Introduction to Clinical PsychologyIntroduction to Clinical Psychology

洪福建洪福建

What is clinical psychologyWhat is clinical psychology

1).a subfield of the large discipline of psychology1).a subfield of the large discipline of psychology 2).conduct research on behavior and mental 2).conduct research on behavior and mental

processesprocesses 3).involvement in the assessment or measurement 3).involvement in the assessment or measurement

of the abilities and characteristics of individual of the abilities and characteristics of individual human beingshuman beings

4).effort to help people who are psychologically 4).effort to help people who are psychologically distresseddistressed

Clinical attitude or clinical approachClinical attitude or clinical approach

The activities of clinical psychologistThe activities of clinical psychologist

Assessment Assessment 衡鑑衡鑑 Treatment Treatment 處置處置 Research Research 研究研究 Teaching Teaching 教學教學 Consultation Consultation 諮詢諮詢 Administration Administration 行政管理行政管理

Distribution of clinical activities(Table 1.1)Distribution of clinical activities(Table 1.1)

Clients and their problemsClients and their problems

Employment settings and salaries for Employment settings and salaries for clinical psychologists (Table 1.2)clinical psychologists (Table 1.2)

Sociocultural diversity among clinical Sociocultural diversity among clinical psychologists psychologists

The roots of clinical psychologyThe roots of clinical psychology

The research tradition in psychologyThe research tradition in psychology

Attention to individual differencesAttention to individual differences

Changing conceptions of behavior disorderChanging conceptions of behavior disorder

Clinical psychology in the 21Clinical psychology in the 21stst century century

The challenges of health care reformThe challenges of health care reform

Trends toward integrated theories and Trends toward integrated theories and

interdisciplinary workinterdisciplinary work

Specialization of clinical activitySpecialization of clinical activity

The challenge of cultural diversityThe challenge of cultural diversity

The scientist-practitioner issueThe scientist-practitioner issue

Assessment in Clinical PsychologyAssessment in Clinical Psychology

DefinitionDefinition the process of collecting information to the process of collecting information to

be used as the basis for informed decision be used as the basis for informed decision by the assessor or by those to whom results by the assessor or by those to whom results are communicated.are communicated.

a process of solving problems (answering a process of solving problems (answering questions) (Maloney, & Ward, 1976)questions) (Maloney, & Ward, 1976)

Reasons for Psychological AssessmentReasons for Psychological Assessment

Help answer specific questions & aid in making Help answer specific questions & aid in making relevant decisions (Groth-Marnat, 2003)relevant decisions (Groth-Marnat, 2003)

Common reasons:Common reasons: 1). Diagnosis1). Diagnosis 2). Treatment planning2). Treatment planning 3). Identifying functional status3). Identifying functional status 4). Self-control problems4). Self-control problems 5). History 5). History

A Model for the Assessment ProcessA Model for the Assessment Process

Cushman & Scherer (1995)Cushman & Scherer (1995) 1). Determine the information you need to 1). Determine the information you need to

answer the referent questionsanswer the referent questions 2). Identify who is to be involved2). Identify who is to be involved 3). Obtain informed consent & releases3). Obtain informed consent & releases 4). Collect & examine medical records4). Collect & examine medical records 5). Identify what is to be measured5). Identify what is to be measured e.g. cognitive function, mood, personality e.g. cognitive function, mood, personality

6). 6). Identify & select your measuresIdentify & select your measures 7). Administer your assessment. Modify as 7). Administer your assessment. Modify as

neededneeded 8). Score measures; analyze & interpret 8). Score measures; analyze & interpret

resultsresults 9). Seek consultation if you are unable to 9). Seek consultation if you are unable to

make sense of the resultsmake sense of the results 10). Write report10). Write report 11). Provide feedback to client & other 11). Provide feedback to client & other

appropriate partiesappropriate parties

Phases in Clinical AssessmentPhases in Clinical Assessment

Groth-Marnat (2003)Groth-Marnat (2003) 1). 1). Evaluating the referral questionsEvaluating the referral questions 2). Acquiring knowledge relating to the 2). Acquiring knowledge relating to the

content of the problemcontent of the problem 3). Data collection3). Data collection 4). Interpreting the data 4). Interpreting the data “ “Conceptual Validity” (Maloney & Conceptual Validity” (Maloney &

Ward, 1976)Ward, 1976)

