Introduction to Clinical Assessment

Question 1

In what ways can psychological assessment inform intervention and treatment planning?

Answer 1

• Allowing the psychologist to identify and prioritise client needs
• Identifing client characteristics that may help or hinder treatment outcomes
• Considering treatment and referral options incl service matching, monitoring change
• Predicting prognosis and treatment outcomes
• NB: Assessment and intervention are integrated and inform each other throughout the treatment process

Question 2

According the the NHMRC guidelines, what are the levels of quality of research findings?

Answer 2

Question 3

What factors are important to consider when interpreting the APS Literature review of evidence based treatment?

Answer 3

• Level, Relevance and Strength of evidence
  
  • Level = See table of level of evidence (RCT vs Case study etc)
  • Relevance = extent to which findings can be applied to different settings
  • Strength = Size of treatment effect
• Some interventions are not supported due to limited research rather than ineffective findings
• The best practice is for psychologists to use evidence based treatments combined with situational other factors to identify treatment efficacy

Question 4

What are some of the evidence findings in the APS literature review?

Answer 4

• Emotional Disorders
  
  • Depression: Level 1; CBT, Interpersonal, Brief Psychodynamic and Self Help. Level 2; Solution based, Dialectical Behaviour, Emotion focused.
  • Bipolar: Level 2; CBT, Interpersonal, family, mindfullness, psychoeducation
• Anxiety Disorders
  
  • GAD: Level 1 CBT, Level 2 psychodynamic. Level 3 mindfullness
  • Social: Level 1 CBT, Level 2 self help and psychodynamic
• BPD; Level 1 DBT, Level 2 Schema and psychodynamic
• Anorexia: Level 2 family therapy and psychodynamic

Question 5

What are some of the limitations of RCTs? What are the arguments against the assumption of specific effects?

Answer 5

• Lack of external validity: The real world is never as controlled as the trial
• The concept of the placebo: RCTs are based on a medical model.
  
  • In psychotherapy everyone knows which treatment is being delivered - there is no true placebo
• The Assumption of Specific Effects: assumption that each therapy has unique active ingredients. 3 Arguments against this:
  
  • The dodo bird verdict: all psychotherapies have very similar, robust success (dodo from Alice in Wonderland - “you are all winners”)
    
    • has been found in many experiments
  • Component Studies: Break down therapies into components (often compounding eg full CBT or parts). Studies find no major differences.
  • Estimates regarding effect of specific techniques on outcome: most estimates are that model/technique factors account for 15% of outcome varience.
• Bias in experiments: unfair comparisons and loyalty

Question 6

What are some alternatives to RCTs that can be used to complement them?

Answer 6

• Effectiveness Studies: Evaluate treatment outcomes in naturalistic settings and provide better generalisability.
• Process Research: breaks down the factors of a treatment to determine the why and how it is effective. This facilitates a deeper understanding of the therapy in clinical settings
  
  • responsive to context and complex factors of theraputic alliance
• Single subject research: addresses threats to internal and external validity.
  
  • Can be used where RCT cannot eg smaller population sizes
• Case Studies; add richness to other data by looking at very specific contexts

Question 7

What are the differences between evidence based treatment and evidence based practice?

Answer 7

Question 8

What are the the common factors in the outcomes of psychotherapy?

Answer 8

There are five common factors in psychotherapy:

• The client/extratheraputic: accounts for 87% of varience
  
  • The client is the agent of change
• Therapist effects: 6-9% overall (49-69% of treatment effect) variance
  
  • Most of this is due to overlap with the alliance
• The Theraputic Alliance: 5-7% (38-54% treatment) varience
• Model Technique (delivered): belief in treatment
  
  • Model alone: 1% (8% treatment effect)
  • Model delivered (including allegence and expectancy) 30% up of treatment effects
• Feedback effect: 15-30% of treatment effects

Question 9

What are the problems with manuals and diagnosis?

