Chapter 1 – Introduction Copyright © 2014 John Wiley & Sons, Inc. All rights reserved

Chapter 1 – Chapter 1 – IntroductionIntroduction

Copyright © 2014 John Wiley & Sons, Inc. Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.All rights reserved.

The challenges facing mental The challenges facing mental health workers health workers

It is often difficult to put a cut-off line It is often difficult to put a cut-off line between normal distress and distress between normal distress and distress that has clinical significancethat has clinical significance

For example- many of us experience For example- many of us experience anxiety, or sadness; when is still within anxiety, or sadness; when is still within the normal range and when is it the normal range and when is it considered an abnormality? considered an abnormality?

Is it a matter of intensity? Duration? Is it a matter of intensity? Duration? Frequency? Frequency?

More Questions More Questions

Do some mental disorders lend themselves Do some mental disorders lend themselves to treatment better than others? to treatment better than others?

For example, schizophrenia is a chronic For example, schizophrenia is a chronic condition, whereas anxiety disorders may condition, whereas anxiety disorders may be more effectively treated. be more effectively treated.

The expression of the same disorder might The expression of the same disorder might take different forms in different people take different forms in different people

There is a high incidence of co-morbidity There is a high incidence of co-morbidity (occurring together) of mental disorders (occurring together) of mental disorders


AssessmentAssessment

The first challenge facing a clinical The first challenge facing a clinical psychologist is the assessment of a psychologist is the assessment of a presenting problempresenting problem

Is the condition fully displayed or is it Is the condition fully displayed or is it still in the process of unfolding?still in the process of unfolding?

To what extent is there a co-To what extent is there a co-existence of several clinical existence of several clinical conditions in the same person? (Co-conditions in the same person? (Co-morbidity). morbidity).


About half of mental disorders begin About half of mental disorders begin before age 14before age 14

Worldwide 800,000 people commit Worldwide 800,000 people commit suicide every yearsuicide every year

1 in 4 adult Americans suffers from a 1 in 4 adult Americans suffers from a mental disorder in any given yearmental disorder in any given year

Worldwide more than 450 million Worldwide more than 450 million people suffer from mental disorderspeople suffer from mental disorders– Most undiagnosed or misdiagnosedMost undiagnosed or misdiagnosed

Importance of Clinical Importance of Clinical Psychology as a DisciplinePsychology as a Discipline


Early definitions Early definitions stressed assessment, evaluation and diagnosisassessment, evaluation and diagnosis

More recent inclusion of intervention More recent inclusion of intervention in various forms as well as preventionin various forms as well as prevention

Evidence-Based PracticeEvidence-Based PracticeActive debate on the ‘science of clinical Active debate on the ‘science of clinical

psychology’psychology’McFall’s Manifesto for a Science of Clinical McFall’s Manifesto for a Science of Clinical

PsychologyPsychology

Defining Scope of Clinical Defining Scope of Clinical PsychologyPsychology


McFall’s Manifesto McFall’s Manifesto Toward research-based practice of Toward research-based practice of

psychology psychology

Clinical psychology needs to be based on the Clinical psychology needs to be based on the results of researchresults of research

The exact nature of the service needs to be The exact nature of the service needs to be described described

The claimed benefits of the service must be The claimed benefits of the service must be described clearlydescribed clearly

These benefits must be validated scientifically These benefits must be validated scientifically Possible negtive side eefefcts must be Possible negtive side eefefcts must be

ruled out empirically ruled out empirically

Copyright © 2014 John Wiley & Sons, Inc. Copyright © 2014 John Wiley & Sons, Inc.

All rights reserved.All rights reserved.

The Shifting Nature of the Field The Shifting Nature of the Field of Clinical Psychology of Clinical Psychology

From the focus on one individual the From the focus on one individual the focus has shifted to couples and focus has shifted to couples and families, both directly as families, both directly as interventions and indirectly as in interventions and indirectly as in prevention activities, consultations, prevention activities, consultations, and research and research

Increasing focus on pharmacological Increasing focus on pharmacological treatment an decrease in traditional treatment an decrease in traditional activites activites


The APA Definition of Clinical The APA Definition of Clinical Psychology: Research-based Psychology: Research-based

“ “ Integrates science, theory and practice Integrates science, theory and practice to understand, predict, and alleviate to understand, predict, and alleviate maladjustment, disability and discomfort maladjustment, disability and discomfort as well as to promote human adaptation, as well as to promote human adaptation, adjustment, and personal development.adjustment, and personal development.

