Clinical Exam 4

Relationship of Emotion Dysregulation to DBT Skills Training

1. Mindfulness 2. Interpersonal Effectiveness 3. Emotion Regulation 4. Distress Tolerance

The Dialectical World View and Basic Assumptions

DBT is based on a dialectic world view "Dialectics" as applied to behavior therapy has two meanings - The fundamental nature of reality. This forms the basis for DBT - The persuasive dialogue and relationship. This refers to the treatment approach or strategies used by the therapist to effect change

Treatment of Forensic Clients: Outpatient Psychotherapy

Successes or failures occur in this setting as much as they do in more traditional settings

The Caregiving Environment (The "Social" in the Biosocial Theory)

The contributions include • A tendency to invalidate emotions and an inability to model appropriate expressions of emotion • An interaction style that reinforces emotional arousal • A poor fit between the child's temperament and the caregivers' parenting style

Characteristics of Emotion Dysregulation

- An excess of painful emotional experiences - An inability to regulate intense arousal - Problems turning attention away from emotional cues - Cognitive distortions and failures in information processing - Insufficient control of impulsive behaviors related to strong positive and negative affect - Difficulties organizing and coordinating activities to achieve non-mood-dependent goals during emotional arousal - A tendency to "freeze" or dissociate under very high stress

Play therapy: Psychodynamic

- The playroom usually contains a variety of objects with which the child can choose to play - Therapists may take note of the objects the child chooses... especially if he or she appears to identify strongly with a particular toy The interpretations the therapist offers the child about his or her actions can • Help make the child aware of inner mental processes • Increase the child's ability to make deliberate choices about behavior in the future

Frequency of Specific Assessment Techniques

2002 survey of members of the APA Division 53 (Clinical Child Psychology) - Interviews were used far more commonly than any specific assessment technique Among non-interview techniques • Greater reliance on self-report measures for adolescents • Greater reliance on behavior rating scales for younger children - Completed by parents or teachers The use of some tests (e.g., the WISC) is relatively common • A significant amount of variation remains

Competency to Stand Trial

A person accused of a crime cannot be tried in court unless that person is mentally fit or... - Competent to stand trial: a required condition of the defendant in the U.S. legal system for which forensic psychologists often conduct assessments Although the focus is on standing trial, there are other important legal competencies as well - e.g., writing wills, entering into a contract, consenting to medical treatment, etc.

Health Psychology

A relatively new subspecialty in clinical psychology - Emergence corresponds with changes in the types of diseases that pose the greatest threats A century ago: Those were pneumonia, tuberculosis, and influenza • Today: They are heart disease, cancer, and stroke The newer killers have clear-cut behavioral components • They are worsened by smoking, poor eating habits, and lack of exercise • Now a rapidly developing field among clinicians and researchers The health psychology division of the APA (Division 38) was founded in 1978 - There are many journals dedicated to publishing research in the field e.g. Health Psychology, Journal of Behavioral Medicine Health psychology - Primarily concerned with the ways our thoughts, feelings, and behaviors influence physical health - Training typically goes beyond the typical doctoral program requirements • Additional coursework and/or internships • Interaction with professionals from health professions outside of psychology

Guilty But Mentally Ill

A relatively new trial outcome in some states - Constitutes a middle ground between full criminal responsibility and a finding of not guilty by reason of insanity

What is Cognitive Behavior Therapy?: Aaron Beck

Aaron Beck developed "cognitive therapy" in the early 1960s - Now "cognitive therapy" is used synonymously with "cognitive behavior therapy" by much of the field It is a structured, short-term, presentoriented psychotherapy for depression • Directed toward - Solving current problems - Modifying dysfunctional (inaccurate and/or unhelpful) thinking and behavior Since this time, he and others have successfully adapted this therapy to a diverse set of populations with a wide range of disorders and problems All forms of cognitive behavior therapy derived from Beck's model are based on - A cognitive formulation - The beliefs and behavioral strategies that characterize a specific disorder - A conceptualization, or understanding, of individual patients i.e., their specific beliefs and patterns of behavior

