behavioral Rehearsal Methods
 Can be used as a means of training new response patterns to get people to respond in a
way they would typically respond in a given situation.
 They have been used as therapeutic devices for many years in which the participant or
patient responds out loud to a scenario.
Inventories and Checklists
 Behavioral checklists like the Fear Questionnaire and the Fear Survey Schedule is used to
assess a patients fear about specific situations.
 Inventories asses a range of the patient’s behaviors—physical activity, binge eating,
alcohol use and other behaviors.
 Behavioral assessors focused on specific deficits and behavioral assets and not
psychiatric diagnostic criteria.

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Cognitive-Behavioral Assessment
 Cognitions relate to the development of pathological situation, its maintenance and

changes.
 Notion that client’s thoughts play a vital role in behavior.
 Cognitive Functional Approach: Functional analysis of the client’s thinking process must
be made to plan an intervention strategy. What underlying cognitions are aiding with lack
of performance, and under what circumstances?
 E.g.-think out loud, verbalize thoughts.
Strengths and Weaknesses of Behavioral Assessments
 Behavioral assessors specify the behaviors targeted for intervention, treatments are
provided before, after and during treatment and on this basis are modified as such.
 Behavioral assessment like natural observation is time intensive and expensive.
 Behavioral assessors now widely use DSM criteria to diagnose disorders.

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Chapter 11—Psychological Interventions (Pg. 311-340)
Intervention Defined
 Psychological Intervention: A method of inducing change in a person’s behavior, thoughts or

feelings. Intervention in the context of a professional relationship (client-patient).
 In referring to treatment the terms intervention and psychotherapy have been used
interchangeably.
 Woolberg (1967): symptoms and treatment, promoting positive growth (type of medical def.)
 Rotter (1971) and Frank (1982) pose different definitions using terms like—interaction between
a healer and sufferer, reliving of distress & disability, personal growth.
Does Psychotherapy Help?
 Need to address both the efficacy of a treatment and the effectiveness of a treatment.
 Efficacy Studies: Average person receiving treatment is demonstrated to be less dysfunctional
than the person not receiving treatment.
o Take place in a research lab/university clinic (focus on internal validity)
 Effectiveness Studies: Focus on external validity and the representativeness of the treatment in
the “real-world”. May not include control groups or random assignment; focus is on whether a
client receiving treatment as it is typically administered reports significant relief/benefits.
Evidence Based Treatment and Evidence Based Practice
 Focus on whether clinical evidence-based treatments (psychotherapy vs. no treatment) are

more effective than other therapies.
 Evidence-Based Treatment (EBT): Refers to treatments/interventions that have produced
significant changes in clients/patients in controlled trials.
o Treatment vs. control group (comes solely from controlled clinical trials)
 Evidence-Based Practice (EBP): Broader practice that includes treatment informed by various
sources.
 Society of Clinical Psychology (sub-division of the APA) developed specific criteria to evaluation
different approaches to therapy/intervention treatments.
 Referred to as “evidence-based treatments” these criteria addresses whether certain therapy
mechanisms may be useful in reducing mental health symptoms.

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Features Common to Many Therapies
 Supportive factors—positive relationship, trust lay the groundwork for change in person’s beliefs
& attitudes (learning factors)  lead to behavioral change (action factors—mastery, risk taking.
Relationship/Therapeutic Alliance & The Expert Role
- Client-therapist relationship is important for successful psychotherapy (accepting, non-

judgmental, insightful and professional)
- Therapists are also expected to be competent as a result of training, knowledge and experience.
Building Competency/Mastery
- Help the client be a more competent human, greater satisfaction. Therapist may work with
client to help them learn new things or alter their faulty ways of thinking.
- It can be a learning experience; develop feelings of self-efficacy in the individual.
- Mastery—confident, expect to do well and feel good about themselves; will function better.
Non-Specific Factors
- Faith, Hope or expectations for increased competence; individuals come to therapy believing
that it will help promote mental health.
- The expectations of the client are vital to the therapy process.
Nature of Specific Therapeutic Variables
The Patient or Client
The Degree of the Patient’s Distress
 Therapists generalization is that people that need therapy the least are ones that will benefit
most from it.
 Research data on this has been inconsistent—greater individual distress greater
improvement, vice-versa and curvilinear (of finding poorer outcomes).
Intelligence
 Communicating with a patient about past experiences, insight & introspection requires some
level of intelligence.
 Behavioral therapy has been successfully used with individuals with different intelligence levels.
Age
 Young adults are viewed as being better for therapy than older adults (more flexible)
 Considering the specific characteristics of the patient and not age alone is important.
Motivation
 In Psychotherapy most of the work occurs outside therapy though homework and between
therapy sessions. Need to engage in anxiety provoking “new behaviors” (i.e. Albert Ellis)
 Psychotherapy is a voluntary process & can’t be forced on a patient
 Varied findings on how to best assess client motivation.