The Clinical Assessment ProcessThe Clinical Assessment Process

Nietzel, Bernstein, & Millich (2003)Nietzel, Bernstein, & Millich (2003) A schematic view of the clinical assessment processA schematic view of the clinical assessment process

Ⅰ Ⅱ Ⅲ Ⅳ Ⅰ Ⅱ Ⅲ Ⅳ Planning Collecting Data CommunicatingPlanning Collecting Data Communicating data assessment processing assessment datadata assessment processing assessment data collection data and hypothesiscollection data and hypothesis procedure formationprocedure formation

Planning for AssessmentPlanning for Assessment

What do we want to know?What do we want to know? Assessment levelsAssessment levels 1). Somatic1). Somatic 2). Physical2). Physical 3). Demographic3). Demographic 4). Overt behavior4). Overt behavior 5). Cognitive/intellectual5). Cognitive/intellectual 6). Emotional/affective6). Emotional/affective 7). environmental7). environmental

Factors guiding assessment choicesFactors guiding assessment choices

Theoretical Model Theoretical Model

Reliability & ValidityReliability & Validity

Clinician-specific factorsClinician-specific factors personal preferences, training experiences personal preferences, training experiences

Clinician’s assessment strategyClinician’s assessment strategy bandwidth-fidelity issuesbandwidth-fidelity issues

The goals of clinical assessmentThe goals of clinical assessment

Diagnostic classificationDiagnostic classification Psychodiagnosis; Differential Diagnosis Psychodiagnosis; Differential Diagnosis DSM- , ICD-10ⅣDSM- , ICD-10Ⅳ DescriptionDescription Person-environment interactionsPerson-environment interactions PredictionPrediction for Selectionfor Selection

Collecting assessment dataCollecting assessment data

How should we go about learning it ?How should we go about learning it ? Sources of assessment dataSources of assessment data 1). Interviews1). Interviews 2). Observations2). Observations 3). Tests3). Tests 4). Life records4). Life records The value of multiple assessment sourcesThe value of multiple assessment sources

Processing assessment dataProcessing assessment data

““Data Processing” or “Clinical Judgment”Data Processing” or “Clinical Judgment” determine what their mean determine what their mean transformed from raw data into interpretations transformed from raw data into interpretations

& conclusions& conclusions Levels & Types of clinical inferenceLevels & Types of clinical inference 1). Goal: 1). Goal: 2). Underlying theoretical approach 2). Underlying theoretical approach 3). Level of abstraction: 3). Level of abstraction: Lowest vs. Highest inference levelLowest vs. Highest inference level

Three views of assessment dataThree views of assessment data 1). Samples1). Samples 2). Correlates2). Correlates 3). Signs3). Signs Approaches, Views, and LevelsApproaches, Views, and Levels The process of clinical inferenceThe process of clinical inference Clinical intuitionClinical intuition The Clinician as inference expert The Clinician as inference expert Formal vs. informal inferenceFormal vs. informal inference

Communicating assessment dataCommunicating assessment data

1). Report clarity1). Report clarity

2). Relevance to goals2). Relevance to goals

3). Usefulness of reports3). Usefulness of reports

Clarity, Meaningful, SynthesisClarity, Meaningful, Synthesis

Clinical interviewClinical interview

A conservation with a purpose or goal.A conservation with a purpose or goal. An interaction: An interaction: at least 2 persons(interviewer v.s. interviewee)at least 2 persons(interviewer v.s. interviewee) face to faceface to face Interview v.s. ConservationInterview v.s. Conservation specific purposespecific purpose participant’s roleparticipant’s role time &placetime &place

Interview structureInterview structure

The degree to which the interviewer determines The degree to which the interviewer determines the content and course of the conversation.the content and course of the conversation.

Nodirective semistructured structuredNodirective semistructured structured 影響使用因素：影響使用因素： 1). 1). Goals of interviewGoals of interview 2). Course of interview2). Course of interview 3). Theoretical orientation3). Theoretical orientation 4). Personal preferences4). Personal preferences Trends toward structured interviewTrends toward structured interview

Stage in the interviewStage in the interview

Stage 1: Beginning the interviewStage 1: Beginning the interview establishment the rapportestablishment the rapport Stage 2: The middle of the interviewStage 2: The middle of the interview informational gathering informational gathering a). nondirective techniquesa). nondirective techniques b). directive techniquesb). directive techniques c). combining interview tacticsc). combining interview tactics Stage 3: Closing the interviewStage 3: Closing the interview

