Download Clinical 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:

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
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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):
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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:
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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
Wakefield’s 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

Wakefield’s attempt to make definition of dysfunction
objective fails
 Examples of Specific Reading Disorder
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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 & Marino’s Example of
“Driving Disorder”
 Lilienfeld & Marino (1999) use Wakefield’s 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 person’s 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:
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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 disorders
Mood 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 disorders
Dissociative disorders
Other conditions that are the
focus of clinical attention
Eating disorders
Sexual and gender identity
disorders
Impulse-control disorders
Adjustment disorders
Sleep 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 obsessivecompulsive, 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
Are DSM-IV Classifications Valid?
 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
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:
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Down Syndrome
Fragile X Syndrome
PKU
Alzheimer’s Disease
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Major Depressive Disorder
Anxiety Disorders
Schizophrenia
Bipolar Disorder
 Most mental disorders appear to merge imperceptably
into one another and into normality (Kendler & Gardner,
1998)
 Examples:
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 nonspecific.
 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 we’ll
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: Cloninger’s 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 didn’t 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?
 Naïve assumption:
 Look for bimodality in distributions of the
characteristic(s) in question.
 But it’s 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
Frequency
60
40
20
0
1
3
5
7
9
11 13 15 17 19
Scores
(A) Dichotomy
There are only two
levels, and all people
are at one of those
two levels
Categorical versus
Dimensional Conditions
60
Frequency
Frequency
60
40
20
0
1
3
5
7
9
11 13 15 17 19
Scores
40
20
0
1
3
5
7
9
11 13 15 17 19
Scores
(B)Dimensional
Considerable
variety across
population
Categorical versus
Dimensional Conditions
60
Frequency
Frequency
60
40
20
0
40
20
0
1
3
5
7
9
11 13 15 17 19
Scores
1
3
5
7
9
11 13 15 17 19
Scores
Frequency
60
Bimodal Distribution
40
20
0
1
3
5
7
9
11 13 15 17 19
Scores
Variability within each
category
Meehl’s 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
 (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
0.7
0.6
0.5
Covariance
 A peaked covariance
curve reveals the taxon.
 The position of the
peak provides a
means of estimating
the taxon base rate
0.4
0.3
0.2
0.1
0
1
2
3
4
5
6
Slabs
7
8
9
10
Other Taxometric Procedures
 Maximum Eigenvalue
Method (MAXEIG)
1.2
Max. Eigenvalue
 Similar to MAXCOV
but can handle more
than 3 indicators.
 Examines the
maximum eigenvalue
of the first principal
component instead of
covariance.
1.4
1
0.8
0.6
0.4
0.2
0
1
2
3
4
5
6
Windows
7
8
9
10
Other Taxometric Procedures
 Latent Mode
Method (L-Mode)
 Factor analysis is
performed on
indicators.
 Frequency plot of
1st 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)
Conduct Problems (z-score)
Results of Wootton et al. (1997)
3
2.5
2
1.5
Low CU Traits
High CU Traits
1
0.5
0
-0.5
Low Negative
Parenting
High Negative
Parenting
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
3.4
1.34
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Eigenvalues
2.27
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2
4
-4
-2
0
X-slabs (Moving Windows)
2
4
MAXEIG Curves for Actual Data:
Input Indicators 1 and 2
Child ICP
Child N
1.75
1.9
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1.17
1.27
Eigenvalues
Eigenvalues
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2
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X-slabs (Moving Windows)
2
4
MAXEIG Curves for Actual Data:
Input Indicators 3-5
Child CU Traits
Parent N
Parent ICP
1.82
2.45
1.99
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X-slabs (Moving Windows)
2
4
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
0.25
0.3
Density
0.2
0.15
0.10
0.1
0.05
Factor Scores
Factor Scores
4
2
0
-2
-4
6
4
2
0.00
0
0.0
-2
Density
0.20
L-Mode Curve for Actual Data
0.25
0.15
0.10
0.05
Factor Scores
6
4
2
0
-2
0.00
-4
Density
0.20
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 clinician’s 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 shouldn’t 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 don’t 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 Don’t Clinicians Develop the
Expertise They Believe They Have

So why doesn’t 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 Cohen’s
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
Cohen’s d ≈ .70
 Average treated person better off than ≈ 75%
of controls.
Common Factors: An Important
Source of Therapy’s 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
Wampold’s meta-analysis were CBT programs.
Some Treatments Are More
Effective Than Others
 Effect sizes for Cognitive-Behavioral Therapy (CBT)
programs are generally quite high:
 Barlow’s Panic Control Therapy Panic Disorder with
Agoraphobia

Cohen’s 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 treatment’s 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
treatment’s 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
Levant’s 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 association’s newsletter.
 He withdrew the critique in one case
because the editor planned to publish a
reply by Larry Beutler
Levant’s 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
Beutler’s 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
not…recover 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 Ost’s 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