1. Clinical Psychological practice: An overview

Question 1

What is the 1 thing you must remember about clinical psychology practice?

Answer 1

BEING PERSON CENTRED

Client is the focus of the session. Use their words and try to remove psychological jargon so it is accessible to them.

Question 2

What is the clinical golden chain? (5)

Answer 2

Assessment 
Formulation
Communication
Intervention
Evaluation

Question 3

Before assessment, what must you do? (5 steps)

Answer 3

1) read existing reports and referral letters (from GPs, school reports etc.)
2) Refresh relevant DSM-5 Symptom profiles.
3) Refresh relevant formulation models
4) Decide who to invite to the session
5) Hypothesize what possible problems could be

Question 4

Why do we need to refresh relevant DSM-5 symptom profiles before assessment?

Answer 4

Helpful to know what symptoms cluster together. Diagnosis is not the main priority, need to know risk factors and maintaining factors. Not just about symptom reduction.

Question 5

What should you do at the beginning of the assessment? (3)

Answer 5

1) introduce yourself and the duration of the meeting
2) explain confidentiality and its limits. create a safe space with confidentiality, but only to the extent of not endangering self or others.
3) Build rapport/working alliance with client.

Question 6

What are the 4 things you need to remember when building rapport with the client?

Answer 6

1) Emotional balancing
2) Appropriate self-disclosure
3) Emotional validation (don’t ignore non-verbal information. Must communicate that you can validate and hear/see what the person is feeling)
4) Active listening

Question 7

What is emotional balancing?

Answer 7

Modulate/regulate the person’s mood. If person is hyper, try calming the person by speaking in a lower tone and at a slower pace. If person is too depressed, try to be more encouraging.

Question 8

How to do active listening? (4)

Answer 8

1) Body language such as eye contact and nodding
2) Appropriate silences
3) checking that you got it right – rephrasing and clarifying, summarising
4) Reflect implicit feelings

Question 9

What should you do during the assessment?

Answer 9

1) observe the client during the interview

2) observe your own emotional reactions to the client (reflective practitioner)

Question 10

What are the 2 concepts associated with being a reflective practitioner?

Answer 10

1) transference - is what one person transfers from a previous relationship to the current one (can occur for therapist or client)
2) countertransference - the response to the transference (can occur for therapist or client)
Key idea is one person transferring his/her own history of relationships from their past into the present relationship.

Question 11

What are the main tasks of assessment? (6)

Answer 11

1) Risk assessment – risk to self (self-harm, suicide), risk to others (homicide), risk from others (abuse, neglect)
2) Identify factors (4Ps)
predisposing, precipitating, perpetuating, protective
3) Identify strategies of coping
4) Set goals for therapy
5) Expectations of Therapy
6) Behavioral observation

Question 12

Describe the 4Ps.

Answer 12

1) Predisposing factors – relevant life history or personality traits that increase vulnerability.
2) Precipitating factors – Recent triggering events. Current concerns.
3) Perpetuating factors – Explore what maintains the problems
4) Protective factors – Strength and resources. (personal strength and resilience, faith/religion, networks and support, positive beliefs)

Question 13

How do we explore current concerns?

Answer 13

By exploring the meaning of the problem. Frequency, duration, and intensity of the problem. Use ratings and anchor points.

Question 14

Which aspects of the client’s history must you ask about? (7) (FEMDOPS)

Answer 14

1) family history
2) educational history
3) medical history
4) developmental history
5) occupational history
6) problem history
7) social/personal history

Question 15

What must you ask regarding family history?

Answer 15

living arrangements, relationship nature + quality with various members, social support network, family psychiatric history

Question 16

What must you ask regarding educational history?

Answer 16

school, year, academic performance, cognitive, speech, reading ability

Question 17

What must you ask regarding medical history?

Answer 17

medication, side effects, previous psychological consultations problem treatment outcome, what worked and what didn’t

Question 18

What must you ask regarding developmental history?

Answer 18

childhood, early years, developmental milestones

Question 19

What must you ask regarding occupational history?