Answer 9

• Diagnosis
  
  • DSM lacks internal reliability ( a lot)
  • There is no ‘baseline’ normal model of mental health
  • Diagnosis provides little information that effects treatment
• Manualisation
  
  • High adherance to manuals is inversely correlated with theraputic alliance and interpersonal skills
  • Manuals depend on specific effects (which are not well suported)

Question 10

What is Behavioural Assessment? What are some of the core assumptions?

Answer 10

• ABC model of behavioural assessment: direct investigation of problematic behaviour by examining antecedents and consequences
  
  • Antecedent (what happened prior) Behaviour (of concern) Consequences
• Behaviours follow the principles of conditioning (operant and classical)
  
  • eg punishment, extinction, positive and negative reinforcement
• Behaviour can be overt (actions) or covert (thoughts) but both are:
  
  • directly or indirectly observable and measureable
  • influenced by behavioural modification
  • reflective of the context or environment

Question 11

How should target behaviours be identified and defined?

Answer 11

• Target behaviours must be observable or measureable. Complex behaviours should be partitioned into modes (affective, motor, cognitive)
• Consider:
  
  • Will the behaviour be reinforced after treatment?
  • Is the behaviour age appropriate?
  • What might replace the behaviour? (eg self harm and distress tolerance)
  • Is the behaviour related to another problem?
• Use operational definitions of the behaviour; state exactly what is done
  
  • Be objective and unambiguous, minimise inferences and avoid labels such as “tantrum” or “being a bad sport”
• Assess related factors - ABC Approach. Emotional cognitive physical and environmental factors and consequences.

Question 12

What six factors need to be considered when observing behavior?

Answer 12

1. Topography: the specific moves involved in making the response.
   
   • Pictures are often useful for this eg height of arm raised.
2. Amount of behaviour
   
   • Frequency of behaviour in given time: measured using frequency or cumulative graphs (when comparing 2+ behaviours or when changes are small)
   • Relative Duration of behaviour: ie minutes in an hour
3. Intensity of behaviour: ususally measured with an instrument ie voice meter
4. Stimulous Control; degree of corrolation between behaviour and response
   
   • eg ABLA tests response to instruction (verbal, imitation etc)
5. Latency; time between stimulus and response
6. Quality of behaviour: A refinement of one or more of the above factors depending on target behaviours

Question 13

What are some examples of behavioural techniques?

Answer 13

• Behavioural Modification: increasing or decreasing behaviour based on learning principles (particularly operant conditioning)
  
  • Relies on a highly controlled environment to avoid conflicting reinforcement
  • Adapted to “behavioural self control” to preserve a collaborative relationship with the therapist
  • Differential reinforcement: a process where one behaviour is reinforced while an alternate (DRA) or incompatible (DRI) behaviour is simultaneously put on extinction
    
    • Used with autistic children. NB Avoid punishment
• Systematic Desentisation: based on classical conditioning and generalisation principles, but also operative (avoidance behaviour)
  
  • The client is re-exposed to conditioned stimuli without the fear inducing elements.

Question 14

What is the Cognitive model in CBT?

Answer 14

• Dr Beck identified common thoughts in depressed patients which when addressed helped overcome depression.
• The central premise of the cognitive model is that conscious thoughts, beliefs and assumptions are central to the development of of common disorders such as anxiety and depression
• The cognitive model says responses are mediated by perception of events which are distorted when individuals are distressed
• Situations lead to automatic thoughts which lead to emotional behavioural and physiological reactions.

Question 15

What are the central principles of CBT?

Answer 15

• Case formulation: With the patient, problematic situations and feelings are understood in terms of thoughts. FActors that may have precipitated the problem are sometimes considered too
• Non Interpretive stance: therapist does not interpret or offer alternative meanings and advice directly
• Collaborative approach: clients offer input and ideally lead the process
• Socratic questioning: therapist takes a curious stance rather than a challenging one
• Empiricism: each intervention is treated as an experiment with hypothesis and new data
• Explicit and specific: qualitative measures are used to guage process
• Role of self practice: homework is central
• Goal oriented and problem focused: client identifies goals to work toward
• Structured, time-limited approach: maximise efficiency and effectiveness
• Flexible, client centred approach: integrate other therapies if needed