Week 1 - Introduction to Clinical Psychology

Week 1 - Introduction to Clinical Psychology Clinical psychology is… “An integration of science, theory and clinical knowledge for the purpose of understanding, preventing and relieving psychologically-based distress or dysfunction and to promote subjective and behavioural well-being” (APA) Who do CPs work with? • Clients, or service users, presenting psychological difficulties. • People of all ages (children, adolescents, adults, older adults). • Problems include: - Anxiety and depression - Addictive behaviours - Enduring mental illness - Developmental disorders - Neurological disorders - Family relationships - Learning disabilities - Eating disorders Where do CPs work? • Mostly NHS services, but also non-statutory mental health providers and private practice • Across all levels of healthcare delivery • Academia Tertiary care - Specialist services for complex needs (e.g. eating disorders wards, dual diagnosis services) Secondary care - Community or hospital-based services (e.g. CMHTs, psychiatric wards) Primary care - First point of contact with clients, (e.g. GP surgeries ) CMHT: Community Mental Health Teams PICU: Psychiatric Intensive Care Units What do CPs do? 1. Assessment 2. Formulation 3. Intervention 4. Evaluation 5. Research 6. Other responsibilities 1. Assessment • Conduct measures to gain insight into, and form hypotheses about, the nature of psychological/behavioural problems. • Results often used to establish a cause and assist in planning treatments or arranging services. • Clinical psychologists have expertise in administering many different types of assessment. Types of assessment Clinical interviews • The clinical interview is often the first form of contact a service user has with a clinician. The objective is to gain a broad insight into the client’s problems. • Questions may relate to the nature of the client’s symptoms, their past history, and their current living and working circumstances. • Types of questions depend on the theoretical orientation of the clinician. • Limitations include low reliability and interviewer bias. Psychological tests • Quantitative assessments that are used frequently in clinical psychological practice. • They usually assess the client on 1 or more specific characteristics or traits (e.g. anxiety level, depression, IQ, paranoia, hysteria etc). • They often have rigid response requirements so questions can be scored via a standardized system. Example question from the “State-Trait Anxiety Inventory” (Spielberger, et al., 1983). This format is common across many tests. • Popular tests are standardized – they have been administered to large numbers of people and statistical norms have been established. • A clinician will identify where a client falls in relation to the normal distribution of scores for a given test. • The client’s score may also indicate whether they meet diagnostic criteria for a psychological disorder. For example, scores on the Clark-Beck Obsessive-Compulsive Inventory (Clark & Beck, 2003) estimate the probability of OCD. • Unlike quizzes and questionnaires you might find in magazines or on Facebook, psychological tests are rigorously screened to ensure validity and reliability. VALIDITY? They actually measure what they claim to (e.g. scores on a written test of anxiety correlate with behavioural measures of anxiety). RELIABILITY? The test is consistent when administered to the same person at different times. Psychological tests: Personality Inventories • Describe patterns of behaviour, thoughts and feelings. • For example, the Minnesota Multiphasic Personality Inventory 2 (MMPI) consists of 567 self-statements which the client scores as “true”, “false” or “cannot say”. • The questions relate to mood, physical concerns, social attitudes, psychological symptoms and feelings of well-being. • Also contains items that allow the clinician to estimate whether the client is providing false information. Psychological tests: Specific Trait Inventories • While personality inventories assess a range of traits, other tests measure functioning in one specific area or one specific psychopathology. • For example, the Obsessive Belief Questionnaire (Steketee et al., 2005) assesses beliefs and appraisals considered critical to the acquisition and maintenance of obsessions: 1. Intolerance of uncertainty 3. Control of thoughts 5. Beliefs about responsibility 2. Overestimation of threat 4. Importance of thoughts 6. Perfectionism Psychological tests: Projective tests • A set of ambiguous stimuli are presented for the client to interpret in their own way. • The objective is to reveal unconscious psychological dynamics such as motivations and perceptions of the self and the world. • Often substantial variation between clients’ responses and clinicians’ interpretations. • Popular examples include the Thematic Apperception Test, the Sentence Completion Test and the Rorschach Inkblot Test. Rorschach Inkblot Test (projective) There are 10 official inkblots and clinicians interpret responses using a structured scoring system (e.g. Exner & Weiner, 1995) that provides personality norms and indicators of psychopathology. Clients’ responses are timed. 