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Openness and Gender
 Patients that willing to be open to psychotherapy and not wanting immediate medical
treatment are easier to work with. More open patient better long-term outcomes.
 Biological sex is not directly linked to treatment outcomes; but therapist gender may be
important to consider in psychotherapy (e.g. rape victims and male vs. female therapist).
Race, Ethnicity & Social Class
 Many therapeutic techniques have been designed for white middle and upper class patients,
and not for minorities.
 Very little research indicating that social class, values, background, and ethnic minorities receive
poorer outcomes.
 But when social class and values of the patient and the therapist differ extensively; there needs
to be some level of cultural sensitivity.
The Therapist
Age, Sex & Ethnicity and Personality
 Therapist’s age is not related to outcome; different genders do not produce better outcomes
that patient-therapist similarity for ethnicity does not play that huge of a role.
 Therapist personality does effect treatment outcomes, but the research in the area is lacking.
o Mature, sensitive, tolerant, free of bias, intelligent, creative, personally secure…
Empathy, Warmth and Genuineness
 Commitment & interest in the patient. The focus on empathy, warmth and genuineness grew
out of Carl Rogers Client-Centered Therapy.
o Necessary & sufficient variables for therapeutic change.
o Only modest relation between these 3 variables and outcomes.
 These three features can be viewed as indicators of the quality of therapeutic alliance.
Emotional Well-Being
 Therapists need to be aware of their emotional state; so self-awareness is an important aspect.

 Therapy is not a place for gratifying the therapist’s emotional needs.
Experience and Professional Identification
 No consistent relationship between therapist experience and outcome; paraprofessional

therapy outcome sometimes exceed even those conducted by trained psychotherapists.
 Psychiatrists often sought to prevent psychologists from conducting therapy without psychiatric
supervision because they were concerned about the medical aspect of treating patients.

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Course of Clinical Intervention: Typical Sequence
Initial Contact
 Often unknowing what to expect, may be anxious or suspicious.

 To patients or parents that contact the clinic, they are first informed of what the clinic is about &
what type of help will be provided.
 After the other steps in the sequence will be covered—professional staff, qualifications, fees…
Assessment
 Variety of assessments are made but there is often an intake interview (to gain case history)
 Consultations with other specialties are also done—neurological workup, medical exam.
 Information is compiled to arrive at a label; will assist with identifying therapy approaches
(assessment is an ongoing process).
The Goals of Treatment
 Negotiation of goals of treatment or therapist & client discuss how patient’s problem will be
alleviated.
 In treating a child, they may not know what therapy is or why they are being asked to go to
therapy. Parents legally have a right to know all information therapist communicates to the
child (this makes confidentiality hard).
Implementing Treatment
 Following goal establishment specific therapy forms/treatment is identified (ex: client-centered,

cognitive, behavioral)
 Treatment needs to be described to client in detail (in terms of length and what is expected of
them).
Termination, Evaluation and Follow-Up
 Once therapist begins to gauge that client is able to handle their problems themselves,
termination discussion begins.
 Client’s feelings and attitudes towards termination should be assessed.
 Sometimes termination is abrupt or forced (in which case referral is done).
Stages of Change
 Refers to a series of stages that represents a client’s readiness of change in psychotherapy.

1. Pre-Contemplation: Client has no intention of changing his/her behavior in the near future.
Come in as a result of outside pressures.
2. Contemplation: Client is aware that a problem exists but has not begun steps to make changes.
3. Preparation: Client intends to make a change in the near future.
4. Action: Clients are changing maladaptive behavior, emotions or environment
5. Maintenance: Client is focused on preventing relapses and continuing the action stage.
6. Termination: Client has made necessary changes (sort of like a habit), no concern for relapse.

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 Therapists need to recognize that not all individuals are ready to make change; the action stage
is where administered treatment is most likely to have an effect.
 As certain processes match certain stages, therapists should only use interventions specific to
that stage.
Issues in Psychotherapy Research
 Hans Eysenck attacked the efficacy of psychotherapy, but many have criticized his work for its
validity as he did not match participants in the treatment vs. control groups.
 Studies that seek to understand the efficacy of psychotherapy use an experimental design with a
control group and a treatment/experimental group.
 Waiting List Control Group: Treatment is delayed until after study is completed
 Attention Only Control Group: Patient meets regularly with a therapist, but there is no treatment
o Matched on age, race, gender, severity of symptoms (factors that could influence
outcome)
 Patient Functioning: Symptoms of psychopathology
Research Considerations
1. What is the sample? —ex: voluntary or coerced patients, were the therapist’s behaviors or
psychoanalysts
2. What relevant variables were controlled? Ex: --control vs. treatment group variables.
3. What were the outcome measures? —were outcomes measured identically for all patients or
were they tailored? Was a single measure used or were there multiple measures?
4. What was the overall nature of the study? (experiments, case studies, correlational studies…)
Comparative Studies
Studies comparing efficacy techniques and not only looking at outcomes.
The Temple University Study
 The study comparing 90 outpatients with neurotic symptoms concluded that patients that
received Behavior Therapy (BT) did the best in the long-term
 Those who obtained Psychoanalytic therapy (PT) improved equally as well as the BT Group; but
those in the BT Group showed slightly more improvement; flexibility & versatility of Behavioral
therapy.
Meta-Analysis
 A method of research that complies all studies relevant to a topic or question and combines the
results statistically.
 Effect size: The size of the treatment effect

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Process Research
 Refers to research that investigates the specific events that occur in the course of the
interaction between therapist & patient. (Rogerians)
 Some therapy processes have been shown to relate to treatment outcome.
 Therapy investigators either looked at process research or outcome research.
 Process therapy researchers felt that the process that was used during therapy related to the
outcome that occurred (film/tape therapy sessions).
 Factors that influence relationship between therapeutic process and outcome
o Client-therapist communication
o Therapist competence and adhere to treatment protocol
o Therapist use of guidance and advice not related to outcome
Recent Trends
Focus of Psychotherapy Research
 Specific factors (motivation, SES) that are related to higher efficacy and effectiveness
 What aspects of specific therapy mechanisms (e.g. CBT therapy) are most important for the
therapy outcome.
 Focus on types of therapies that work for each specific diagnosis.
Practice Guidelines
 Clinical psychologists are being held accountable for the services they provide by insurance
companies.
 Several professional organizations have developed practice guidelines that recommend specific
forms of treatment/intervention for specific psychological problems.
Manualized Treatment
 Treatment manuals were originally developed to ensure standardized treatment across patients.
 Manualized treatment has been criticized for undermining clinical judgement, treatment not
being tailored to patients with comorbid conditions.
 Manualized treatment is more focused and, easier to teach and supervise and more focused
from the patient’s perspective and are far more appealing to managed care companies.