Stress: Walter Cannon

Although the terms health psychology and behavioral medicine weren't coined until the 1970's the idea that stress could negatively impact the body was known Walter Cannon - Fight-or-Flight Response: When an organism perceives a threat, the body rapidly mobilizes energy reserves via the sympathetic nervous system and endocrine system to either fight or flee Long ago, the behavioral responses were probably actually fighting or fleeing (perhaps from a dangerous predator) - Todays "fighting" and "fleeing" look a bit different • Fighting: Honking your horn at a careless driver • Fleeing: Withdrawing from anxiety-provoking situations

A Comprehensive Assessment

An extensive amount of background information might be relevant - This can help the psychologist appreciate the full set of circumstances in which the child's presenting problems have emerged

Assessment of Children and Adolescents

Any assessment must adopt a... - Developmental perspective: an essential aspect of clinical child psychology whereby clinicians understand the child's behavior within the context of the child's developmental age Problems of childhood may take on different meanings and require different interventions depending upon their commonality at a given age Example • Beth and her parents visit a clinical psychologist because of Beth's defiant, rule-breaking behavior. On several occasions, Beth has ignored her parents' curfews and prohibitions about smoking • An accurate understanding of the problem depends on Beth's age - The problem would be very different if Beth is 7 then if she was 17

Assessment Methods: Self-Report Scales

Any assessment scale completed directly by the client Require a certain reading level, attention span, and motivation for the child to complete • For this reason, they are more commonly used with adolescents than with younger children - These are like those used with adults • The Minnesota Multiphasic Personality Inventory (MMPI) and Millon Clinical Multiaxial Inventory (MCMI) both have adolescent versions

Cognitive-Behavioral Therapies for Children: Applied Behavioral Analysis

Applied Behavioral Analysis: a behavioral approach that relies heavily on operant conditioning principles (i.e., reinforcement, punishment, shaping, and extinction) Evidence based therapy for children with autism spectrum disorder • Most commonly utilized and recommended therapy for this disorder Therapists first help the child identify and define very specific behaviors to target • Goal could be to increase the frequency (e.g., eye contact or using the toilet) • Goal could be to decrease the frequency (e.g., injuring himself or others) A frequency goal is met - Then, in the child's environment (and at the child's pace) the behavior is subjected to consequences through contingency management The child receives rewards and punishments effective in changing the behavior in the desired direction

Basic Principles of Treatment: Basic Principle No. 5

Basic Principle No. 5: Cognitive behavior therapy initially emphasizes the present The treatment of most patients involves a strong focus on • Current problems • Specific situations that are distressing to them Therapy starts with an examination of here-and-now problem, regardless of diagnosis Attention then shifts to the past in two circumstances • One, when patients express a strong preference to do so and a failure to do so could endanger the therapeutic alliance • Two, when patients get "stuck" in their dysfunctional thinking and an understanding of the childhood roots of their beliefs can potentially help them modify their rigid ideas

Assessment Methods: Behavior Rating Scales

Behavior Rating Scales: standardized forms that parents, teachers, or other adults complete regarding a child's presenting problems - Typically consists of a list of items describing behaviors and a range of responses e.g., "The child pushes other children" - very frequently, frequently, sometimes, infrequently, and very infrequently - Scores are then summed across subscales. This allows the clinical child psychologist to compare responses with norms from other children of the same age Advantages -Convenience -inexpensiveness -objectivity Disadvantages • Respondents are restricted from elaborating on their responses • Scale items may not adequately capture the child's problem behaviors

Biological Vulnerabilities (The "Bio" in the Biosocial Theory)

Biologically based precursors to emotion dysregulation include • Dispositions to negative affectivity • High sensitivity to emotion cues • Impulsivity Biological influences • Heredity • Intrauterine factors • Childhood or adulthood physical insults affecting the brain • The effects of early learning experiences on brain development and/or functioning