1. What might this be? 2. Tell me everything you see in the blot and where you see it. Sentence Completion Test (projective) • The clinician provides the first part of a sentence which the client must complete in their own words: “I feel…” “My father…” “I need…” “Most girls…” * Individuals suffering a particular psychopathology may have biases in the accessibility, encoding and retrieval of certain sorts of information (e.g. Kimble et al., 2002). Psychological tests: Intelligence tests • Measure a client’s IQ in comparison to a population of people with similar characteristics (e.g. age or education). • Most have a M of 100 and an SD of 15-16; 68% of the population score between 84-116 and approx. 2-3% score <70. • Intelligence tests are used by CPs for a number of purposes: 1. Diagnose intellectual & learning disabilities. 2. Identify specific areas of need. 3. Research. Psychological test example: Leiter-R intelligence test • Being one of the five most used international tests in the world, the Leiter test is a nonverbal IQ test that helps evaluate intelligence on more cognitive and intellectual bases, and which has fewer requirements compared to other IQ tests. • There have been different versions of the Leiter test until this day (Leiter, Leiter R, etc.). As its first versions were only suitable for children aged 2 to 20, the latest version, the Leiter-3 test, which was revised in 2013, is used for ages 2 to 75+. • It is considered to be a fair testing for children all around the world as it doesn't require knowledge of any specific language. Psychological tests: Neurological impairment tests • Identify psychopathologies caused by damage to the structure and functioning of the brain or CNS rather than problematic life experiences or dysfunctional thinking. • Neurological damage can be caused by traumatic injury (e.g. car accident), cardiovascular problems (e.g. stroke), cerebral infection (e.g. meningitis), a brain tumour, or a degenerative brain disorder (e.g. Alzheimer’s disease). • CPs employ a battery of tests, including EEG, PET and fMRI scans and blood tests. Psychological tests: Neurological impairment tests • Neurological tests measuring cognitive, perceptual and motor performance indicate underlying brain dysfunction (Rao, 2000). • Different psychological functions are localised in different areas of the brain, so discovering a specific cognitive deficit can help identify which brain region is damaged. Clinical Observation • In addition to conducting psychological tests, CPs need to assess behaviour in its natural context (e.g. home, classroom, community setting). • Involves recording behaviour frequencies and allows identification of events that trigger (precede) or reinforce (follow) problem behaviours. • Excellent ecological validity and can suggest workable solutions. However, training takes time, behaviour can be context specific, and raters may code behaviours differently. 2. Formulation • Information generated through assessment is used to formulate an understanding of the client’s difficulties and develop a treatment plan. • The medical approach is to establish a diagnosis using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). • They describe categorical disorders that can be identified by set lists of criteria. The practitioner will work out whether the client’s symptoms meet criteria for a specific disorder. • Many CPs believe that each client’s problems are unique and thus require an individualised approach (Persons, 1989). • In collaboration with the client, the CP will develop a precise psychological account of their problems (not imposed on them like a psychiatric diagnosis). Persons’ (1989) 6 formulation components: 1. Create a list of the client’s problems. 2. Identify and describe the underlying psychological mechanisms that might be mediating these problems. 3. Understand the way that these psychological mechanisms generate the client’s problems. 4. Identify the events that may have precipitated the client’s problems. 5. Identify how these precipitating events may have caused the current problems through the proposed psychological mechanisms. 6. Develop a treatment plan based on these explanations and predict any obstacles. 5 advantages over diagnosis (Tarrier, 2006): 1. Flexible and idiosyncratic understanding of each client’s problems irrespective of diagnostic labels. 2. Collaborative, treats the client with regard. 3. Based on a theoretical understanding of causal psychopathology (diagnosis is based on description of symptoms). 4. Can include information about a client’s history and their personal, social, and familial circumstances. 5. Allows development of treatment strategies that are moulded to the individual’s needs. 3. Intervention • Involves using a psychological model or therapeutic approach to facilitate the relief of problems. • Involves a formal relationship between the CP and client(s) – an individual, couple, or family . • Employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving. • The nature of intervention will differ depending on the CP’s theoretical affiliation and specific training. Psychodynamic • “Psychoanalysis” – based on the theoretical work of Sigmund Freud (1856-1939). • Assumes that unconscious conflicts (the cause of psychopathology symptoms) develop early in life, and psychodynamic interventions aim to identify these events. • Once identified, the CP will help the client to acknowledge these conflicts, bring them to conscious awareness, and develop strategies for change. • Techniques: Free association, transference, dream analysis. Behavioural • In the 1940s and 1950s, there was growing dissatisfaction with the unscientific psychodynamic approach. • Many psychologists turned to behaviourism for objective knowledge that could inform conceptualisation and treatment of psychopathology. • Numerous psychological disorders were the result