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Chapter 12—Psychotherapy: The Psychodynamic Perspective (Pg. 343-366)
Psychoanalysis: The Beginnings

 Focus is on unconscious motives and conflicts in the search for roots of behavior.
 Freud was influenced by Jean Charcot (famous work on hysterics), and his use of hypnosis.
The Case of Anna O.
 Josef Bruer’s work with Anna O’s, patient with severe hysteria led Freud to develop his
initial theories on catharsis, transference and moral anxiety.
 Freud over time asked patients to simply talk about whatever came to their minds; this
method led to the development of a concept known as free association.
The Freudian View: A Brief Review
 Psychic Determinism: Everything we do has meaning and purpose and is goal-directed.
 To account for different aspects of behavior Freud also assumed the existence of unconscious
motivation.
o A person understands motivation for healthy behavior; the causes of disturbed
behavior are unconscious; so to treat these they need to be made conscious.
The Instincts
 Life energy is provided by the life instincts/Eros and the death instinct/Thanatos.
 Life instincts: All positive aspects of behavior—thirst, sex, hunger, creative aspects (ex:
music)
 Death instincts: Self-destructive behavior; Freud believed all behavior was instinctual.
Personality Structures—The Id, Ego and Superego (Iceberg)
 Id: Deep inaccessible part of the personality. Instinctual gratification urges that need to be
immediately met (access is gained via dreams & neurotic behavior; has no value, logic or
ethics).
o Pleasure Principle: One seeks to obtain pleasure and avoid pain. Discharge tension.
Uses the primary process (ex: dreaming)
 Ego: Organized, rational system that uses perception, learning and memory to gain
satisfaction.
o Reality Principle: Attempts to delay gratification of the Id until a suitable mode &
object are identified. Uses secondary process (ex: learning, memory, planning).
o The Ego balances the demands of the Id and the Superego (provide
satisfaction/prevent from being killed).
 Superego: Develops during childhood from the Ego. Ideas and values of society as conveyed
by parents as well as rewards and punishments. Its goal is to block extreme impulses of the Id
o Oedipus Complex—Child’s sexual attraction to the parent of the opposite sex.
o Ego Ideal—Reward (pride + worth)/Conscience—Punishment (guilt +worthlessness)

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The Psychosexual Stages

 Oral Stage—the mouth is the means of satisfaction (ex: breastfeeding). Lasts for about 1 yr.
 Anal Stage—Attention to defecation and urination (6 months-3 years)
 Phallic Stage—Sexual organs are the sources of satisfaction (3-7 years)
 Latency Stage—Lack of sexual activity; negative attitude towards anything sexual (5-12
years)
 Genital Stage—Mature expression of sexuality
 Disruptions to any stage maladjustment
Anxiety
 Circumstances that give rise to the Ego and the Superego. There are 3 types
 Reality Anxiety: Real danger from the outside world.
 Neurotic Anxiety: Fear that Id’s impulses with remain unchecked trouble from external
environment.
 Moral Anxiety: Fear that one will not conform to the standards of the conscience.
 Warning sign to the Ego that certain steps must be taken to reduce danger for protection.
The Ego Defenses or Defense Mechanisms
 Regarded as pathological because they divert energy from the more constructive activities
whilst also distorting reality.
 Ego defense mechanism is repression—banishment from consciousness of threatening
sexual/aggressive material.
 Fixation: Frustration and aggression at the next psychosexual stage is so great that an
individual remains at their current psychosexual level of development.
 Regression: Return to a previous psychosexual stage
 Reaction Formation: An unconscious principle is consciously expressed by its behavioral
opposite. (Ex: “I hate you” is expressed as “I love you”).
 Projection: One’s unconscious feelings is attributed to another and not oneself (Ex: “I hate
you” is changed to “You hate me”).
From Theory to Practice
 Free Association: Patient is supposed to say everything that comes to mind, regardless of
what it is.
 Transference: Patient reacts to therapist as if they represent an important figure in the
patient’s past/life (ex: transference of feelings onto therapist).
 Catharsis: Release of energy that could have benefits (ex: related to trauma experienced).
 Resistance: Reluctance to discuss, remember or think about events that are
troubling/threatening.
 Repression: Banishment of a thought/impulse to the unconscious (area of the mind
inaccessible to conscious thought).