Clinical psychology focuses on the Clinical psychology focuses on the intellectual, emotional, biological, social intellectual, emotional, biological, social and behavioral aspects of human and behavioral aspects of human functioning across the life-span, in varying functioning across the life-span, in varying cultures and Socio-economic levels. cultures and Socio-economic levels.


Elements of the APA Definition Elements of the APA Definition of Clinical Psychology of Clinical Psychology

1. Integration of theory and research – 1. Integration of theory and research – bi-directional relationship: the theory bi-directional relationship: the theory is an attempt to explain the is an attempt to explain the symptoms; it generates research to symptoms; it generates research to assess the explanation, and the assess the explanation, and the research results may change the research results may change the theory- that is –our understanding of theory- that is –our understanding of the causes of the symptoms (as one the causes of the symptoms (as one example) example)


Elements of the APA definition Elements of the APA definition (cont-d) (cont-d)

2. The goals are on the one hand to remove 2. The goals are on the one hand to remove distress and suffering, but also to promote distress and suffering, but also to promote adaptation; that is- sometimes a conditions adaptation; that is- sometimes a conditions may not go away, and the person needs to may not go away, and the person needs to learn to live with it and to adapt to it. learn to live with it and to adapt to it.

3. The various aspects of human 3. The various aspects of human functioning (e.g. biological, emotionalfunctioning (e.g. biological, emotional, , intelelctual etc are inter-related and intelelctual etc are inter-related and affect one another. They cannot be affect one another. They cannot be viewed in isolation . viewed in isolation .


Importance of Clinical Importance of Clinical Psychology as a Psychology as a DisciplineDiscipline Evidence-Based Practice Evidence-Based Practice

(cont.)(cont.) Importance of using only practices Importance of using only practices

empirically found to be effectiveempirically found to be effective Intuition should not be a part of Intuition should not be a part of

assessment or treatmentassessment or treatment

– Critics argue (among other points):Critics argue (among other points): Group-based data is not always sufficient Group-based data is not always sufficient

in working with individualsin working with individuals Research is not always available for all Research is not always available for all

problemsproblems Each person is unique in many different Each person is unique in many different

ways (culture, class, family etc.)ways (culture, class, family etc.)

Copyright © 2014 John Wiley & Sons, Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.Inc. All rights reserved.

Counseling vs. Counseling Counseling vs. Counseling Psychology Psychology

Counseling is a generic term use d to Counseling is a generic term use d to describe a range of mental health describe a range of mental health professions with various training and professions with various training and licensure requirements. licensure requirements.

Counseling psychology has a great deal in Counseling psychology has a great deal in common with clinical psychology common with clinical psychology

It started in he field of vocational It started in he field of vocational counseling in an attempt to match counseling in an attempt to match between traits and aptitudes (skills) and between traits and aptitudes (skills) and the demands of a given job. the demands of a given job.


Counseling Psychology (cont-d) Counseling Psychology (cont-d)

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


Traditional distinctions between Traditional distinctions between clinical and counseling clinical and counseling

psychologists are fading psychologists are fading

Today counseling psychologists Today counseling psychologists provide services in more severe provide services in more severe cases, such as depression, panic, cases, such as depression, panic, social phobia or eating disorders social phobia or eating disorders

Clinical psychologists have expanded Clinical psychologists have expanded their services to conditions that do their services to conditions that do not represent psychopathology such not represent psychopathology such as chronic illness or stress- related as chronic illness or stress- related conditions conditions


Cont-d Cont-d

It is difficult to mark professional It is difficult to mark professional boundaries on the basis of what boundaries on the basis of what constitutes normal vs. abnormal constitutes normal vs. abnormal range of distress range of distress

Depending on the point in time in Depending on the point in time in which someone seeks help, the which someone seeks help, the same person may present clinical same person may present clinical or subclinical symptoms or subclinical symptoms


School PsychologySchool Psychology– Training in both psychology and educationTraining in both psychology and education– Work in diverse education-related settingsWork in diverse education-related settings– There is a natural overlap between school There is a natural overlap between school

psychology and child clinical-psychology psychology and child clinical-psychology – Traditionally, school psychologists provided Traditionally, school psychologists provided

services related to assessment of intellectual services related to assessment of intellectual functioning, learning difficulties, consultation functioning, learning difficulties, consultation to teachers on the basis of the assessment of to teachers on the basis of the assessment of a given child- how to translate the assessment a given child- how to translate the assessment into instructional objectives, and parent into instructional objectives, and parent consultation. consultation.