Child Custody Evaluations

Child custody evaluations: evaluations conducted by forensic psychologists for the purpose of providing recommendations for child custody - "May be the most complex, difficult, and challenging of all forensic evaluations" The area is fraught with challenges due to - The importance of the decision - Competing interest of the parents Custody decisions are made based on the legal principle known as the "best interest of the child doctrine" - Thus, the parents' interests are not the most important in child custody decisions In a divorce, when the parents are in a custody dispute, even the parents are often not able to make well-reasoned decisions for the children - Here, the courts will sometimes appoint a... - Guardian ad litem: a neutral party (often an attorney unaffiliated with either parent) appointed to protect the rights of the child • This is to avoid decisions being made by individuals who would have conflicts of interest

Commitment to Mental Institutions

Civil commitment: a process by which a person is involuntarily hospitalized by civil authorities for the welfare of the person and others Decisions generally follow a two-step process - Jurisdictions initially grant emergency admission by a clinician or other authority, but - Judicial approval is required for continued confinement All states have criteria for involuntary commitment that required the following conditions be met - The fundamental and first criterion for all state statutes is that the individual have a mental disorder - Second, some statutes require that the person be unable to appreciate the need for treatment because of this disorder - Third, the person must be dangerous to self or others due to the mental disorder - Fourth, most states also consider an individual's ability to care for basic needs as part of the commitment criteria - Fifth, some states require that there be a need for treatment - Sixth, the commitment must occur in the least restrictive environment Clinical psychologists are well-equipped to help to determine whether these criteria apply - Often seek the input from third parties to help them make decisions • e.g., family members, friends, employers, etc.

Clinical Child and Adolescent Psychology

Clinical psychologists have worked with children and adolescents since the inception of the field - The first psychological clinic focused on the assessment and treatment of children with learning and behavioral problems Along with the rest of the profession, clinical child psychology has grown tremendously The Society of Clinical Child and Adolescent Psychology (Division 53 of the APA) - Currently has a membership in the thousands - Many graduate programs train psychologists specifically to work with children and adolescents Clinical child psychologists engage in a diverse set of activities - Assessment: Often regarding problems related to behavioral, emotional, or intellectual functioning - Therapy:This could be working with children and/or their families - Research and/or training - Academia: Sometimes have the combination of applied and academic roles

Forensic Psychology: Clinical psychologists

Clinical psychologists working in forensic settings commonly - Evaluate criminal defendants' sanity - Assess legal competency to stand trial - Assess families in child custody disputes - Predict dangerousness - Serve as expert witnesses Ott and Heilbrun (2002) - Called forensic assessment "the psychological assessment of persons for the purpose of assisting the legal fact finder" (p. 5). - Clinical psychologists are uniquely trained to conduct assessments that are • Comprehensive • Valid • Reliable Forensic work is a unique specialty area for clinical psychologists - Places the clinical psychologist in the midst of an adversarial relationship between parties in conflict - "The good feelings and positive relationships common in the psychotherapeutic relationship do not exist in the forensic setting" The clinical psychologist's goal • Not necessarily to help the individual • To help the legal system by offering information and recommendations regarding the individual • When conducting forensic assessments, clinical psychologists must interact with clients in a "detached, neutral, and objective" manner rather than the "supportive, empathic" approach used in other clinical settings The trust that characterizes and facilitates clinical work is necessarily lacking in forensic work • This is because the increased likelihood that that client will falsely present themselves to appear either more or less disturbed than they really are

Basic Principles of Treatment: Principle No. 6

Cognitive behavior therapy is educative, aims to teach the patient to be her own therapist, and emphasizes relapse prevention In our first session I educate Sally about • The nature and course of her disorder • The process of cognitive behavior therapy • The cognitive model - i.e. how her thoughts influence her emotions and behavior I help Sally • Set goals • Identify and evaluate thoughts and beliefs • Plan behavioral change • ... I also teach her how to do these things After each session, I ensure that Sally takes home therapy notes - important ideas she has learned • This helps her benefit from her new understanding in the ensuing weeks and after treatment ends