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The Role of Insight

 Insight refers to total understanding of the unconscious determinants of irrational feelings,
thoughts, behaviors that are producing personal misery.
 Analysis leading to insight is slow and very time consuming (years).
 Working Thought Process: True insight brought into patient’s consciousness. Careful and
repeated examination of how one’s conflicts and defenses have operated in different areas of
life.
Techniques of Psychodynamic Psychotherapy
 Neurosis symptoms are signs of conflict between the Id, Ego and Superego & demands of
reality.
 Psychoanalysis aims to dissolve defenses and confront the unconscious.
Free Association
 Patient must say anything and everything that comes to mind. Requires that the patient stop
screening their thoughts.
 Helps discover the basis of the patient’s problem
 The patient lies on a couch and the psychoanalyst sits on a chair (not in line of vision)
 Psychoanalyst assumes that associations are linked and one will lead to another bringing the
patient closer to unconscious thoughts and urges.
Analysis of Dreams
 Reveal the nature of the unconscious because they are steeped in unconscious wishes
(symbolic).
 Dream material provides gratification to the Id but is not threatening as to terrorize the Ego.
 Manifest Content: What actually occurs during a dream.
 Latent Content: The symbolic meaning behind a dream. Patient asked to free-associate.
 Patients often distort the manifest content of a dream as they retell it.
Psychopathology of Everyday Life
 In Freud’s view everything is determined and there are no accidents (ex: a missed
appointment is not a simple mistake)
o Represent conscious expression of an unconscious wish.
Resistance
 Reluctance to open up to the therapist and discuss problems; doesn’t want to give up a certain
behavior even though it may cause distress.
 Prevents insight or prevents material from the unconscious into being brought to
consciousness.
 Patients may engage in long periods of silence, discuss irrelevant topics, or omit certain
information, constantly miss meetings.
 Patient’s resistance can lead to a flight into health—leads to patient getting better.
 In one form or another resistance is always present in therapy

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Transference
 When a patient reacts to a therapist as if they were some important figure that is part of the
patient’s childhood.
 The conflicts that were present during childhood are voiced in therapy and transference
provides the therapist with important clues.
o Encourage transference—sitting on the couch, away from therapist, no advice given.
 Transference can be both positive and negative—ex: direct admiration, love, anger,
comments about the therapy room, attack on the therapist.
 Both positive and negative transference are forms of resistance.
Interpretation
 The method by which the therapist reveals patient’s unconscious thoughts or feelings.
 Allows patients to view their thoughts, feelings. This is a slow repetitive process.
 Interpretations are limited to important life areas that relate directly to patient’s problem.
 It should be offered when it arouses enough anxiety in the patient for serious consideration
but not when too much anxiety is present or else the patient may reject it.
 Small doses of interpretation over time are best.
Psychoanalytic Alternatives
 Psychoanalytic theory was also influenced by Alfred Adler, Carl Jung & other neo-Freudians.
 The neurotic symptoms were now seen as being rooted not only in sexual or aggressive urges
but it was now being associated with the fear of being alone/adult insecurity.
 How interpretation occurred and by whom was different (family, spouse, friends…)
Ego Analysis
 Origination from traditional psychoanalysis, this theory held that there was an overemphasis
on unconscious and instinctual determinants that occurred at the expense of the ego process.
 Conflict-free functions of the ego—memory, learning, perception; apart from mediating
demands between the Id & the real world.
 Focus on contemporary problems in living than examination of the past.
Contemporary Psychodynamic Psychotherapy

 Those who no longer practice the Freudian techniques are said to practice
“psychoanalytically oriented” therapy or psychodynamic psychotherapy.
 May involve only one or two vs. five sessions in one week, short-term treatment or can be
open-ended.
 Greater flexibility has been introduced.

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Interpersonal Psychotherapy: An Empirically Supported Treatment (Form of Psychodynamic)

 Interpersonal Psychotherapy (IPT): Brief, insight oriented approach mainly used for
depressive disorders.
 Involves through assessment of depressive symptoms, targeted intervention and reducing
symptoms by improving relations with others.
Does Psychodynamic Psychotherapy Work?
 Support for psychodynamic psychotherapy work with children and adolescents is not
promising. The findings for adults are slightly more supportive.
 For those studies showing support criticisms include: poor quality meta-analysis studies, poor
methods and the failure to specify the effects of psychodynamic therapy for a disorder.
 There is slight support for psychodynamic therapy for major depressive disorder, panic
disorder, bipolar disorder and substance abuse & dependence.
Interpretation and Insight
 Psychotherapeutic treatment and psychoanalysis use of insight into solving problems is its
greatest asset but can also cause problems (ex: too much examination of the past).
 Learning specifics behind their problems may help in the short-term but a failure to
emphasize alternative ways of behaving may be a shortcoming of psychoanalysis.
 Psychoanalysis assumes that insight behavioral change; but others have argued that it is
behavioral change insight.
Curative Factors
 Positive outcomes in psychodynamic psychotherapy depend of client-therapist alliance in
terms of quality & strength.
 Therapeutic alliance: Refers to patient’s affective bond to the therapist.
o Allows for self-examination by the patient and allows for interpretation.
The Lack of Emphasis on Behavior

 Psychoanalysis engages in interpretation but fails to deal with behavior.
 A therapist that engages in interpretation but also guides the patient in learning situations will
be more effective than one who relies solely on insight.
 This may be linked to rise of behavioral therapist; psychoanalysis does not focus on behavior.
The Economics of Psychotherapy
 The fact that psychoanalysis (reconstruction of the personality) takes anywhere from 3-5
years means that it is expensive, and so only those in need for psychotherapy are likely to go
in for it (not poor, uneducated minorities).
 Psychoanalysis is viewed as being limited as it can only help some, but it has proved to be
helpful for those who can afford it.
 Brief psychodynamic psychotherapy treatments with manuals have shown to be more
effective than those without manuals.

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Chapter 13—Psychotherapy: Phenomenological & Humanistic-Existential Perspectives (Pg. 370-388)
Client-Centered Therapy (CARL ROGERS)
Origins
 1930’s—Psychoanalysis was dominant in both theory and practice; focus was being kept on
theories that had a close association with treatment.
 Carl Rogers resided in New York and was heavily exposed to psychoanalytic thinking.
 Influenced by the ideologies of Otto Rank and Jessie Taft.
 Rogers adopted therapeutic notions of permissiveness, acceptance, and the refusal to give
advice.
The Phenomenological World
 Teaches that behavior is totally determined by the phenomenal field of the person.
 Phenomenal Field: Everything that is experienced by a person at any given point in time.
 To understand a patient, one must know what the world is like for them.
 Phenomenal Self: The part of the phenomenal field that the person experiences as the “I”.
o Adjustment issues occur when the phenomenal self is threatened.
Theoretical Propositions of Client-Centered Therapy
 Individuals exist in a world of experience of which they are the center.