Answer 19

first job, adjustment to work, relationship with boss + colleagues, satisfaction

Question 20

What must you ask regarding problem history?

Answer 20

frequency, intensity, duration, onset, previous episodes, previous attempts to solve, triggers

Question 21

What must you ask regarding personal/social history?

Answer 21

hobbies/interests, peer relationships, personality, religion, impact of presenting problems on activities

Question 22

What demographic information must you collect during the assessment? (4)

Answer 22

• Age
• DOB
• Gender
• Race

Question 23

How do you assess risk?

Answer 23

1) risk to self
2) risk to others
3) risk from others
In terms of:
- ideation, frequency, last episode, plan, access to means, protective factors
Substance use:
- what, when, how much, legality and jail time, hospitalization
Violence:
- forensic history (trouble with police)

Question 24

What are some expectations of therapy that you must establish with the client?

Answer 24

goals, timelines, number of sessions and how often, motivation, attitudes

Question 25

What are some behavioral observations that you have to make?

Answer 25

• clothing and hygiene
• alertness
• mood
• voice (pitch, clarity)
• motor
• facial expression
• flow of thought
• association
  1) activity level
  2) attention span
  3) impulsivity
  4) social relationships. eg. how mother relates to son.

Question 26

Why must you know about the person’s personal history?

Answer 26

Move away from a problem-focused conversation. Other real aspects of the person’s life is being ignored because there is too much focus on the problem.

Question 27

How should you set goals for therapy? (3)

Answer 27

1) Measurable - so progress can be tracked
2) Shared goals - client must define their personal goals. client must have a sense of responsibility so he/she will be more likely to come back for sessions.
3) Concrete - make the problem concrete (eg. “wally” the anxiety creature)

Question 28

What are the 4 different kinds of formulation approaches?

Answer 28

1) Behavioral theory
2) Cognitive behavioral theory
3) Systemic theory
4) Psychodynamic theory

Question 29

Describe Behavioral Theory.

Answer 29

Considers people’s behaviors, the function they serve, and the environmental factors that may reinforce them. “Functional Analysis” - All behaviors have a purpose.
Figuring out the links between:
- Antecedent triggering events
- Behaviors
- Consequent reinforcing events
A triggers B (precipitating factors)
C reinforces B (operant conditioning principles)
You want to change B (problematic behaviors), SO you must first alter A or C.

Question 30

Describe Cognitive Behavioral Theory. (4)

Answer 30

• Concerned with the interactions between thoughts (cognition), behaviors, and emotions. Emotions, behavior are shaped by thoughts about events which result from beliefs and schemas. Aim of CBT is to identify and change these maladaptive beliefs and thoughts.
• “Guided discovery” strategy for assessment and intervention.
• Core beliefs & Intermediate beliefs
• Triggering event
• Vicious cycle

Question 31

What are Core Beliefs?

Answer 31

beliefs about the self, others, and the future. (“Others are evil and out to get me.”)

Question 32

What are intermediate beliefs?

Answer 32

beliefs in response to core beliefs and to mitigate the impact of core beliefs (“I must never show weakness and vulnerability.”)

Question 33

Describe a vicious cycle.

Answer 33

Automatic Unhelpful Thoughts, Emotions, Unhelpful Behaviors, Bodily sensations -> Consequence

Question 34

Describe Systemic Theory. (4)

Answer 34

• Focuses on the environmental systems in which the individual is located (eg. family, couple, school). ‘Stuckness’ of the system gives rise to these symptoms. Must work with stuck system to promote change.
• “Circular questioning” strategy for assessment and interview (eg. how A causes B, which reinforces A in a feedback loop etc.)
• Problem definition from the view of each member (complex non-linear relationship)
• Progression and evolution of problem over time.

Question 35

What are the 4 general principles of formulation?

Answer 35

1) Integrate multiple sources of information gathered (referral letters, observation, client’s self-report, social system around client)
2) Map out problem in a collaborative way
3) Formulation as a form of intervention and therapy in itself.
4) 4P framework - predisposing, precipitating, perpetuating, protective factors

Question 36

How should we map out the problem in a collaborative way?

