Clinical Psychology: A Brief Tour of the Field A Workshop for Members of the OSU Social Psychology...

Clinical Psychology: A Brief Tour of the Field A Workshop for Members of the OSU Social Psychology Program Michael Vasey Ohio State University September 20, 2005

Overview What is Clinical Psychology? Setting the Context: Video examples Major Domains of Clinical Psychology Psychopathology Classification Assessment Diagnosis and clinical decision-making Intervention Treatment and prevention

What is Clinical Psychology? APA Division 12 definition (1991): Clinical Psychology involves research, teaching, and services relevant to the application of principles, methods, and procedures for understanding, predicting, and alleviating intellectual, emotional, biological, psychological, social and behavioral maladjustment, disability and discomfort, applied to a wide range of client populations.

Branches of Clinical Psychology: Trend Toward Increasing Specialization The generalist training model is no longer predominant Specialized graduate training programs are becoming the norm: Examples: Clinical Child and Adolescent Psychology Clinical Geropsychology Clinical Neuropsychology Clinical Health Psychology Pediatric Psychology

Board Certification Specialties American Board of Professional Psychology (ABPP) now lists 8 specialties relevant to clinical psychology: Child & Adolescent Clinical Health Clinical Neuropsychology Cognitive & Behavioral Family Forensic Group Psychoanalysis More are undoubtedly on the way

Getting a Feel For the Territory: Some Case Examples Purpose: To illustrate the great diversity of problems of living dealt with in clinical psychology. Examples (based on DSM-IV categories): Anxiety Disorders Affective Disorders Schizophrenia Borderline Personality Disorder Bulimia Nervosa

Anxiety Disorders Most common mental disorders in the U.S. In any given year, they affect 19% of the adult population in the U.S. Most common to meet criteria for more than one at a time Anxiety disorders cost about $42 billion each year in health care, lost wages, and lost productivity

Anxiety Disorders Six major categories: Obsessive-compulsive disorder (OCD) Generalized anxiety disorder (GAD) Panic disorder and Agoraphobia Specific phobias Social anxiety disorder Post-traumatic stress disorder (PTSD)

Social Anxiety Disorder Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur May be narrow talking, performing, eating, or writing in public May be generalized general fear of functioning inadequately in front of others

Social Anxiety Disorder Affects 8% of U.S. population in any given year Women outnumber men 3:2 Often begins in youth and persists for many years Can greatly interfere with functioning Often kept a secret Fewer than 20% of sufferers seek treatment

Posttraumatic Stress Disorder (PTSD) Symptoms of PTSD: Reexperiencing the traumatic event Flashbacks, nightmares Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt

Posttraumatic Stress Disorder (PTSD) Can occur at any age and affect all aspects of life 4% of U.S. population affected each year 8% of U.S. population affected sometime during life Ratio of women to men is 2:1 Some events are more likely to cause disorders than others Examples: combat, disasters, abuse, and victimization

Dysthymic Disorder Depressed mood for most of the day, for more days than not, for at least 2 years. Presence of at least 2 of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or diff. making decisions Feelings of hopelessness Often punctuated by major depressive episodes Called Double Depression

Borderline Personality Disorder People with this disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity Interpersonal relationships are also unstable People with borderline personality disorder are prone to bouts of anger, which sometimes result in physical aggression and violence Just as often, however, they direct their impulsive anger inward and harm themselves

Borderline Personality Disorder Many of the patients who come to mental health emergency rooms are individuals with borderline personality disorder who have intentionally hurt themselves Their impulsive, self-destructive behavior can include: Alcohol and substance abuse Reckless behavior, including driving and unsafe sex Cutting themselves Suicidal actions and threats

Bulimia Nervosa Bulimia nervosa, also known as binge-purge syndrome, is characterized by binges: Bouts of uncontrolled overeating during a limited period of time Often objectively more than most people would/could eat in a similar period

Bulimia Nervosa: Binges For people with bulimia nervosa, the number of binges per week can range from 2 to 40 Average: 10 per week Binges are often carried out in secret Binges involve eating massive amounts of food rapidly with little chewing Usually sweet foods with soft texture Binge-eaters commonly consume more than 1500 calories (often more than 3000 calories) per binge episode

Bulimia Nervosa: Binges Binges are usually preceded by feelings of tension or negative affect Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and discovery

Bulimia Nervosa The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition: Purging-type bulimia nervosa Vomiting Misusing laxatives, diuretics, or enemas Nonpurging-type bulimia nervosa Fasting Exercising excessively