 The person is the best source of information about the self (as they are most aware of their own
world).
 Relied largely on non-judgmental atmosphere, verbal self-reports rather than inferences or
observations; focus on the inner world as reported by the person.
 Self-Actualization: Human tendency to maintain and enhance experience of the self. Behavior is
a goal-directed for an organism to satisfy its needs.
 Self: A crucial concept, that refers to the awareness of one’s being and functioning.
o Based on interaction with environment and the evaluation of others.
 The self-structure is revised to assimilate experiences that are inconsistent with the self.
 Growth Potential: A capacity for competence that all individuals have. Goal of client-centered
therapy is to release this capacity self-actualization tendencies.
Core Features of Client-Centered Therapy
Three core therapist characteristics: accurate and empathetic understanding, unconditional positive
regard and genuineness or congruence.
Empathy
 Patient needs to feel that they are understood so the therapist has to convey a sensitivity to the
needs, feelings and circumstances of the patient.
 Empathy does require some level of detachment in the part of the therapist.

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 Deep understanding and acceptance of the attitudes consciously held by the patient at a given
moment.
Unconditional Positive Regard (UPR) + Congruence or Genuineness
 Refers to respect for the client as a human being; not based on any conditions.
 Therapist must put aside all preconceived notions about the patient & be caring and accepting.
 According to Rogers every client is worthy of unconditional positive regard no matter what.
 Congruence: Refers to the honest expression by the therapist of their behaviors, attitudes &
feelings that have been stimulated by the client. Seems almost opposite of empathy/UPR.
Attitude Versus Technique
 Client-centered therapy is a state of mind rather than a state of technique.

 Therapist relinquishes any produces that points to them as being the individual that will
diagnose the client’s ill’s & recommend medication for alleviation.
 Rogers saw clients as wanting to reach for health and self-fulfillment.
 Rogers did not focus on past experience but no the PRESENT.
 Rogerians focus is that the client’s inner experiences that are the most informative.
 Behavior therapists focus on manipulating the environment to elicit change but Rogers focused
on change that come from within the client.
 Client centered therapy does not—give information or advice, reassurance, ask questions, make
criticisms or give interpretations.
The Therapeutic Process in Client-Centered Therapy
 Structuring: Therapist explains the roles of the patient and the role of the therapist to client.
 Reassurance is conveyed by tone of voice, choice of words, facial expressions, general demeanor
 Providing information and interpretation are avoided; implies that therapist knows what is best
for the client.
 Acceptance allows the client to reach their potential self-actualization and growth level
 The therapist provides warmth and understanding through accepting client’s feelings.
 There are seven stages that generally occur during client-centered therapy, and at each stage
the client becomes a little more open with the therapist.
Diagnosis
 Diagnosis/Assessment is de-emphasized in client-centered therapy.

 Rogerians believe that assessment places the therapist in a “superior role” that can impede the
self-actualization development.
 The focus of client-centered therapy is the patient’s current feeling, not interpretation of
whether they are right or wrong.
 Other applications: Developed in the counseling psychotherapy context which is its primary
application but is also used for human relations training, nurses, counseling, Peace Corps…

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Concluding Remarks on Client-Centered Therapy: The Positive
 It is one of the main alternative forms to psychoanalytic therapy; focused on inner feelings
rather than the biological urges/instincts of the Freudian view.
 Emphasis on the client-therapist relationship & technique application was placed at the back.
 Move away from long therapy sessions focused on the past/cathartic experiences and less role
of the therapist required less training
 Rogers was the first therapist to carry out research on therapeutic sessions.
o Recorded therapy sessions
o Also developed indices for interpretations out outcome
 Research suggests that client-centered therapy is more effective than those patients not
receiving any therapy; but is no more effective than any other form of psychological treatment.
Concluding Remarks on Client-Centered Therapy: The Negative
 Client-centered therapists often argue that their client’s do not change but their inner potential
for growth is released.
 All clients are treated in only one manner—with empathy, acceptance and unconditional
positive regard. So the therapist does not need to specify their method to the client (this is really
a technique!).
 The notion that client knows best and not using interpretation, advice of the therapist limits this
type of therapy. Client may provide incomplete or distorted information.
 Description of client-centered therapy involve undefined terminology—being, becoming,
actualizing, congruency—difficulty communicating.
 Client-centered therapy grew on college campuses and the clients were college students; the
therapists then went on to become staff at other college counseling centers.
o Brighter, more educated, less maladaptive issues with college students.
The Humanistic-Essential Movement
Humanism
 From a humanistic perspective people are not the products of the past, unconscious or the
environment.
 Humanism: People exert free choice in the pursuit of their inner potential or self-actualization.
 People are unified, whole & unique beings; focus is on freedom, positive striving, self-
actualization and naturalness.