Answer 36

Psychologist, MDT team, client, and social system must come to a consensus to work on the same framework. Can readjust the formulation overtime based on feedback and repropose.

Question 37

In what ways is formulation itself a form of intervention and therapy in itself? (3)

Answer 37

1) Helps to break down and make sense of the problem, and make it look more manageable.
2) Formulation is like a road map that gives you direction and what to do next.
3) Informs treatment planning. Viewed as hypotheses to be confirmed or disconfirmed by later information. Can be modified and refined as the intervention progresses.

Question 38

What are the 3 forms of communication as a therapist?

Answer 38

1) Formal letters to or meetings with other professionals. Coordinate care and reinforce work done.
2) Informal communications to client’s social system. (especially for child clients who are dependent on family system)
3) Therapeutic letters to client (empowerment and collaboration, build rapport) Other professionals will be copied the letter.

Question 39

What are 3 forms of behavioral intervention?

Answer 39

1) Graded exposure (phobias) - do it in stages and slowly increase intensity. must be comfortable with one stage before moving on to the next.
2) Response inhibition - stop avoidance
3) Reward charts - reward for every rung achieved to reinforce behavior

Question 40

What are 2 forms of cognitive behavioral intervention?

Answer 40

1) thought challenging
2) emotion regulation skills
- deep breathing
- muscle relaxation
- safe place imagery

Question 41

How to engage in thought challenging? (3 steps)

Answer 41

1) Identify the unhelpful thought/belief
2) Find evidence for and evidence against (client led)
3) Experiential learning with ‘Behavioral Experiments’ - experiment with alternative thought by testing it out. Experience it to strengthen and reinforce the new thought.

Question 42

What are some actions to take with regard to systemic intervention? (3)

Answer 42

1) self-care plan for caregivers/parents
2) parental coaching (mum can be home therapist to the child and administer emotion regulation exercises with child)
3) Attempt to involve other important people

Question 43

What are 3 general principles for interventions?

Answer 43

1) intervention plans must be formulation derived. provides structure and basis.
2) choose intervention based on TRIPOD - evidence based, clinician’s expertise, client & social system’s preference
3) Eclectic/integrative approach

Question 44

What are 3 general principles for evaluation of interventions?

Answer 44

1) Quantitative measures
- standardized measures; symptom reduction
2) Qualitative measures
- personal goal ratings
- caregivers’ impressions of whether intervention is helping
- be mindful of bias
3) review sessions
- check in after each session
- midterm review session after 6 weeks. slow down, quicken, change directions, or end therapy.

Question 45

What kind of bias can appear when it comes to qualitative measures in evaluation?

Answer 45

• some clients may want to please their psychologist so they give overly positive answers
• some clients may not want the work to finish so they overemphasize their problems
• if evaluation really suggests that intervention is not helping, explore possible reasons why and modify formulation accordingly

Question 46

Communication: What are 3 points to consider with regard to communication?

Answer 46

• what information needs to be conveyed?
• what emotional impact does it have?
• what is the most effective way to convey it?

Question 47

What are some benefits and disadvantages to group intervention?

Answer 47

Benefits:
1) can meet other clients with similar difficulties and make them feel less alone as they provide mutual support
2) build confidence when they explore how to relate to others
Disadvantages
1) can be daunting to some clients
2) Group dynamics may not work out well

Question 48

Describe short term psychodynamic therapy.

Answer 48

• focus on ways in which emotional and relationship dynamics early in life come to be replayed in later life in unhelpful ways that give rise to psychological symptoms
• early life experiences (usually with early caregivers) give rise to internalised models and behaviors about what it takes to remain connected emotionally to that caregiver. While these models have been adaptive in childhood, these internalised models of relationships can lead the person into repeated relationship patterns which are unhelpful and distressing.
• focus on changing ingrained patterns of interpersonal relating. Give clients new experiences of relationships and integrating these new experiences into their conscious awareness.

Question 49

When is short-term psychodynamic approach used?

Answer 49

used when the origins of a person’s difficulties have a strong interpersonal focus
useful even if main therapy is centred in CBT-based framework.