Other Related Mental Health Other Related Mental Health Professions (and Differences)Professions (and Differences)


School Psychology (cont-d) School Psychology (cont-d)

Over time, the scope of school Over time, the scope of school psychology has expanded, to include psychology has expanded, to include attention to parental psychopathology attention to parental psychopathology and stressful family circumstances and stressful family circumstances affecting the learning of childrenaffecting the learning of children

The legal obligation to provide the most The legal obligation to provide the most appropriate education to any child, no matter appropriate education to any child, no matter what is the level of the child’s disability, also what is the level of the child’s disability, also affected the role of the school-psychologist. affected the role of the school-psychologist.

Copyright © 2014 Jowhat is the levels of Copyright © 2014 Jowhat is the levels of the child's dsabiluty, hn Wiley & Sons, Inc. the child's dsabiluty, hn Wiley & Sons, Inc.

All rights reserved.All rights reserved.

School Psychologists (cont-d) School Psychologists (cont-d)

All these changes affected the role All these changes affected the role of school psychologists, who today of school psychologists, who today deal with a wide range of disorders deal with a wide range of disorders of childhood as well as with of childhood as well as with developing school-based and developing school-based and family-based programs such as the family-based programs such as the promotion of social skills, fighting promotion of social skills, fighting bullying, conflict-resolution and bullying, conflict-resolution and prevention of violence. prevention of violence.


Psychiatrists: MD’s who Psychiatrists: MD’s who specialize in mental disorders specialize in mental disorders

Trained as physicians with an additional Trained as physicians with an additional training in mental disorders training in mental disorders

Require 5 years of residency after the Require 5 years of residency after the regular medical school regular medical school

Training focuses on biological functioning Training focuses on biological functioning Interactions between the physical and the Interactions between the physical and the

emotional, also the results of medications emotional, also the results of medications Less training in psychological development Less training in psychological development


Psychiatrists (cont-d) Psychiatrists (cont-d)


More psychopharmacological (medication) More psychopharmacological (medication) therapies therapies

Less trained in conducting psychological Less trained in conducting psychological assessment assessment

Traditionally leaning toward the Traditionally leaning toward the psychoanalytic (Freud), psychodynamic psychoanalytic (Freud), psychodynamic models of therapy models of therapy

Shift toward evidence-based therapies e.g. Shift toward evidence-based therapies e.g. Cognitive–Behavioral and Interpersonal Cognitive–Behavioral and Interpersonal

Psychiatrists (con-d) Psychiatrists (con-d)

Until recently an important distinction Until recently an important distinction between clinical psychologists and between clinical psychologists and psychiatrists has been that only psychiatrists has been that only psychiatrists could prescribe medicationpsychiatrists could prescribe medication

This is in general still the case, though in some This is in general still the case, though in some jurisdictions clinical psychologists are being jurisdictions clinical psychologists are being trained to prescribe psychoactive medication trained to prescribe psychoactive medication

There is a decline in the number of graduate There is a decline in the number of graduate students wishing to specialize in psychiatry. students wishing to specialize in psychiatry.


Social WorkSocial Work– Emphasis on social/community conditionsEmphasis on social/community conditions– Different settings than clinical Different settings than clinical

psychologists (especially community psychologists (especially community agencies)agencies)

– Social conditions that facilitate optimal Social conditions that facilitate optimal development development

– Program planning and management Program planning and management – Diversity of settings Diversity of settings – Many function as part of mental-health Many function as part of mental-health

team team

Other Related Mental Health Other Related Mental Health Professions (and Differences)Professions (and Differences)


Social Work (cont-d) Social Work (cont-d)

Case-workers and coordinators of Case-workers and coordinators of services services

Help patients navigate in a maze Help patients navigate in a maze of mental-health services of mental-health services