of “faulty learning” and symptoms were acquired through simple conditioning processes. • For example, anxiety symptoms could be acquired through classical conditioning, and behavioural problems could be acquired through operant conditioning. • Behavioural interventions use conditioning principles to “unlearn” problematic associations and behaviours. • Techniques: Flooding, systematic desensitisation, exposure therapy, aversion therapy, functional analysis. Cognitive • Current most popular model of psychopathology; 1 in 4 CPs identify with this approach (Prochaska & Norcross, 2003). • Some psychopathologies are caused by dysfunctional thinking about the self or the world, or dysfunctional processing and interpretation of incoming information. • For example, anxiety disorders are characterised by a bias towards processing threatening information and interpreting ambiguous information negatively. • Cognitive treatments try to change dysfunctional processing in order to relieve related psychopathology. A popular and varied therapeutic approach is Cognitive Behavioural Therapy (CBT). • A CBT intervention often has the following characteristics: 1. The client keeps a diary noting how events, feelings, moods and thoughts co-occur. 2. The CP helps the client to challenge irrational, dysfunctional or biased thinking. 3. At home, the client is instructed to test the rationality of their thoughts via behavioural experiments. 4. The client is trained to think, behave and react differently in situations that evoke their psychopathology. Systems/Family • Addresses psychopathology resulting from relationship dynamics within the family. • It views the family as a social system. It seeks to identify the complex relationships and alliances that exist between family members, and re-mould these into those expected in a well functioning family. • Usually involves ensuring the primary relationship in the family – between the two parents – is strong and functional (Minuchin, 1985). 4. Evaluation • Continuous assessment of the effectiveness of an intervention and the client’s ongoing needs. Which treatment approaches are most effective? • Several studies have shown that most common therapies do not differ in their effectiveness, but are all more effective than “placebo” and “no treatment” conditions (Gibbons et al., 1993; Smith et al., 1980). • “Dodo Bird Verdict” 5. Research CPs as “scientist-practitioners” • Widely held view that CPs should be scientist-practitioners: applied scientists with expertise in research and therapeutic practice. • Most clinical training courses are based in University psychology departments and involve substantial research components. • Current view in the UK is that research methods and findings should be systematically integrated into clinical work (Barker, Pistrang & Elliott, 2002). • Mental health services are increasingly required to provide scientific evidence that treatments are effective. • In the UK, the National Institute for Health and Care Excellence (NICE; see www.nice.org.uk) promotes and recommends treatments that are “evidence-based” – their efficacy has been demonstrated through scientific research. • Many forms of therapy are not amenable to assessment through traditional scientific methods (e.g. psychoanalysis). What sorts of research do CPs conduct? 1. Basic Research - Investigations into the “aetiology” (causes/origins) of psychological disorders. 2. Primary Research - Development of interventions based on understanding of aetiology. 3. Secondary Research - Evaluations of treatment efficacy or comparisons between types of interventions (e.g. drug vs psychological treatment of depression). Research designs in clinical psych Correlational Designs • Very common; determine whether there is a statistically significant relationship between variables. • Examples: - Is trait anxiety associated with worrying? - Is body dissatisfaction associated with excessive dieting? - Is the drug availability associated with substance abuse? • Does not imply a causal relationship or explain why the variables are related. Longitudinal/Prospective Designs • Measures the same participants on two or more occasions to specify time relationships between variables. • As measurements are taken at Time 1 and Time 2, it is possible to identify concurrent and longitudinal predictive relationships between variables. • For example, does body dissatisfaction in childhood predict harmful eating behaviour during childhood (Time 1) and/or adolescence (Time 2). Indicative of causal relationships. Epidemiological design • Typically a large-scale survey that provides descriptive details about the prevalence of psychological disorders. • Can identify what factors correlate with a specific disorder, whether a disorder is more prevalent in a particular group (e.g. men vs women, young vs old), what risk factors are associated with a disorder, and whether a disorder’s incidence rate is increasing or decreasing. • Require a large sample that is representative of all types of people in the specified population. Experimental design • Involves recording how the manipulation of a variable (e.g. mood) influences an outcome measure (e.g. worrying). • Enables the determination of causal relationships and the direction of causal effects. • Vital to developing theories and models about the aetiology of psychopathologies (Field & Davey, 2005). Mixed design • Experimental study in which participants are NOT randomly assigned to conditions. • If we wished to discover whether negative mood caused anxious