Bulimia Nervosa: Compensatory Behaviors After a binge, people with bulimia nervosa try to compensate for and undo the caloric effects The most common compensatory behaviors: Vomiting Affects ability to feel satiated greater hunger and bingeing Laxatives and diuretics Almost completely fail to reduce the number of calories consumed

Major Aspects of Clinical Psychology Psychopathology Classification Research on etiology, course, etc. Assessment and Clinical Decision-Making Diagnosis Case conceptualization and treatment planning Outcome evaluation Intervention Treatment and prevention

Psychopathology The study of the origins, course, and manifestations of mental or behavioral disorders. Classification: The lynchpin of a scientific approach to psychopathology.

The Problem of Classification

Goals of Classification Definition of disorder constructs is meant to describe and distinguish between problems in ways that permit or lead to understanding of their: Behavioral, psychological, social, and biological correlates Etiological and maintaining factors Course Prognosis Treatment response

Characteristics of A Useful Diagnostic System Facilitates Communication Possesses Etiological Validity Provides Reliable Information on Disabilities, Abilities, Functional Impairments, etc. Guides Research (homogeneous groups) Informs Treatment Decisions Predicts Clinical Course

What Is Psychological Abnormality? Many definitions have been proposed, yet none are universally accepted Most definitions, however, share some common features The Four Ds Deviance Different, extreme, unusual Distress Unpleasant & upsetting Disability Causes interference with life Danger Poses risk of harm

Definitions Typically Involve Social Judgment

Wakefields Concept of Disorder as Harmful Dysfunction Meant to reduce extent of social value judgment in definitions of mental disorders. Harmful: Reflects a subjective value judgment that a problem is unpleasant or undesirable. This means that some things that are disorders in one culture, may not be in another if the dysfunction does not cause harm in that culture. Dysfunction: A supposedly objective feature. Dysfunction exists with a physiological or psychological system fails to perform one of its natural functions. Natural function: the function that it was evolutionarily selected to perform.

But Even Dysfunction Has Subjective Component Wakefields attempt to make definition of dysfunction objective fails Examples of Specific Reading Disorder Reading cannot be the natural function of whatever systems support it. Wakefield responds by saying the HD analysis permits the harm to be an indirect consequence of the failure. But this leads to serious problems for the HD analysis because, when H and D are dissociated, all sorts of things end up qualifying as disorders that are difficult to justify.

Lilienfeld & Marinos Example of Driving Disorder Lilienfeld & Marino (1999) use Wakefields indirect harm rationale to support Driving Disorder: The attribution of disorder to the inability to drive is based on a line of reasoning roughly as follows: 1) inability to drive is a significant harm, 2) the brain was not designed specifically to enable people to learn to drive; 3) however, when all of a persons brain and motor systems are functioning as they were designed to function, a side effect is that the person can learn to drive; 4) therefore, the inability to learn to drive (despite conducive environmental and motivational circumstances) is caused by some underlying dysfunction of brain or motoric system and is thus a disorder.

DSM-IV Published in 1994, revised slightly in 2000 (DSM-IV Text Revision) Lists approximately 400 disorders Describes criteria for diagnoses, key clinical features, and related features which are often but not always present People can be diagnosed with multiple disorders

Understanding DSM-IV: Some Definitions Sign/Symptom: single behavior (sign) or subjective report of single characteristic (symptom). By itself, a sign/symptom has multiple possible meanings Syndrome: A group of signs and symptoms which covary systematically Disorder: Syndrome with specified duration, and (hopefully) course, prognosis, treatment response and etiology.

Assumptions of DSM-IV Neo-Kraepelinian Approach: Assumes mental disorders are discrete entities separated from one another, and from normality, either by: Recognizably distinct combinations of symptoms and signs, and/or Demonstrably distinct etiologies Assumes meaningful syndromes can be identified based on clusters created based on similarity of symptom/sign topography. Ultimately, each syndrome will be refined until it is homogeneous in terms of: Etiology, course, treatment response, etc.

DSM-IV Definition of Disorder Each disorder is conceptualized as: A clinically significant behavioral or psychological syndrome or pattern Occurring in an individual That is associated with: Distress OR Disability in one or more areas of functioning OR A significant increase in risk of death, pain, disability, or important loss of freedom Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. BUT dysfunction is not defined Not merely an expectable and culturally sanctioned response to a specific event.