Need to have either a BSW or Need to have either a BSW or MSW and supervise training MSW and supervise training progarm progarm


History of Clinical Psychology History of Clinical Psychology

Early views that did not include Early views that did not include demonic possession or evil spirits demonic possession or evil spirits causing mental illness were rarecausing mental illness were rare

Hippocrates may be first to consider a Hippocrates may be first to consider a “biopsychosocial approach”“biopsychosocial approach”– Biological, psychological and social Biological, psychological and social

factors all need to be considered.factors all need to be considered.– S t. Vincent de Paul (late 1500’s) S t. Vincent de Paul (late 1500’s)

emphasized natural forces and not emphasized natural forces and not witchcraftwitchcraft


Other Mental Health Other Mental Health Professionals Professionals

Psychiatric nurses: Psychiatric nurses: Managing Managing administrative matters in inpatient administrative matters in inpatient settings; psychoeducation and settings; psychoeducation and counseling. counseling.

Child and Youth Care-Workers: Child and Youth Care-Workers: Two-Two-year college training in child development year college training in child development and behavior management and behavior management

Applied Behavior Analysis: Using behavior Applied Behavior Analysis: Using behavior modification strategies with autistic modification strategies with autistic children children


Enlightenment period (later 1700’s) Enlightenment period (later 1700’s) – Philippe Pinel – French reformer: Philippe Pinel – French reformer:

humane treatment of the mentally illhumane treatment of the mentally ill– William Tuke – English reformer: William Tuke – English reformer:

hospitals based on appropriate carehospitals based on appropriate care– Benjamin Rush – U.S.: moral therapyBenjamin Rush – U.S.: moral therapy

1800’s – neurology as a discipline 1800’s – neurology as a discipline recognizing hysteria could not be recognizing hysteria could not be recognized as biological: Charcot, recognized as biological: Charcot, Janet and FreudJanet and Freud

History of Clinical PsychologyHistory of Clinical Psychology


Early Clinical Psychology was almost Early Clinical Psychology was almost entirely an assessment fieldentirely an assessment field

Late 1800’s – Francis Galton: differences Late 1800’s – Francis Galton: differences in reaction time as intelligence differencesin reaction time as intelligence differences

Wilhelm Wundt (Germany) first Wilhelm Wundt (Germany) first psychology laboratory, studied sensation psychology laboratory, studied sensation and perceptionand perception

James McKeen Cattell: studied connection James McKeen Cattell: studied connection between reaction time and intelligencebetween reaction time and intelligence– Coined term “mental tests”Coined term “mental tests”

History of Assessment in History of Assessment in Clinical PsychologyClinical Psychology


Emil Kraepelin (Germany)Emil Kraepelin (Germany)– Believed in biological causes to mental illnessBelieved in biological causes to mental illness– Worked on classifications of Worked on classifications of syndromes – syndromes – much much

of his work formed basis for DSM and ICD (chp of his work formed basis for DSM and ICD (chp 3)3)

Alfred Binet (France) Alfred Binet (France) – French government asked Binet and collaborator French government asked Binet and collaborator

Theodore Simon to design a measure to assess Theodore Simon to design a measure to assess children with cognitive deficitschildren with cognitive deficits

– 1908 Binet-Simon scale measured 50 tests of 1908 Binet-Simon scale measured 50 tests of mental skillsmental skills

– 1916 Lewis Terman (US) modified it, first widely 1916 Lewis Terman (US) modified it, first widely available test of cognitive abilityavailable test of cognitive ability



WWI – APA asked to develop a scale to WWI – APA asked to develop a scale to measure mental functioning of recruits measure mental functioning of recruits – Army Alpha Test (verbal abilities)Army Alpha Test (verbal abilities)– Army Beta Test (non-verbal abilities – for those Army Beta Test (non-verbal abilities – for those

who could not read or spoke limited English)who could not read or spoke limited English)– These tests and the value they gave These tests and the value they gave

recognized clinical psychology as a sub-recognized clinical psychology as a sub-discipline of psychdiscipline of psych

Testing began to flourishTesting began to flourish– Wechsler-Bellevue intelligence test 1939 Wechsler-Bellevue intelligence test 1939

(considered the gold standard in IQ tests)(considered the gold standard in IQ tests)– Projective tests – Rorschach Inkblot 1921, Projective tests – Rorschach Inkblot 1921,

Thematic Apperception Test (TAT) etc. Thematic Apperception Test (TAT) etc.



