Ethical Issues in Clinical Psychology

This chapter examines how ethical issues are approached differently by two prominent psychological associations, how they are encountered by psychologists, the formal complaints they give rise to, and how they can be approached systematically to avoid missteps. Included are basic assumptions about ethics; the unique approaches to developing a ethics code taken by the American Psychological Association (APA) and the Canadian Psychological Association (CPA), and what each of these two codes provides; empirical data about what ethical problems psychologists encounter and what formal complaints they face; four major sets of ethical issues that are particularly complex and challenging (confidentiality, informed consent, competence, and boundaries); an area of major controversy (clinical psychology and national security); steps in ethical decision-making; and four possible lines of future research.

Evidence-based Assessment

Evidence-based assessment relies on research and theory to inform the selection of constructs to be assessed for a specific assessment purpose, the methods and measures to be used in the assessment, and the manner in which the assessment process unfolds. An evidence-based approach to clinical assessment necessitates the recognition that, even when evidence-based instruments are used, the assessment process is a decision-making task in which hypotheses must be iteratively formulated and tested. In this chapter, we review (a) the progress that has been made in developing an evidence-based approach to clinical assessment in the past decade and (b) the many challenges that lie ahead if clinical assessment is to be truly evidence-based.

Research Methods in Clinical Psychology

This chapter describes methodological and design considerations central to the scientific evaluation of treatment efficacy and effectiveness. Matters of design, procedure, measurement, data analysis, and reporting are examined and discussed. The authors consider key concepts of controlled comparisons, random assignment, the use of treatment manuals, integrity and adherence checks, sample and setting selection, treatment transportability, handling missing data, assessing clinical significance, identifying mechanisms of change, and consolidated standards for communicating study findings to the scientific community. Examples from the treatment outcome literature are offered, and guidelines are suggested for conducting treatment evaluations that maximize both scientific rigor and clinical relevance.

Working with Sexual-Minority Individuals

The present chapter provides a review of some of the primary psychological issues confronting sexual minorities (i.e., individuals with same-sex attractions and relationships). Our goal is to provide a flexible set of preliminary questions that can be used to help sexual-minority clients to articulate their own idiosyncratic experiences and give voice to their own unique needs. We begin by addressing two of the most common and important clinical issues faced by sexual minorities: generalized “minority stress” and acceptance and validation from the family of origin. We then turn attention to the vast—and vastly underinvestigated—population of individuals with bisexual attractions and behavior, who actually constitute the majority of the sexual-minority population, despite having been systematically excluded from most prior research. We review the increasing body of research suggesting that individuals with bisexual patterns of attraction and behavior actually face greater mental health risks than those with exclusive same-sex attractions and behavior, and we explore potential processes and mechanisms underlying this phenomenon, focusing particular attention on issues of identity development and transition over the life span. We conclude by outlining a number of areas for future clinically oriented research.

Interventions for Mental Health Problems in Later Life

Older adults are increasingly making up a larger segment of the worldwide population, which presents both challenges and opportunities for the clinical psychologist in the 21st century. In this chapter, we address some of the unique aspects of working with this population, focusing on general guidelines for tailoring interventions for older adults, specific treatments for particular problems commonly faced in later life, as well as issues of diversity and how they might impact psychotherapy with older clients. We also outline several areas in geropsychology that are in need of further investigation, namely the use of technology, post-traumatic stress, and family therapy, and offer some recommendations for future directions in this field of study.

Behavioral Emergencies and Crises

This chapter illustrates the mental health clinician’s relationship with behavioral emergencies. The chapter begins by distinguishing the terms behavioral emergency and behavioral crisis, and underlying themes among all behavioral emergencies are identified. Given that most clinicians will face a behavioral emergency in their careers, the importance of enhancing the process of educating and training practitioners for such situations far beyond the minimal training that currently exists is highlighted. The chapter continues by exploring various aspects of evaluating and managing high-risk patients (i.e., those who exhibit violent tendencies toward themselves or others, and those at risk for victimization). It includes a discussion of the benefits and limitations to estimating life-threatening risk factors and specific protective factors. The chapter concludes by discussing the emotional impact that working with high-risk patients has on clinicians, and an emphasis is placed on the importance of creating a supportive work environment.

Clinical Psychology Interventions in Primary Care

This chapter reviews the need for clinical psychology services that are integrated into the primary health-care environment and covers in depth the issues that an effective primary care clinical psychologist must understand to function effectively in primary care. These are understanding the primary medical care environment, recognizing the unique characteristics of primary medical care patients who seek psychological services, and the key treatment tactics and strategies necessary for effective work in a primary care environment. Recommendations are illustrated with numerous case examples adapted from the experiences of a veteran primary care clinical psychologist.

Disorders of Development

Disorders of development include a range of problems first evidenced in childhood. Although most disorders have their origins in childhood, a few fully express themselves before early adulthood. This chapter describes the nature, assessment, and treatment of the more common disorders that are revealed in a clinically significant way during a child’s developing years. The disorders of development affect a range of functioning, from single skills deficits to more pervasive problems that negatively impact a child’s ability to function. Included is coverage of several disorders usually diagnosed first in infancy, childhood, or adolescence, including attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, learning disorders, communication and related disorders, pervasive developmental disorders (including autistic disorder and Asperger disorder), and intellectual disabilities. Recommendations for future research on the potential for advancing knowledge regarding spectrums within some of these disorders, as well as recommendations for treatment, are outlined.

Disorders of Impulse Control and Self-Harm

Disorders of impulse-control and self-harm are dangerous clinical problems that often present significant challenges for scientists and clinicians. In this chapter, we provide a comprehensive review of each disorder on the impulse-control spectrum. We begin by describing the clinical presentation and epidemiology of each disorder. Next, we discuss what is currently known about the etiology of these disorders, summarizing recent research on genetic/neurobiological factors, environmental factors, and psychological factors that appear to influence these disorders. The assessment and treatment of disorders of impulse-control and self-harm is complicated by the relatively low base-rate of these disorders, as well as by their dangerous and sensitive nature. Nevertheless, several evidence-based approaches to assessment and treatment have been developed and also are reviewed here. We conclude with recommendations for future scientific and clinical efforts aimed at better understanding, predicting, and preventing disorders of impulse-control and self-harm.

Diagnoses, Dimensions, and DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) is often said to have provided a significant paradigm shift in how psychopathology is diagnosed. The authors of DSM-5 have the empirical support and the opportunity to lead the field of psychiatry to a comparably bold new future in diagnosis and classification. The purpose of this chapter is to address the validity of the categorical and dimensional models for the classification and diagnosis of psychopathology. Considered in particular will be research concerning substance use disorders, mood disorders, and personality disorders. Limitations and concerns with respect to a dimensional classification of psychopathology are also considered. The chapter concludes with a recommendation for a conversion to a more quantitative, dimensional classification of psychopathology.