DSM-IV Multiaxial System Axis I Clinical disorders Axis II Personality disorders Mental retardation Axis III General medical conditions Axis IV Psychosocial and environmental problems Axis V Global assessment of functioning

Major Axis I Diagnostic Categories Anxiety disordersMood disorders Disorders first diagnosed in infancy and childhood Substance-related disorders Schizophrenia and other psychotic disorders Delirium, dementia, amnestic, and other cognitive disorders Mental disorders due to a general medical condition Somatoform disorders Factitious disordersDissociative disorders Other conditions that are the focus of clinical attention Eating disorders Sexual and gender identity disorders Impulse-control disorders Adjustment disordersSleep disorders

Axis II Disorders Mental Retardation Personality Disorders 10 categories Generally having poor reliability and validity Cluster A: Marked by odd, eccentric behavior, including paranoid, schizoid and schizotypal personality disorders. Cluster B: Marked by dramatic, emotional behavior, including histrionic, narcissistic, antisocial and borderline personality disorders. Cluster C: Marked by anxious, fearful behavior and include obsessive- compulsive, avoidant and dependent personality disorders.

Lifetime Prevalence of DSM Diagnoses (Axes I & II)

Are DSM-IV Classifications Reliable? DSM-IV has greater reliability than any previous editions Used field trials to increase reliability But reliability is still a concern Especially for Axis II Personality Disorders and Childhood Disorders

DSM-IV has greater validity than any previous editions Disorder-specific subcommittees conducted extensive literature reviews and studies - But only for a subset of categories But validity of many categories remains a serious concern Validity of many categories inadequately studied. Especially Axis II Personality Disorders Are DSM-IV Classifications Valid?

Problems With DSM Approach Individuals who share few signs/symptoms receive the same diagnosis Example: Major Depressive Disorder Of 9 criteria only 5 must be met. Must have either depressed mood or loss of pleasure Plus 4 of remaining 8 features But many of these specify several possibilities Examples: Insomnia or hypersomnia; weight loss or weight gain; agitation or psychomotor retardation; feelings of worthlessness or excessive guilt Thus, any 2 MDD patients may be more different than similar

Problems With the DSM Approach Within syndrome heterogeneity presents a potential problem Even those people sharing the same symptoms may vary in important ways: Example: Variable treatment response Only about 50% of depressed patients respond to treatments (both biological and psychosocial) DSM-approach responds by dividing syndromes further or narrowing the diagnostic criteria. But this can lead to excessively complex taxonomy We are at nearly 400 disorders and counting

Problems With the DSM Approach Original DSM-III disorders and their lists of criteria were not founded on research Validity was largely unknown Revisions have tended to preserve these questionable disorders and criteria Improvements were begun in producing DSM-IV Revisions based on: Comprehensive literature reviews Analyses of existing databases Some new research (field trials) But only for a subset of categories Further, the process was rushed

Problems With the DSM Approach Comorbidity Comorbidity is the rule single disorders are the exception Raises questions about the distinctions between many categories Leads to problems interpreting results because we are typically dealing with combinations of disorders rather than one disorder at a time. Sub-clinical cases DSM-IV is a dichotomous system Leaves unclear the status of those who nearly meet criteria Also means diagnostic status can be a poor outcome measure

Toward DSM-V Preliminary work has begun on DSM-V Series of planning conferences have produced a monograph comprising 6 white papers detailing a research agenda for DSM-V (Kupfer et al., 2002). Produced under a partnership between the American Psychiatric Association and NIMH Explicit goal: To provide direction and potential incentives for research. Target date for DSM-V: 2010 Many changes recommended in Kupfer et al. (2002) are unlikely to occur until DSM-VI or even DSM-VII

Highlights of Kupfer et al. (2002) Enhanced reliability has been obtained at the expense of validity. Exclusive reliance on discrete categories has not produced a satisfactory system. No biological markers distinguishing disorders have been found. High degree of short-term diagnostic instability

Questioning the Categorical Approach Many have begun to argue for a dimensional approach Especially in the case of PDs (Frist et al., 2002). Cloninger (1999): There is no empirical evidence for natural boundaries between major syndromes and that the categorical approach is fundamentally flawed (pp. 174-175).

Questioning the Categorical Approach Examples: Research shows anxiety and depression share much in common and may be better conceptualized as points on a continuum of negative affect (Barlow, 2002) Even for severe disorders with high genetic loading like schizophrenia, a dimensional approach may prove superior (e.g., Widiger & Sankis, 2000). Carson (1996) reviewed the lack of progress in understanding schizophrenia and attributed it to use of the DSM approach.