Communication in the interviewCommunication in the interview

Verbal v.s. Nonverbal communicationVerbal v.s. Nonverbal communication Use of LanguageUse of Language Focus on the intervieweeFocus on the interviewee Active listeningActive listening Response to silenceResponse to silence Channel of communicationChannel of communication The clinician’s values & bacgroundThe clinician’s values & bacground

Rapport of interviewRapport of interview A comfortable atmosphere and a mutual understanding of A comfortable atmosphere and a mutual understanding of

the purpose of the interviewthe purpose of the interview

Positive rapport: Positive rapport: 1). be more receptive to the message being sent.1). be more receptive to the message being sent. 2). be characterized by feelings such as trust, relaxation, 2). be characterized by feelings such as trust, relaxation,

comfort, respect, warmth, safetycomfort, respect, warmth, safety

Negative rapport:Negative rapport: 1). Less desire to share oneself and less readiness to 1). Less desire to share oneself and less readiness to

believe what’s being saidbelieve what’s being said 2). be characterized by feelings such as hostility, 2). be characterized by feelings such as hostility,

defensiveness, unease, mistrust, disrespect, dagerousdefensiveness, unease, mistrust, disrespect, dagerous

Techniques of interviewTechniques of interview

Interviewer attitude:Interviewer attitude: acceptance, understanding, sincerityacceptance, understanding, sincerity Five types of interview questionsFive types of interview questions 1). Open-ended1). Open-ended 2). Facilitative2). Facilitative 3). Clarifying3). Clarifying 4). Confronting4). Confronting 5). Direct5). Direct

基本的溝通技巧基本的溝通技巧 注意（注意（ AttendingAttending ）） SS ：：直接地面對 直接地面對 OO ：：開放的姿勢 開放的姿勢 LL ：：身身

體前傾 體前傾 EE ：：眼睛接觸 眼睛接觸 RR ：：保持放鬆保持放鬆 傾聽（傾聽（ ListeningListening ）） 經驗（經驗（ ExperiencesExperiences ）） VS. VS. 行為行為

（（ BehaviorsBehaviors ）） VS. VS. 感受（感受（ FeelingsFeelings ）） 外顯（外顯（ OvertOvert ）） VS. VS. 內隱（內隱（ CovertCovert ）） 內容（內容（ ContentsContents ）） VS. VS. 歷程（歷程（ ProcessesProcesses ））

瞭解（瞭解（ UnderstandingUnderstanding ）） 同理心瞭解（同理心瞭解（ Empathic understandingEmpathic understanding ）） 探求（探求（ ProbingProbing ）） 澄清（澄清（ ClarifyClarify ）：）：問題具體化問題具體化

（（ ConcreteConcrete ））的歷程的歷程 聚焦（聚焦（ FocusingFocusing ）） 聚焦主題的標準：嚴重性（聚焦主題的標準：嚴重性（ SeveritySeverity ）、）、緊急緊急

性（性（ UrgencyUrgency ）、）、 重要性（重要性（ ImportanceImportance ）、）、即時性即時性

（（ TimingTiming ）、）、複雜性（複雜性（ ComplexityComplexity ））

溝通技巧溝通技巧 ((柯柯 ))

1). 1). 增強談話的動機增強談話的動機

2). 2). 減低個案對於談話的焦慮減低個案對於談話的焦慮

3). 3). 幫助個案想起過去發生的事以利晤談幫助個案想起過去發生的事以利晤談

4). 4). 潤滑交談過程的幾種提問或接洽技巧潤滑交談過程的幾種提問或接洽技巧

The physical setting arrangementThe physical setting arrangement

Note taking & recordingNote taking & recording

The patient’s frame of referenceThe patient’s frame of reference

The clinician’s frame of referenceThe clinician’s frame of reference

Reliability of interviewReliability of interview

ReliabilityReliability 1). information variance:1). information variance: refer to the variation in the questions the clinicians ask, refer to the variation in the questions the clinicians ask,

the observations that are made during the interview, and the observations that are made during the interview, and the method of integrating the information that is obtained. the method of integrating the information that is obtained.