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Existential Therapy
 Rejects Freud’s views and instead views people as searching for meaning.
 There is a focus on restoring meaning of life and increased spiritual awakening.
 Basic human nature characteristic: search for meaning (imagination, symbolization &
judgement). This search occurs within a social context/interaction with people.
 Decision making and personality (i.e. what one is & what one might become) is also a part of it.
The Goals and Techniques of Existential Therapy
 To help the individual reach a point at which awareness and decision making can be exercised
responsibly.
 Does not emphasize techniques; emphasis is on understanding and experiencing the client as a
unique essence.
 Therapist may ask clients questions that force them to examine the failings in their life or to
search for meaning in life.
A Form of Existential Therapy: Logotherapy
 Developed by Viktor Frankl; technique encourages clients to find meaning in what appears to be
callous, uncaring and meaningless world.
 He developed this therapy of meaning based on his experiences in a Nazi concentration camp.
 When agonizing over the meaning of life; Frankl believes that Logotherapy should be the
therapy of choice. Client’s own responsibility & obligation to the future.
 Paradoxical Intention: Client is told to perform the behavior or response that is the object of
anxiety/concern.
 De-Reflection: Therapist instructs the client to ignore a troublesome behavior or symptom.
Gestalt Therapy
Emphasis is on present experience and immediate awareness of emotions and actions.
Movement of Heterogeneity
 Frederick (Fritz) Pearls whose education was grounded in psychoanalysis is regarded as the
founder of Gestalt Therapy.
 Gestalt therapists do not agree and at times; the goal of therapy is to express an individual’s
own sense of uniqueness and their interpretation of life.
Basic Notions of Gestalt Therapy
 Conceptualizes the person as an absolute whole, not disjointed.

 NO! —Individual developing an awareness of themselves. The focus is on the NOW.
 Therapist facilitates client’s awareness and how inner potential is being deflected from
expression (in-the-moment basis).

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 Focus on current awareness not recovery of memories or repressed impulses.
The Now and Nonverbal Behavior
 Reality is now, behavior is now, and experience is now. It all occurs in the now; seeking answers
in the past is dealing with that which no longer exists.
 Anxiety is the gap between the now and the later.
 Therapist does not interpret patient’s feelings but asks them to focus on their present
emotions.
 The therapist pays close attention to non-verbal behavior (ex: using the patient’s stiffness)
Dreams
 Psychoanalyst asks the patient to associate various elements of the dream while the Gestalt
therapist asks the patient to relive the dream in the now.
 Patient confronts the dream directly (deal with conflicting parts of the self).
Topdog-Underdog and Defenses
 Patient asked to take part in a conversation when opposing parts of the self are in conflict.
 (Topdog—superego “should’s” of the personality) and (Underdog—id “primitive, evasive,
disrupts efforts of the Topdog”). Goal is to integrate both parts of the self.
 Gestalt therapy aims to expose the defenses and games behind which client’s hide.
Responsibility and Rules
 Gestalt therapy focuses on getting the client to accept responsibility for their own actions and
feelings. Can’t blame feelings on something else or someone else.
 Pillars of Gestalt therapy—Awareness, experience, now & responsibility
 Rules
o Communication in the present tense (no past or future focus)
o Communication is between equals (one talks with, not at)
o Use of “I” language not “it” language—client takes responsibility
o Client’s focus is on immediate experience “feelings of this moment”
o No gossip talk or talking about someone else
o Questions are discouraged

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Moral Precepts or Rules to Live by for Gestalt Therapy
1. Live Now (be concerned with the present not past or future)
2. Live here (concerned with what is present not absent)
3. Stop imagining (experience only that what is real)
4. Stop unnecessary thinking (experiencing only the senses)
5. Express directly (do not explain, judge or manipulate)
6. Be aware of pleasant and unpleasant
7. Reject all “shoulds” and “oughts” that are not your own
8. Take full responsibility for your actions, thoughts and feelings.
9. Surrender to being yourself.
Concluding Remarks
 Gestalt therapists vehemently opposed to the idea of research.

 Clients were mostly young, well educated people whose problems were mainly alienation and
estrangement.
Emotion Focused Therapy
 Also termed process-experiential therapy (PET); this integrates client-centered and Gestalt
therapy.
 Emotions are adaptive and give out life experience its value, meaning and direction.
 Dysfunction is the result of an impairment in being able to integrate experiences into a coherent
self.

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Chapter 18—Neuropsychology
Perspectives and History—Definitions
 Neuropsychology: The study of the relationship between brain function and behavior (how do
complex brain properties allow behavior to occur?).
 Neuropsychological Assessment: Non-invasive method of describing brain function based on a
patient’s performance on standardized tests.
o Cerebral brain lesions, localization, limitations on educational, social or vocational
adjustment.
o Can aid with assisting the manner in which an illness or injury progresses.
Perspectives and History—Roles of Neuropsychologists
 Neuropsychologists are called by neurologists to help establish/rule out a specific diagnosis.

o Ex: to rule out a disorder with neurological/emotional basis (what is the basis?)
 Neuropsychologists can make predictions for the prognosis of recovery (due to understanding
functional systems of the brain).
 Intervention and rehabilitation for treatment—domains of functioning for rehabilitation.
 Evaluate patients with mental disorders to help predict course of illness and to tailor treatment
to patient’s strengths and weaknesses.
History of Neuropsychology—Theories of Brain Functioning
 Different time periods have been suggested from Edwin Smith Surgical Papyrus to the
Pythagoras and his claim that behavior reactions occur in the brain.
 19th century—damage to cortical areas has related to impaired functioning of certain behaviors.
o Franz Gall and currently discredited phrenology—differences in intelligence and
personality due to bumps and indentations on the skull.
 Localization of Function: Certain brain regions are responsible for specific functions/behaviors.
 Work during this period was being conducted by Broca, Pierre Flourens, Karl Lashley and others.
 Equipotentiality: Though there is localization of function, the cortex functions as a whole and
not in isolated units. Damage will impair higher functioning; substitutions can occur for damage.
 Functional Model: Integrates localization of function and Equipotentiality theory, states that
areas of the brain interact with each other to produce behavior. Several functions behavior,
and does not view behavior as the result of discrete brain regions.
 Reorganization: Recovery from brain damage can occur.