Reasons for Questioning the Categorical Approach Only a few mental disorders have been shown to have distinct etiologies: Examples: Down Syndrome Fragile X Syndrome PKU Alzheimers Disease Most mental disorders appear to merge imperceptably into one another and into normality (Kendler & Gardner, 1998) Examples: Major Depressive Disorder Anxiety Disorders Schizophrenia Bipolar Disorder

Reasons for Questioning the Categorical Approach Specific underlying causes for each disorder category have not emerged. The genetic and environmental factors underlying syndromes are typically non- specific. Example: Genetic factors associated with depression and anxiety overlap completely (Eley & Stevenson, 1999; Kendler et al., 1992)

Reasons for Questioning the Categorical Approach Treatments are effective for a large number of diagnostic categories that are not supposed to be all that similar Examples: SSRI drugs similarly effective for depression, anxiety disorders, bulimia, etc. Cognitive-behavioral therapy is effective for depression, anxiety disorders, bulimia, etc. CBT for one disorder typically helps with comorbid disorders as well.

What About a Dimensional Approach? Dimensional model of psychopathology Advantages: No loss of information Full range of severity preserved Complete coverage of all areas of behavior for each case Reduced diagnostic overshadowing Could include strengths as well as problems Improved validity Permits identification of empirically-supported dimensions and clusters

What About a Dimensional Approach? Disadvantages raised in defense of status quo: Complex But perhaps no more so than categorical system with hundreds of categories Also, complexity is dictated by the phenomena The extant research literature is based on the categorical system of DSM. Expense of changing would be huge Practitioners likely to resist So the advantages of a dimensional approach will need to be large to support a change. Strong need for dimensional models to be developed and compared to extant categorical approach.

Personality Disorder Modifications PDs are probably the first place well see a dimensional approach taken. If it is successful and well-received by clinicians, then we may see it in at least some Axis I disorders.

Problems with PD Categories Criteria fail to specify the threshold for diagnosis Examples: Narcissistic PD symptoms/signs include: Has a grandiose sense of self-importance But just what qualifies as grandiose is not specified. Lacks empathy Just what qualifies as a lack is not specified.

Problems with PDs PD diagnoses co-occur to a high degree. Examples: Oldham et al. (1992) studied 100 patients at a long-term care clinic for PDs Average patient met criteria for nearly 3 PD diagnoses. Only 15% met criteria for only one PD

Problems with PDs Despite the high degree of overlap among the 10 PD categories Inadequate coverage of maladaptive personality traits by DSM PD categories: PD NOS is often the most commonly used PD diagnosis in clinical practice (e.g., Fabrega et al., 1991). Diagnostic overshadowing is a problem Clinicians apply only 1 diagnoses when several are met (Adler et al., 1990)

PD Symptoms As Extremes of Normal Personality Traits The symptoms of PDs are maladaptive variants of personality traits found in the normal popualtion. Examples: The symptoms of Borderline PD can be viewed as extremes of the traits comprising Neuroticism/Negative Affectivity Many aspects of Antisocial PD can be viewed as the low extreme of the Big 5 dimension of Conscientiousness

What Might a Dimensional Scheme for PDs Look Like? 4-5 factors appear to underly the symptoms of the 10 PDs 4 Factor Model (Livesly et al., 1998) Compared phenotypic and genetic structure of PD symptoms The same 4 dimensions appeared in the phenotypic and genetic analyses: 1) Emotion Dysregulation; 2) Dissocial Behavior; 3) Inhibitedness; and 4) Compulsivity These closely resemble 4 of the Big 5 factors Big 5 Factors fit well (Lynam & Widiger, 2001)

Example: Cloningers Approach Cloninger (2000): A PD is diagnosed based on clinically low levels of traits related to self-regulation Specific variants of PDs would be governed by levels of other traits, such as: Novelty Seeking Harm Avoidance Reward Dependence Persistence

Possible Addition of Relationship Disorders DSM has defined disorders as residing within the individual. This has always been problematic, especially for child disorders Example: Oppositional Defiant Disorder typically reflects parenting problems so how does it qualify as a disorder? First et al. (2002) call for addition of Relationship Disorders to DSM-V Example: Marital conflict

Use of DSM in Non-Clinical Settings Rounsaville et al. (2002): Call for redefinition of disorder criteria so they are truly operationalized (like MR) Need to reduce reliance on clinical judgment because of its attendant problems. Example: Depression might be defined in part in terms of BDI score threshold.