Relationship of Emotion Dysregulation to DBT Skills Training: Mindfulness

Common Feelings among those with severe emotion dysregulation include: • Dysregulation of the sense of self - In BPD it is not unusual to report having no sense of a self at all, feeling, empty, and not knowing who they are • Being disconnected from others • Contempt of self • Invalidity and/or worthlessness Mindfulness addresses dysregulation of the sense of self Mindfulness skills: skills having to do with the ability - To consciously experience and observe oneself and surrounding events with curiosity and without judgement - To see and articulate reality as it is - To participate in the flow of the present moment effectively

Stress and Coping

Coping: the process of managing demands that are appraised as exceeding the resources of the person What factors determine how well someone copes with stress? - The answer involves both nature and nurture

The DBT Model of Emotions

DBT is based on the view that emotions are: Brief, involuntary, full-system, patterned responses to internal and external stimuli • DBT emphasizes the importance of the evolutionary adaptive value of emotions in understanding them Emotional responses are systemic and can be viewed as consisting of the following interactive subsystems - Emotional vulnerability to cues - Internal and/or external events that, when attended to, serve as emotional cues (e.g., prompting events) - Appraisals and interpretations of cues - Response tendencies, including neurochemical and physiological responses, experiential response, and action urges - Nonverbal and verbal expressive responses and action - Aftereffect of the initial emotional "firing," including secondary emotion The patterned actions associated with emotional responses - Should be considered to be part and parcel of the emotional responses rather than consequences of the emotions - Each element is combined into one interactional system Emphasis of DBT - Modifying any component of the emotional system is likely to change the functioning of the entire system - If one wants to change one's own emotions, it can be done by modifying any part of the system • This includes the actions that are the results of emotions

Biosocial Theory of DBT: How Emotion Dysregulation Develops

DBT was originally developed for individuals who were highly suicidal - It was secondarily for individuals who met criteria for BPD Linehan's first task was to develop a theory that would let her understand the act of suicide and BPD Linehan had three criteria - Guide treatment implementation - Engender compassion - Fit the research data Biopsychosocial theory: Based on the premise that both suicide and BPD are, at their core, disorders of emotion dysregulation • Suicidal behavior is a response to unbearable emotional suffering • BPD is a severe mental disorder resulting from serious dysregulation of the affective system - Individuals show a characteristic pattern of instability in affect regulation, impulse control, interpersonal relationship, and self-image

What is Dialectical Behavior Therapy?

Dialectical Behavior Therapy: A broad-based cognitive-behavioral treatment originally developed for chronically suicidal individuals diagnosed with borderline personality disorder (BPD) Consists of a combination of • Individual psychotherapy • Group skills training • Telephone coaching • A therapist consultation team Was the first psychotherapy shown through controlled trials to be effective with BPD - Now, many clinical trials have been conducted demonstrating the effectiveness of DBT - Not only for BPD, but a wide range of other disorders and problems - These include those with difficulties in the under-control and over-control of emotions and the associated cognitive and behavioral patterns Many studies suggest that skills training alone is a promising intervention for a variety of populations. These include, but are not limited to - Drinking problems - Families of suicidal individuals - Victims of domestic abuse Based on a dialectical and biosocial theory of psychological disorder Emphasizes - Difficulties in regulating emotions, both over- and under- control - Difficulties in regulating behaviors Emotion dysregulation has been linked to a variety of mental health problems. These stem from patterns of instability in - Emotion regulation - Impulse control - Interpersonal relationships - Self-image DBT skills are aimed directly at these dysfunctional patterns

Psychological Issues of Childhood

Disorders of childhood Some disorders are especially common among children -e.g., attention-deficit/hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, and separation anxiety disorder Children and adolescents can also be diagnosed with disorders that are common among adults -e.g., major depression, posttraumatic stress disorder, anorexia, bulimia, substance use, adjustment disorders, phobias, generalized anxiety disorder, etc. In some cases, diagnostic criteria are adjusted for children Major depressive disorder: -In children and adolescents, irritable mood can replace depressed mood. -Failure to gain weight according to growth expectations can replace weight loss PTSD: -Has a distinct set of criteria for children 6 years old and younger » e.g., diminished interest in playing or playing that involves reenactment of the trauma Some clinical psychologists divide children's problems into two broad categories -Externalizing disorders -Internalizing disorders