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History of Neuropsychology—Neuropsychological Assessment
 For a long time viewed brain damage as a unitary phenomenon

 Benton Visual-Retention Test and the Graham-Kendall Memory-for-Designs Test—targeted
assessment of absence/presence of brain damage.
 Neuropsychology began to grow after WWII due to extensive number of head injuries, and the
development of the field of clinical psychology.
 Wald Halstead—looked at brain damage and characteristics of subsequent behavior; developed
a test battery composed of 10 measures through factor analysis. Revised by Ralph Reitan
o Half-Reitan Neuropsychological Test Battery
 Flexible battery approach assessment: Allows each assessment to be tailored to an individual
based on the clinical presentation and the hypothesis of the neuropsychologist.
 Standard battery approach assessment: Very structured, time consuming and rarely flexible.
Brain Structure and Function
 Left Hemisphere: Controls right side of the body, involved with language function, logical
inference, detailed analysis.
 Right Hemisphere: Controls the left side of the body, involved with visual-spatial skills, creativity,
musical activity & perception of direction.
o Communicate via Corpus Callosum that integrates complex behavior.
 Frontal Lobes: Most developed, allows us to compare our behavior & reactions of others in
order to obtain feedback and alter our behavior as necessary. Associated with executive
functions and emotional control. Development largely occurs in adolescence.
 Temporal Lobes: Linguistic expression, reception and analysis, interpreting of non-verbal cues.
 Parietal Lobes: Tactile and kinesthetic perception, spatial perception, body awareness and a
little language understanding.
 Occipital Lobes: Visual processing and visual memory
 Cerebellum: Motor coordination, equilibrium control and muscle tone functioning.
Antecedents or Causes of Brain Damage
Trauma
 Brain tumors can grow outside, within the brain or can be the result of cells spreading from
other body areas.
 Increase in tumor size poor memory, affect problems, judgement issues…
 Treatment surgery or radiation
Degenerative Diseases
 Neuron degeneration in CNS

 Includes Huntington’s, Parkinson’s, Alzheimer’s and Dementia
 Alzheimer’s is most common followed by Parkinson’s and then Huntington’s
 Disturbances—motor, speech, language, memory, judgment

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Nutritional Deficiencies and Toxic Disorders
 Malnutrition can lead to neurological and psychological deficits

 Metals, toxins, gases, some plants can be absorbed through the skin toxic consequences or
brain damage
o Delirium: Disruption of the consciousness
Chronic Alcohol Abuse
 Can lead to tolerance and dependence on the substance; changes in neurotransmitter sensitivity
or shrinkage of brain tissue.
 Deficits of Limbic system—memory formation, emotional regulation & sensory integration.
 Diencephalon: Region near center of the brain that includes the bodies of the hypothalamus.
o Shrinkage or lesions in these areas.
 Atrophy of the cerebral cortex & damage to the cerebellum
Consequences and Symptoms of Neurological Damage
 Impaired orientation—difficulty recalling name, day of week, surroundings

 Impaired memory—difficulty recalling loved ones, memories, filling in gaps, learning issues
 Impaired intellectual functions—difficulty with comprehension, speech production, general
knowledge
 Impaired judgement—difficulty with decisions
 Shallow and Labile Affect—laughing/weeping easily and switching emotions inappropriately
 Loss of emotional and Mental Resilience—can function in daily life but difficulty functioning
under stress (ex: fatigue, mental demands), emotional reactions.
 Frontal Lobe Syndrome: Personality deficits—ex: poor impulse control, planning issues, temper
tantrums.
Brain-Behavior Relationships
 Important to determine where in the brain the injury occurs, same-size lesions in different brain
regions will produce different behavior deficits.
 Brain damage can lead to deficits in visual perception, auditory perception, voluntary motor
coordination, memory and other brain regions.
 Clinicians are called to determine level of intellectual deterioration—involves comparison to
previous levels of functioning.
o Decline due to psychosocial factors (ex: motivation, emotional issues) or brain injury.

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Methods of Neuropsychological Assessment
Major Approaches
 Standard Battery Approach/Fixed Battery Approach: Evaluates patients for all basic
neuropsychological abilities.
o Very expensive, possibility of patient becoming fatigued, not tailored/inflexible
 Process/Flexible Approach or Hypothesis-Testing Approach: Assessment is tailored to the
individual patient and the neuropsychologist chooses specific tests.
o Can be very useful but can also lead to the clinician choosing the wrong test.
Interpretation of Neuropsychological Test Results
 Interpretation in the context of normative data (ex: patient score below average mean score).
 Various methods also include Difference Scores for impairment, Pathognomonic signs of brain
damage (failing to draw the left side of a picture), Pattern Analysis & statistical formulas.
 Cutoff scores or absolute scores shoved the most accuracy.
Neurodiagnostic Procedures
 Neurodiagnostic Procedures: CAT scans, fMRI’s, spinal taps and other procedures for detecting
the presence and location of brain damage. Variation in expense, sensitivity, risk for patients.
 SPECT & fMRIs assess blood flow changes in the brain; are useful for assessing brain function.
Testing Areas of Cognitive Functioning
Intellectual Functioning
 Include WAIS-IV and modified versions of it (ex: adding additional subtests).