But Categorical Versus Dimensional is an Empirical Question Whether a problem is best approached as a dimension or a category can be tested. Several methods available: Taxometric Analytic Techniques Latent Class Analysis Likely that some problems are dimensional but others are categorical

What Is the Structure of Psychopathology? Are psychopathological problems continuous with the broader range of individual differences? Do the same factors which contribute to variation in the typical range of individuals also account for the extremes? Or are such problems qualitatively distinct? Do they have different etiology than individual differences in the broader population distribution?

The Example of PKU PKU leads to MR unless affected individuals are place on a special diet. But the value of this special diet would be missed if we didnt know that individuals with PKU are a discrete subgroup in the population of individuals with MR.

How Do We Find Out If a Syndrome is Dimensional or Categorical? Nave assumption: Look for bimodality in distributions of the characteristic(s) in question. But its not that simple: Few characteristics correlate so strongly with category membership as to produce non-overlapping or clearly bimodal distributions. Bimodality is neither necessary nor sufficient to conclude a construct is categorical.

Categorical vs. Dimensional Conditions 20 60 40 0 135791113151719 Frequency Scores (A) Dichotomy There are only two levels, and all people are at one of those two levels

Categorical versus Dimensional Conditions 20 60 40 0 135791113151719 Frequency Scores 20 60 40 0 135791113151719 Frequency Scores (B)Dimensional Considerable variety across population

Categorical versus Dimensional Conditions 20 60 40 0 135791113151719 Frequency Scores 20 60 40 0 135791113151719 Frequency Scores 20 60 40 0 135791113151719 Frequency Scores Bimodal Distribution Variability within each category

Meehls Taxometric Approach Paul Meehl developed a set of procedures for testing the categorical versus dimensional nature of a construct. Bootstrap Taxometrics Provisional identification of taxon members permits refinement of assessment methods. Example: Choose items most strongly correlated with taxon membership

A Brief Introduction to Taxometrics The logic of taxometrics can be illustrated by the example of biological sex: Suppose we had a random sample of 50 men and 50 women And we measured the following characteristics: Height, Baldness, and Waist to Hip Ratio These would be correlated in our mixed sex sample but not in samples of either men or women alone. Such indicators permit us to find evidence for the discrete nature of biological sex using taxometric procedures.

The Logic of Coherent Cut Kinetics: The Example of MAXCOV MAXCOV (Maximum Covariance Method) MAXCOV examines the covariance between pairs of indicators But first it cuts the sample up into slabs based on their scores on a third indicator (i.e., the input indicator) For example: A sample of 50 men and 50 women (N=100) could be sorted in terms of Height and cut into 10 slabs. Slab 1 would be the 10 shortest subjects Slab 10 would be the 10 tallest subjects The covariance of Baldness and Waist to Hip Ratio could then be computed for each slab.

Sample MAXCOV Plot A peaked covariance curve reveals the taxon. The position of the peak provides a means of estimating the taxon base rate (about.50 in this case) The line would be flat in the case of a dimensional construct. That is, the covariance would be similar across slabs

Other Taxometric Procedures Maximum Eigenvalue Method (MAXEIG) Similar to MAXCOV but can handle more than 3 indicators. Examines the maximum eigenvalue of the first principal component instead of covariance.

Other Taxometric Procedures Latent Mode Method (L-Mode) Factor analysis is performed on indicators. Frequency plot of 1 st factor scores should reveal bimodality of data if taxonic.

The Example of Psychopathy in Youth Psychopathy has been studied as both a category and a dimension. Why does it matter? We may miss important nonlinear relations if we approach a categorical construct dimensionally and vice versa (see Farrington & Loeber, 2000) Which it is has important implications for the ways in which it is assessed Ultimately, it should reduce measurement error and increase predictive power (Ruscio & Ruscio, 2002)

Results of Wootton et al. (1997)

Methods (Vasey et al., 2005) Sample: 386 youth ages 8-18 years 30% with significant antisocial behavior 5 putative indicators: Subscales drawn from the Antisocial Process Screening Device (APSD; Frick & Hare, 2001) CU, N, and ICP scales from Youth APSD N and ICP scales from Parent APSD (the Parent CU scale did not correlate sufficiently with the other 5 scales to be included)

MAXEIG Curves for Simulated Data Simulated Taxonic Data Simulated Dimensional Data

MAXEIG Curves for Actual Data: Input Indicators 1 and 2 Child ICP Child N

MAXEIG Curves for Actual Data: Input Indicators 3-5 Child CU Traits Parent ICP Parent N

Summary of MAXEIG Results All 5 input indicators yielded plots consistent with a low base rate taxon Avg. base rate =.08 (SD =.03) Further, results were: Closely consistent with analyses of simulated taxonic data Inconsistent with analyses of simulated dimensional data.