Clinical Applications: Alcohol Use

Drinking alcohol occasionally or in moderation does not in itself constitute a problem • The use of alcohol becomes a problem when certain criteria are met e.g. strong cravings, repeated failures due to alcohol, etc. Two hallmarks of problematic alcohol use - Tolerance: a phenomenon whereby the body requires increasing amounts of a substance to achieve the desired effect - Withdrawal: a phenomenon whereby cessation of a substance produces negative symptoms Research estimates that about 4% of Americans use alcohol in a way that involves tolerance and withdrawal - This qualifies alcoholism as a large-scale social health issue along with obesity and smoking Alcoholics Anonymous (AA) - A self-help support group - The most commonly sought source of help for alcoholrelated problems - Not affiliated with health psychology, though uses many of the same principles • Social support • Relapse prevention - Differs from health psychology in that it incorporates a spiritual component to its recovery process

Emotion Dysregulation vs. Systemic Dysregulation

Emotion Dysregulation: Can also present as emotion overcontrol and suppression • This leads to - Pervasive negative affect - Low positive affect - An inability to up-regulate emotions - Difficulty with affective communication Systemic Dysregulation is produced by • Emotional vulnerability • Maladaptive and inadequate emotion modulation strategies Emotional Vulnerability: Defined by these characteristics • Very high negative affectivity as a baseline • Sensitivity to emotional stimuli • Intense response to emotional stimuli • Slow return to emotional baseline once emotional arousal has occurred

Emotion Dysregulation in DBT

Emotion Dysregulation: The inability to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under normative conditions, even when one's best efforts are applied Pervasive emotion dysregulation: Seen when the inability to regulate emotions occurs across a wide range of emotions, adaptation problems, and situational contexts - Due to • A vulnerability to high emotionality • An inability to regulate intense emotion-linked responses

Emotion Regulation in DBT

Emotion regulation is the ability to - Inhibit impulsive and inappropriate behavior related to strong negative or positive emotions - Organize oneself for coordinated action in the service of an external goal • That is, act in a way that is not mood-dependent when necessary - Self-soothe any physiological arousal that the strong emotion has induced - Refocus attention in the presence of strong emotion In DBT, emotion regulation can be automatic as well as consciously controlled - First focus is on increasing conscious control - Second focus is on eliciting sufficient practice to overlearn skills such that they ultimately become automatic

NGRI and GBMI

Evaluations involving NGRI or GBMI strategies are especially challenging for clinical psychologists - Often involve the assessment of mental state at the time of the crime • This may have been weeks or months prior to the time of evaluation - There is often disagreement among experts' conclusions Gowensmith, Murrie, & Boccaccini (2013) - Examined 483 psychological reports written by forensic evaluators about defendants in real court cases - Found that the conclusions of those reports agreed with each other only about half the time - This rate was even lower when • The evaluators were on opposite sides of the trial • When alcohol or drugs were involved in the crime - This rate was higher when • A diagnosis of a psychotic disorder (i.e., schizophrenia) or mental retardation (intellectual disability) was present

Dialectical Perspectives on the Nature of Reality - Three Characteristics (#1)

First, dialectics stresses the fundamental interrelatedness of wholeness of reality Analyses of individual parts of a system are of limited value unless the analysis relates the parts to the whole • Dialectics directs our attention to - The individual parts of a system (i.e., one specific behavior) - The interrelatedness of the part to other parts (e.g., other behaviors, the environmental context, etc.) - The larger wholes (e.g., the culture, the state of the world at the time) Regarding skills training • Therapists must consider the interrelatedness of skills deficits - Learning one new set of skills is extremely difficult without learning other related skills simultaneously » This is even more difficult

Behavioral medicine

Focuses on the impact of behavior on wellness - Involves the integration of knowledge from a wide variety of social sciences with medical disciplines • These include psychology, sociology, and anthropology

Treatment of Forensic Clients

For what reasons should criminals be incarcerated? Melton et al., 2007 - Retribution - Deterrence - Incapacitation - Rehabilitation

Hugo Munsterberg

Forensic psychology did not become a major subdiscipline within psychology until the latter half of the 1900s Hugo Munsterberg: Among the first major promoters of the use of psychology in the legal arena Wrote the best-selling book, On the Witness Stand - Chapters on many topics of interest to the modern-day forensic psychologist - Memory of witnesses, untrue confessions, detection of crimes, etc.