 WAIS-R-NI—most information provided for person’s cognitive strategies; WAIS-IV most used
subtest is the Information, Comprehension and Vocabulary subtests.
o Can be used as baseline—least affected by trauma
Abstract Reasoning
 Patients with brain damage approach abstract tasks in a concrete manner.

 Similarities subtests of WAIS-IV and Wisconsin Card Sorting Test (WCST)
Memory and Visual-Perceptual Processing
 Wechsler Memory Scale (WMS/WMS-IV is most recent)

 Performance is assessed with 5 index scores—Auditory, Visual, Visual Working, Immediate and
Delayed Memory.
 Discrepancy between scores—contrast scores.
 Benton-Visual Retention Test—test of memory for designs
 Rey-Osterrieth Complex Figure Test—assesses visual-spatial memory (draw a picture from
memory & then draw it again after a certain period of time).
 Needed for activities like reading a map, parallel parking; use of certain WAIS-IV subtests.

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Language Functioning
 Brain damage impacts the production or comprehension of language—repeating words,

sentence, difficulties with articulation.
 Language comprehension can be assessed using the Receptive Speech Scale.
Test Batteries
The Halstead-Reitan Battery
 Most widely used test-battery, and is made up of several measures (ex: Category Test)
 These tests can be supplemented by the MMPI-2 and the WAIS-IV
 Provides information about the localization of lesions and if they appear to be gradual or of
sudden onset.
 This test is very time consuming—takes 6 hours to administer; but highly valid & reliable.
The Luria-Nebraska Battery
 Alternative to Halsterad-Reitan, 269 tasks of 11 subtests. Viewed as reliable & valid.

 High agreement with results found on the Halstead-Reitan Battery.
 Main advantage is unlike the Halstead-Reitan it only takes 2.5 hours to administer
Variables That Affect Performance on Neuropsychological Tests
 Includes biological sex, age and educational level.

 Variables like motivational variables (cooperation, level of arousal).
 Malingering: A motivational variable; refers to faking on psychological tests. It’s difficult to
detect even for the most knowledgeable clinician.

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Intervention and Rehabilitation
 Questions of impairment focus on—nature of the deterioration of damage & is there any form
of brain damage that can account for a patient’s behavior?
o Focal damage—more specific limited effects on behavior
o Diffuse damage—wide effects on behavior
 Rehabilitation: One of the major functions of neuropsychologists. Rehabilitation tasks are
generally formulated to treat the patient’s deficits.
Concluding Remarks: Training
 Specialty training is necessary; some psychologists training in neuropsychology is limited so

they’re no qualified to give assessments.
 Clinical neuropsychology is a subspecialty—trains individuals to understand both typical brain
function and brain dysfunction effects.
Concluding Remarks: The Future
 Developing increasingly more sophisticated individuals tests and batteries.

 Better methods of assessment, therapy and rehabilitation—focusing on helping the patient
adjust and recover by develop tests that predict extent and rate of injury and rehabilitation
programs that offer hope for families and the patient.
 Currently relatively few neuropsychologists have obtained training in rehabilitation.
 Neuropsychologists are more likely to currently specialize in forensic neuropsychology, sports
neuropsychology or military neuropsychology.

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Summary - book "Clinical Psychology" - Chapters

Introduction to Clinical Psychology (University of Texas at Austin)

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Chapter 1: Clinical Psychology Pages 3-30

 A physician rooted in medicine

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Clinical Social Workers

 Work to improve social functioning of individuals, groups, or communities.

 Working alongside psychiatrists and clinical psychologists

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Professionals and Titles Not Regulated by the Government

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 Scientist-Practitioner model was adapted—thinking like a scientist.

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o Acquisition of specific clinical skills

 Competence needs to be developed in computer software, technology and research methods

 Preliminary or comprehensive examination, it is three written exams each lasting 4-hours

 Provides experience to complete the scientist-practitioner role, required of all clinical

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Chapter 2: Historical Overview of Clinical Psychology pages 32-58

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 Wechsler Intelligence Scale for Children—Alternative to Stanford-Binet scale.

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World War II and Beyond (1940-Present)

Between the Wars (1920-1939) + World War II and Beyond (1940-Present)

 Behaviorism (power of conditioning) and Gestalt psychology (emphasized patient’s

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The Beginnings (1850-1899)

 1892—Founding of the American Psychological Association (APA)

The Advent of the Modern Era (1900-1919)

 1909—Establishment of the Psychopathic Institute in Chicago (Healy)

Between the Wars (1920-1939)

World War II and Beyond (1940-1969)

The Growth of the Profession (1970-Present)

 1960’s—shift towards focusing on conditioning and altered reinforcement contingencies.

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The 1988 Schism

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Chapter 3: Current Issues in Clinical Psychology pages 59-92

 Boulder Model/Scientist-Practioner Model: Attempts to marry science and clinical

The Doctorate of Psychology Degree (Psy.D.)

 Emphasis on the development of clinical competence, de-emphasis on research

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 Focused on building a science of clinical psychology, by integrating scientific principles

Combined Professional-Scientific Training Programs

Graduate Programs: Past and Future

 1960’s: Shift from university based jobs to private practice work.

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Requirements for Licensure

 Doctoral degree from APA accredited program (e.g. clinical)

 Clinical Psychology moving in the direction of policies, legislation and greater

The Costs of Health Care

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1. Health Maintenance Organization (HMO’s): restricted number of providers and

Pro Arguments for Prescription Privileges

Con Arguments for Prescription Privileges

Implications for Training

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 Level 1—Basic Pharmacology Training: knowledge of medication and substances that

Culturally Sensitive Mental Health Services

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o Dynamic sizing; when to generalize vs. when to individualize

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