WWII – Psychologists again active in WWII – Psychologists again active in tests for armed forces tests for armed forces – MMPI – (personality test) 1943MMPI – (personality test) 1943

Heavy use of statistics and test developmentHeavy use of statistics and test development

Criticisms of Early AssessmentCriticisms of Early Assessment– Paul Meehl – importance of using statistics Paul Meehl – importance of using statistics

to testing viability of hypothesesto testing viability of hypotheses– Walter Mischel’s work showing personality Walter Mischel’s work showing personality

traits as having problems with validitytraits as having problems with validity– Behavioral assessment as a field grew in Behavioral assessment as a field grew in

part from these criticismspart from these criticisms



1980’s – Diagnostic and Statistical 1980’s – Diagnostic and Statistical Manual for Mental Disorders (DSM-III) Manual for Mental Disorders (DSM-III) published published – DSM-III more focused on observable DSM-III more focused on observable

symptomssymptoms– Focus on reliabilityFocus on reliability

Several changes in psychological Several changes in psychological assessment have recently occurredassessment have recently occurred– Clinical utilityClinical utility – does the assessment help – does the assessment help

with treatmentwith treatment– Service evaluationService evaluation – do treatments work – do treatments work



Sigmund Freud Sigmund Freud – First elaborated treatment of mental health First elaborated treatment of mental health

issuesissues– Early connection to neurology and work of Early connection to neurology and work of

CharcotCharcot– Focus on role of unconscious Focus on role of unconscious – Many subsequent followers elaborating related Many subsequent followers elaborating related

psychodynamic theories (e.g., Jung, Adler, etc.)psychodynamic theories (e.g., Jung, Adler, etc.) Lightner Witmer – coined term ‘clinical Lightner Witmer – coined term ‘clinical

psychology’ – opened a clinic (1904) to psychology’ – opened a clinic (1904) to assess and remediate learning difficulitiesassess and remediate learning difficulities

Demand for therapy increases in 1940’s Demand for therapy increases in 1940’s and 50’sand 50’s

History of Intervention in History of Intervention in Clinical PsychologyClinical Psychology


WWII WWII – Soldiers needing therapy when returning Soldiers needing therapy when returning

from warfrom war– Members of public affected by lossMembers of public affected by loss– VA hired many clinical psychologistsVA hired many clinical psychologists

Many therapy approaches developed in Many therapy approaches developed in 1940’s – 60’s1940’s – 60’s– Carl Rogers Client-centered approachCarl Rogers Client-centered approach– Several adaptations to Freud’s modelSeveral adaptations to Freud’s model– Fritz Perls – Gestalt therapyFritz Perls – Gestalt therapy– Joseph Wolpe – Systematic desensitizationJoseph Wolpe – Systematic desensitization



Criticisms of PsychotherapyCriticisms of Psychotherapy– Hans Eysenck 1952 Hans Eysenck 1952 – Levitt, 1957Levitt, 1957– Resulting in enormous amount of research Resulting in enormous amount of research

on whether psychotherapy workson whether psychotherapy works Efficacy studiesEfficacy studies – focus on studies that – focus on studies that

emphasize internal validity of the studyemphasize internal validity of the study Effectiveness studiesEffectiveness studies – focus on studies – focus on studies

that look at real world conditionsthat look at real world conditions– Meta-analysisMeta-analysis – statistical technique – statistical technique

combining several studies, showed combining several studies, showed psychotherapy effective psychotherapy effective



Contemporary approachesContemporary approaches– Albert Ellis – Rational Emotive TherapyAlbert Ellis – Rational Emotive Therapy– Aaron Beck – Cognitive TherapyAaron Beck – Cognitive Therapy– Cognitive Behavioral TherapyCognitive Behavioral Therapy– Short-term Dynamic TherapyShort-term Dynamic Therapy

Prevention in Clinical PsychologyPrevention in Clinical Psychology– A growing area of Clinical PsychologyA growing area of Clinical Psychology



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Chapter 1 – Introduction Copyright © 2014 John Wiley & Sons, Inc. All rights reserved