L-Mode Curves for Simulated Data Simulated Taxonic Data Simulated Dimensional Data

L-Mode Curve for Actual Data

Summary of L-Mode Results L-Mode results also suggested the presence of a taxon Base rate =.04 Again, analyses of simulated data supported the presence of a taxon.

Comparison of MAXEIG and L-Mode Results The two sets of analyses suggest a taxon with a base rate of approximately.06 This base rate is consistent with expectations for psychopathy within this sample.

Implications To the extent that these results are replicated, it will permit bootstrapping of the validity of indicators of psychopathy in youth. e.g., it should permit identification of optimal cut-off scores on the APSD or other measures. It may also ultimately permit early identification of taxon members for purposes of prevention or early intervention.

Other Taxometric Findings Some apparently categorical phenomena: Dissociation Schizotypal Personality Some apparently dimensional phenomena: Generalized anxiety Depression Bulimia

Factors Contributing to Psychopathology

Factors Emphasized in Current Research Biological Factors Neuroscience research Behavior genetics Molecular genetics Strong push to realize the potential of advances in these areas to enhance understanding of psychopathology Social neuroscience research has strong potential to make important contributions.

Factors Emphasized in Current Research Psychological Factors Examples: Motivation and temperament Emotions and emotion regulation Learning and cognition Examples: Social cognition The self Strong emphasis on social cognition and personality in current research Offers considerable room for contributions by social psychologists

Factors Emphasized in Current Research Social Factors Examples: Relationships and psychopathology e.g., Interpersonal theory of depression (Coyne, Lewinsohn) Gender and gender roles Prejudice Poverty Strong potential for social psychologists to make important contributions regarding the roles played by such factors.

The Scientist-Practitioner Model

The Scientist-Practioner Model Call for clinical psychologists to be scientists goes back to the earliest days of the field. Witmer (1907) argued that the pure and applied sciences advance as one what retards or fosters progress in one, retards or fosters progress in the other. The Boulder Conference (1949) Formulated the Boulder Model Scientist-Practitioner Model

Main reasons for joint training as scientists and practitioners So students could develop interests in both research and practice, despite the fact that most would concentrate on one or the other in their careers. Underlying assumptions: Specialization in either research or practice was seen as likely to contribute to narrowness of thinking and rigidity of action. Direct involvement in clinical work by researchers would foster their knowledge of important clinical issues so they would be more likely to study them.

Main reasons for joint training as scientists and practitioners The manifest lack of dependable knowledge in clinical psychology and personality demands research be considered a vital part of the field Research training seen as a means of separating fact from fiction and identifying the kinds of solutions that were likely to be permitted by the facts through application of: Critical thinking skills Skills of empirical observation

The Growing Gap Between Scientists and Practitioners Professionals in the 1960s increasingly complained that the science half of the model involved training in research methods that were of little use in answering important questions. Chicago 1965 Reaffirmed the scientist-practitioner model but showed the growing tension by so broadening the definition of research (i.e.,science) as to weaken it substantially. Vail Conference, 1973 Culminated the trend toward rejection of science. The conference went far beyond previous conferences Explicitly endorsed creation of professional schools Suggested that the scientist-practitioner model should no longer be the dominant training model in clinical psychology

Assessment

Clinical Assessment: How and Why Does the Client Behave Abnormally? What is assessment? The collecting of relevant information in an effort to reach a conclusion Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped Focus is idiographic on an individual person Also may be used to evaluate treatment progress

Clinical Assessment: How and Why Does the Client Behave Abnormally? The specific tools used in an assessment depend on the clinicians theoretical orientation Hundreds of clinical assessment tools have been developed and fall into three categories: Clinical interviews Tests Projective Tests Questionnaires IQ tests Neuropsychological Tests Behavioral Observations

Requirements of Assessment Instruments Standardization Of stimuli Of administration Of scoring Reliability Validity Norms