2). Criterion variance:2). Criterion variance: refer to the variation in scoring thresholds among refer to the variation in scoring thresholds among

cliniciansclinicians Two types of reliabilityTwo types of reliability: : 1). Interrater or interjudge reliability1). Interrater or interjudge reliability 2). Test-retest reliability2). Test-retest reliability

Validity of interviewValidity of interview

Content validityContent validity

Criterion-related validityCriterion-related validity

Discriminant validityDiscriminant validity

Construct validityConstruct validity

Suggestions for improving Suggestions for improving reliability & validityreliability & validity

Whenever possible, use a structured Whenever possible, use a structured interviewinterview

If a structured interview does not exist for If a structured interview does not exist for you purpose, consider developing oneyou purpose, consider developing one

Certain interviewing skills are essentialCertain interviewing skills are essential Be aware of the patient’s motives & Be aware of the patient’s motives &

expectancies with regard to the interviewexpectancies with regard to the interview Be aware of your own expectations, biases, Be aware of your own expectations, biases,

and cultural valuesand cultural values

Varieties of interviewVarieties of interview

The intake-admission interviewThe intake-admission interview

The case-history interviewThe case-history interview

Mental status examination interviewMental status examination interview

The crisis interviewThe crisis interview

The diagnostic interviewThe diagnostic interview

Mental status examination(MSE) Mental status examination(MSE)

General appearance and behaviorGeneral appearance and behavior

Speech & thoughtSpeech & thought

ConsciousnessConsciousness

Mood & affectMood & affect

PerceptionPerception

Obsessions and compulsionsObsessions and compulsions

OrientationOrientation

MemoryMemory

Attention & concentrationAttention & concentration

Fund of general informationFund of general information

IntelligenceIntelligence

Insight & judgmentInsight & judgment

Higher intellectual functioningHigher intellectual functioning

The diagnostic interviewThe diagnostic interview

Structured diagnostic interviewStructured diagnostic interview

1).Careful history-taking1).Careful history-taking

2).Clinical examination: 2).Clinical examination: eliciting clinical signeliciting clinical sign

Clinical Observational AssessmentClinical Observational Assessment

Goals:Goals: 1). Collect informational that is not 1). Collect informational that is not

available in any other wayavailable in any other way

2). Supplement other data as part of a 2). Supplement other data as part of a multiple assessment approach multiple assessment approach

Benefits of observational assessmentBenefits of observational assessment

Supplementing self-reportsSupplementing self-reports

Highlighting situational determinants of behaviorHighlighting situational determinants of behavior signs v.s. samplessigns v.s. samples

Minimizing inferenceMinimizing inference

Enhancing ecological validityEnhancing ecological validity

Observational methodObservational method 1). Selection: 1). Selection: people, classes of behavior, events, situations, timepeople, classes of behavior, events, situations, time 2). Provocation:2). Provocation: provoke or waitprovoke or wait 3). Recording:3). Recording: observer memory, record sheet, audio- or videotape, observer memory, record sheet, audio- or videotape,

physiological monitoring system, timers, countersphysiological monitoring system, timers, counters 4). Encording: 4). Encording: most difficultmost difficult a system for encoding raw observations into usable form a system for encoding raw observations into usable form

must be developedmust be developed

Approach to observational assessmentApproach to observational assessment

Naturalistic v.s. controlled observationNaturalistic v.s. controlled observation

Participants v.s. nonparticipants Participants v.s. nonparticipants 1). Complete observer1). Complete observer 2). Observer as participant2). Observer as participant 3). Participant as observer3). Participant as observer 4). Complete participant4). Complete participant

Naturalistic observationNaturalistic observation

Hospital observationsHospital observations

School observationsSchool observations

Home observationsHome observations

Observations by insidersObservations by insiders

Self-observation(self-mnitoring)Self-observation(self-mnitoring)

Controlled observationControlled observation

Also referred to as analogue behavior Also referred to as analogue behavior observation (ABO), situation tests, and observation (ABO), situation tests, and contrived observationcontrived observation

Performance measuresPerformance measures

Role-playing testsRole-playing tests

Reliability & Validity of observationReliability & Validity of observation

Reliability of observation:Reliability of observation: 1). Complexity of target behavior1). Complexity of target behavior 2). Training observers2). Training observers Validity of observationValidity of observation 1). Mechanics of rating1). Mechanics of rating 2). Observer error2). Observer error 3). Reactivity3). Reactivity 4). Ecological validity4). Ecological validity

Behavioral AssessmentBehavioral Assessment

SORC Model (Kanfer & Phillips, 1970)SORC Model (Kanfer & Phillips, 1970) Stimulus(S)Stimulus(S) Organism(O)Organism(O) Response(R)Response(R) Consequence(C)Consequence(C)