individuals to worry more than depressed individuals, we would ensure that one group contained only anxious individuals and another group contained only depressed individuals. • Used frequently to assess the effectiveness of a particular intervention on people with different psychiatric diagnoses. Natural experiment • Data collected in non-laboratory contexts following natural events (e.g. large scale disasters). • Griensven et al. (2006) found that survivors of the 2004 tsunami in Thailand exhibited increased symptoms of PTSD, anxiety and depression. • Weems et al. (2007) found that PTSD symptoms in children after Hurricane Katrina were highest in those with previously high trait anxiety. Single case study • Most employ an “ABA” design: 1. An initial baseline stage involves measurement of behaviour prior to intervention (A). 2. Next comes a treatment stage where the experimental manipulation is introduced and its effect on behaviour is measured (B). 3. Finally, a second baseline stage is included to assess effect longevity and ensure changes at B were not random (A). • One individual both an experimental and control participant. Enables inferences about causal relationships. Qualitative methods • Rather than numbers, the data for qualitative research is often language (e.g. a participant’s description of themselves, their feelings, thoughts about the world, emotions etc). • Participants are selected based on the psychopathology or phenomenon of interest (e.g. sufferers of childhood abuse, parents of autistic children etc; Cresswell, 1998). • Data usually collected in a semi-structured, open-ended interview (Kvale, 1996). The researcher tries to interpret the transcript, picking out consistent themes and deciding how these themes relate to their research question. 6. Other responsibilities Consultation; provide psychological perspective as part of a multi-disciplinary team. Supervision & training; train other professionals in specific psychological assessments and interventions. Teaching; contribute to training of new clinical psychologists as part of a DClinPsy programme. Expert testimony; offer scientific expertise in legal contexts. How do I become a clinical psychologist? UK training pathway • 30 universities offer NHS funded DClinPsy degrees. All BPS & HCPC accredited. • 3 years, full-time, doctoral level training. Includes academic (teaching), clinical (placements) and research (dissertation) components. • Paid – “Trainee Clinical Psychologist” • Highly competitive – in 2020 there were 4225 applicants for 770 places (18% success rate). How to get on the DClinPsy? - Academic Qualifications: 1) BPS Graduate Basis for Chartered Membership. 2) 1st or 2:1 class BSc/BA in Psychology (or 2:2 with evidence of further academic qualifications). 3) *OPTIONAL* Relevant MSc. Benefits: get ahead of candidates who only have a UG degree, additional research experience, opportunity to specialise/acquire skills/knowledge. 4) *OPTIONAL* Relevant PhD. Benefits: highest academic qualification, 3-years’ paid research & clinical experience, opens new career doors. - Relevant experience: Vocational: • Voluntary or paid work (part- or full-time) involving caring or service roles with a relevant client group (any vulnerable population). Must be obtained BEFORE applying. • Provides an opportunity to work in the field before committing to CP. Experience first-hand the contexts and people that CPs work with. Strengthens your CV even if you decide to pursue another career path. • Need to convince course selection panel that (a) you know what you’re applying for, and (b) you possess the personal and professional attributes to succeed on the DClinPsy course and as a future Clinical Psychologist. - What counts as “relevant”? • Many DClinPsy trainees apply from mental health roles in the NHS (e.g. IAPT, assistant psychologist). • Other successful applicants have worked in Social Services, services for people with disabilities or psychological problems, or charitable organisations. • If possible, seek regular supervision or contact from a qualified clinical psychologist. - How much is enough? • No definitive answer. • Quality is as important as quantity. • Selection panels are primarily interested in what you have learned/gained from your experiences personally and professionally. Effective and convincing communication is vital. • Individual course centres will provide details on their entry requirements. - When should I get experience? • Plan your time effectively to maximise the amount of experience you obtain. • Tip: volunteer over the summer, in the evenings or at the weekends so you have an emerging portfolio of experience before you graduate. • Apply to the Psychology Employability Programme! - Relevant experience: Research • In addition to your UG project, it is necessary to gain additional research experience. • Options include a Research Assistant post or a clinically relevant PhD. • Research might be related to clinical psychology in some way – either it involves direct contact with users of clinical psychology services, or the results have clinical implications. • Do not necessarily need a specific “research post” – this experience can be gained in a clinical role that is associated with research or service evaluation. - How do I apply? • Apply through the Clearing House website. • Select several institutions; the same application goes to each. • Multi-stage selection process (online & written tests, presentations, group work, problem solving, role plays); differs between course centres.