Persistent Use of Tests Failing to Meet Psychometric Requirements Projective tests remain widely used The Projective Hypothesis The notion that highly unstructured stimuli, as in the Rorschach, are necessary to bypass defenses in order to reveal unconscious motives and conflicts. Such ambiguous stimuli require a person to impose structure upon them. The way they do so may reveal much about the person. Most such tests lack evidence for their reliability and validity and lack norms. Rorschach is particular focus of controversy

Rorschach Controversy Illustrates Ongoing Scientist-Practitioner Conflict Roots of the Controversy: Principle of Informal validation Klopfer held that informal observations by individual interpreters were sufficient to demonstrate validity. Principle of Intuitive Information Integration Klopfer held that individual Rorschach scores do not usually bear a straightforward relationship to personality characteristics but a skilled interpreter can intuitively integrate the scores into a complete picture This means that attempts to validate individual scores will fail and that shouldnt concern us. This view is also taken by current proponents They argue it is impossible to validate the Rorschach using traditional psychometric approaches because each individual is unique and no systematic rules can be given for the intuitive integration process

Clinical Decision Making Clinicians are prone to a wide range of cognitive errors and biases in clinical judgment situations. Only by being aware of this susceptibility and taking steps to address it can a clinician be as effective a decision maker as possible. Decision aids be they actuarial formulas, treatment manuals, etc., are an effective means of limiting such bias and error.

Clinical Versus Actuarial Prediction Two approaches to making decisions: Reliance on clinical expertise and intuition. This is by far the preference of clinicians Practitioners tend to have strong belief in the value of their own experience Use of actuarial decision aids Use of formula based on empirically established relations Note such formula dont exclude clinician judgments if those judgments have value

Clinical Versus Actuarial Prediction Meehl (1954) first raised the issue and established conditions for fair comparisons More than 100 studies to date Evidence overwhelmingly favors actuarial approaches. Experienced clinicians are no more accurate than novices

Why Dont Clinicians Develop the Expertise They Believe They Have So why doesnt experience bring much improvement in clinical judgmental accuracy? Cognitive biases and errors (universal to human beings not specific to clinicians) Such biases and errors are often a result of relying on judgment heuristics (shortcuts) that often work well in everyday life, but which may lead to errors in clinical judgment Such errors are most likely under conditions of INFORMATION OVERLOAD Information overload: situation in which there is a large amount of information and no way to determine what is important and what is not Precisely the situation in clinical assessment

A Sampling of Important Cognitive Biases and Errors Confirmatory Bias Illusory Correlation Availability Bias Hindsight Bias Overpathologizing Bias Overconfidence

Intervention

Interventions

Major Schools of Psychotherapy Eclecticism Both theoretical and technical Cognitive-Behavioral Therapies Interpersonal Therapy Psychodynamic Therapy Humanistic Therapy Existential and Gestalt Therapy

The Effectiveness of Treatment Over 400 forms of therapy in practice, but is therapy effective?

The Effectiveness of Treatment Is therapy generally effective? Research suggests that therapy is generally more effective than no treatment or than placebo Best estimate of average effect is Cohens d .50 (Lipsey & Wilson, 1993) That means the average treated person does better than about 66% of those in placebo condition Efficacy compared to wait-list control averages Cohens d .70 Average treated person better off than 75% of controls.

Common Factors: An Important Source of Therapys Efficacy Frank & Frank (1991) define common factors as including: Setting designated as a place of help Therapeutic relationship With an expert who is empathic, warm, supportive, and hopeful A conceptual scheme or theory to explain the problem Compelling narrative may promote mastery and control Therapeutic rituals Activities embedded in the explanation offered May augment the persuasive power of the narrative

The Dodo Bird Verdict Broad claim that all forms of psychotherapy which contain common factors are equally effective. Example: Wampold et al. (1997) Bona fide treatments differ hardly at all in efficacy (d =.20) Conclusion based on meta-analysis of head-to-head comparisons of bona fide treatments. But as Crits-Christoph (1997) pointed out: Virtually all of the bona fide treatments in Wampolds meta-analysis were CBT programs.

Some Treatments Are More Effective Than Others Effect sizes for Cognitive-Behavioral Therapy (CBT) programs are generally quite high: Barlows Panic Control Therapy Panic Disorder with Agoraphobia Cohens d = 1.34 for avoidance and 1.87 for general anxiety. NOTE: these are relative to PLACEBO Similar results for other anxiety disorders and depression Examples: Exposure and Response Prevention treatments for Obsessive-Compulsive Disorder (Foa) Group CBT for Social Anxiety Disorder (Heimberg) Cognitive Therapy for Depression Interpersonal Therapy starting to show similar results

The Empirically-Supported Treatments (ESTs) Movement APA Division 12 Task Forces (1995) Task Force on Psychological Intervention Guidelines Goal was to produce practice guidelines Task Force on Promotion and Dissemination of Psychological Procedures Goal was to help educate therapists about extant treatments.