Functional analysis(ABC Model)(Skinner, 1953)Functional analysis(ABC Model)(Skinner, 1953) Antecedent event(A)Antecedent event(A) Behavior(B)Behavior(B) Consequence(C)Consequence(C)

Two broad categories of behaviorTwo broad categories of behavior

1). 1). Respondents: Respondents: are the antecedent-controlled behaviors are the antecedent-controlled behaviors which function in a reflexive mannerwhich function in a reflexive manner

a). Somatic reflexesa). Somatic reflexes b). Emotional reactions & other responses of the smooth b). Emotional reactions & other responses of the smooth

muscles, gland & heartmuscles, gland & heart c). Sensationsc). Sensations

2). Operants: 2). Operants: are consequence-controlledare consequence-controlled a). Actionsa). Actions b). Instrumental responses of the smooth muscles, glandb). Instrumental responses of the smooth muscles, gland c). Cognitionsc). Cognitions

Assessment taskAssessment task 1). 1). Identify:Identify: respondent, operant, consequence of operant, respondent, operant, consequence of operant,

setting eventsetting event

2). Classify:2). Classify: behavioral excesses, behavioral deficits, behavioral excesses, behavioral deficits,

behavioral anomalies, behavioral assetsbehavioral anomalies, behavioral assets

3). Prophesy:3). Prophesy: theoretical orientation:theoretical orientation:

4). Specify: recommendations4). Specify: recommendations precise goals, methods of interventions, precise goals, methods of interventions,

therapeutic agentstherapeutic agents

5). Evaluation: what changes are occurring 5). Evaluation: what changes are occurring in behavior treatmentin behavior treatment

processes evaluation, processes evaluation, outcome evaluation outcome evaluation follow-up evaluationfollow-up evaluation

Methods of behavioral assessmentMethods of behavioral assessment

Behavioral interviewBehavioral interview

Direct observationDirect observation

Psycho-physiological measuresPsycho-physiological measures

Behavioral Inventories & ChecklistBehavioral Inventories & Checklist BDI, CBCLBDI, CBCL

Behavioral SamplingBehavioral Sampling Event samplingEvent sampling

Duration samplingDuration sampling

Time samplingTime sampling

Interval samplingInterval sampling

Subject samplingSubject sampling

Situation samplingSituation sampling

臨床工具的選擇臨床工具的選擇 使用心理測驗的目的使用心理測驗的目的 時間向度的考量時間向度的考量 個案條件的考量個案條件的考量 年齡、教育程度、生理條件等年齡、教育程度、生理條件等 受測動機受測動機 選擇測量不同心理特質的測驗選擇測量不同心理特質的測驗 增加效度增加效度 ((incremental validity)incremental validity) 概念效度概念效度 ((conceptual validity)conceptual validity) 經濟效益考量經濟效益考量

臨床上常使用的心理測驗臨床上常使用的心理測驗 WAIS - ⅢWAIS - Ⅲ WISCWISC B-G TestB-G Test Rorschach TestRorschach Test TATTAT Projective drawingProjective drawing Self-Report: MMPI, CPI, KMHQ, HPH….Self-Report: MMPI, CPI, KMHQ, HPH….

心理測驗的臨床使用心理測驗的臨床使用 觀察記錄施測時的各項反應觀察記錄施測時的各項反應 標準化的施測、計分、及解釋程序標準化的施測、計分、及解釋程序 解釋測驗意義時，需重視其他收集到資解釋測驗意義時，需重視其他收集到資

料料 在施測時，同時利用其他方式收集更多在施測時，同時利用其他方式收集更多

資，如簡短晤談資，如簡短晤談

觀察→記錄→問自己問題→回答問題→觀察→記錄→問自己問題→回答問題→再提出問題…再提出問題… ..

各項測驗的施測順序各項測驗的施測順序

簡單的先做簡單的先做

順序不可減低測驗原有的效度順序不可減低測驗原有的效度

費時的測驗放在最後費時的測驗放在最後

心理測驗的評價心理測驗的評價 理論取向理論取向 ((Theoretical Orientation)Theoretical Orientation)

實務考量實務考量 ((Practical Considerations)Practical Considerations)

標準化標準化 ((Standardization)Standardization)

信度信度 ((Reliability)Reliability)

效度效度 ((Validity)Validity)