Categories of Efficacy (Chambless & Hollon, 1998) Well-Established Treatment: When two independent studies show a treatments efficacy compared to another treatment or to a placebo control Assuming: The placebo condition was equally credible to the treatment condition. The other treatment was implemented well. Probably Efficacious Treatment: Treatments for which there are two studies demonstrating efficacy as compared to no treatment and done by independent research teams Promising Treatment: Treatments for which there is only one study supporting a treatments efficacy, or all studies conducted by only one investigative team.

The Infamous List of ESTs 1995 the first list identified 25 treatments as well-established or probably efficacious. 1998 71 treatments 2001 108 treatments for adults 37 treatments for children

What Types of Treatments Are on the List? Mainly CBT-based interventions CBT therapy has been allied with a research emphasis since its inception Interpersonal Therapy for various problems also now prominent on the list But other orientations are appearing The emphasis on ESTs has stimulated research by proponents of other approaches Example: Brief Psychodynamic Therapy

Important questions about empirically supported treatments: Chambless & Hollon (1998) suggest consideration of: Efficacy: Has the treatment been shown to be beneficial in controlled settings? Effectiveness: Is the treatment useful in applied clinical settings? Efficiency: Is the treatment efficient in the sense of being cost-effective relative to alternatives?

Heated Debate Over EST List and the EST Movement Critics predicted the list would be used by insurance companies and others to limit payment This has happened Several states now limit reimbursement to those providing ESTs (e.g., Hawaii, New Mexico) Critics also charge that the movement: Interferes with innovation Requires rigid adherence to manuals which may reduce efficacy

Levants Critique of Evidence-Based Practice (ESTs) Ron Levant is currently APA president Prior to his election, he published a critique of ESTs in nearly every state psychology associations newsletter. He withdrew the critique in one case because the editor planned to publish a reply by Larry Beutler

Levants Main Points ESTs generalize poorly Studies limited to homogeneous samples that are unlike real-world patients. ESTs are lacking for most DSM Axis I disorders Levant advocated giving equal weight to three sources of evidence: Best research evidence With a much broadened definition of what qualifies as research evidence Clinical expertise Patient values

Beutlers Reply Evidence actually shows EST study samples and real-world patient samples are quite similar If any difference exists, it is that EST study samples tend to be more severe. ESTs exist for most Axis I disorders Weighing clinical expertise and empirical evidence equally ignores a vast literature on problems of clinical judgment.

More Recent Debate Over Efficacy of ESTs Westen et al. (2004) Controversial Psychological Bulletin article arguing that research evidence for many ESTs is weak Specifically argued: Most studies exclude 1/3-2/3 of patients who present for treatment. Excluded cases are more difficult and more representative of real-world cases ESTs reduce immediate symptoms but the average patient for most disorders does notrecover and stay recovered (p 658).

Critiques of Westen et al. (2004) Two set of researchers provide devastating critiques of Westen et al. Crits-Christoph, Wilson, & Hollon (2005) Weisz, Weersing, & Henggeler (2005) Both list many problems with the Westen et al. article Biased review of EST research Failure to mention many findings inconsistent with their arguments. Serious double standard in evaluating evidence Inaccurate characterization of assumptions underlying ESTs Example: Westen et al. argued that ESTs assume most patients have only one problem Research actually shows that patient samples in EST studies are very similar to patients seen in community

Psychological Treatments (Barlow, 2004) Psychology has recently identified itself as a health care profession Change has been codified in APA bylaws Evidence supports the efficacy of many psychological interventions Dissemination of these interventions is proceeding slowly Barlow advocates a change in terminology from Psychotherapy to Psychological Treatments to enhance dissemination

Video Example of an EST Lars-Goran Osts Single Session CBT program for specific phobia Woman in video has a severe snake phobia Ost does graduated exposure in an extended session Current theoretical basis for exposure therapy emphasizes cognitive change Prevention of avoidance allows new information to be learned

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Clinical Psychology: A Brief Tour of the Field A Workshop for Members of the OSU Social Psychology...

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