Stress and coping: Nurture

Genetics only account for only half the story... - What nongenetic factors affect how we cope with stress? Perception of stress - This may or may not be a realistic appraisal - The perception of stress can predict levels of stress-related illness -Perception as opposed to actual amount or degree of stress Study of women with breast cancer (Barez, et al. 2009) • Found that both psychological and physical distress was significantly related to the amount of control the women felt they had • Those who felt they had more control had significantly less distress than those who believed they had less control Health psychologists can do little about genetics • Instead, they commonly work with clients to - Challenge cognitive misconceptions - Replace cognitive misconceptions with healthier points of view Health psychologists can foster problem-focused coping • Emphasizes proactive, constructive attempts to take action about a stressful situation. • Example: The person who knows that a hurricane is approaching and still works to stockpile emergency supplies and create an evacuation plan Pittner et al. (1983) - Those who believe they can exert some personal control over stressful situations are better off emotionally and physically • ... in comparison to those who view themselves as having little or no control over stressors

Resilience and Grotberg (2003)

Grotberg (2003) studied children who were able to thrive in risky environments in which many of their peers struggled Sorted differentiating factors into three categories • External supports • Inner strengths • Interpersonal problem-solving skills Each child was assigned a kid-friendly label • "I Have" (external supports) • "I Am" (inner strengths) • "I Can" (interpersonal and problem-solving skills) I Have (external supports) • People in my family I can trust and who love me • People outside my family I can trust • Limits to my behavior • People who encourage me to be independent • Good role models • Access to health, education, and other services I need • A stable family and community I Am (inner strengths) • A person most people like • Generally a good boy/girl • An achiever who plans for the future • A person who respects myself and others • Caring towards others • Responsible for my own behavior • A confident, optimistic, hopeful person I Can (interpersonal and problem-solving skills) • Generate new ides or new ways to do things • Work hard at something until it is finished • See the humor in life • Express my thoughts and feelings • Solve problems • Manage my behavior • Ask for help when I need it

Stress

Health psychologists now have a wide selection of areas in which they can practice - This wasn't always the case The first applications of health psychology dealt solely with the topic of... - Stress: the psychological and/or physiological response to difficult or demanding internal or external circumstances The duration of stressors can vary greatly - Chronic stress: stress levels that are consistently high and unremitting • Often due to a hectic, fast-paced lifestyle Hamermesh and Lee (2007) - 55% of adult American women and 43% of adult American men report feeling stressed "always" or "often Our bodies are not set up to handle long-term exposure to stress - Given a long enough period, we become exhausted and vulnerable to illness Hans Selye (1956) - General Adaptation Syndrome hypothesis • When confronted with a temporary stressor, our fight-or-flight system often works very effectively • But with repeated or prolonged exposure to stress, our bodies eventually wear out and break down

Health Psychology Vs. Behavioral Medicine

Health psychology: A subdiscipline of behavioral medicine - Deals specifically with how psychological processes (e.g. cognitions, moods, social networks) influence health and illness Primary responsibility of health psychologists is the development, assessment, and application of programs designed to promote wellness - Often work in hospitals or specialized clinics for issues such as weight management, smoking cessation, or pain control -Frequently work • Within primary care teams • Alongside physicians, nurses, dieticians, physical therapists, occupational therapists, and other health professionals Health psychologists often ask questions like: - "Why do students tend to get sick more often around exam week?" - "Will keeping a food diary help my clients lose weight?" Health psychologists can engage in research or activities promoting healthy behaviors

The Consequences of Emotion Dysregulation

Impulsive behavior - Especially self-injurious and suicidal behaviors • These are maladaptive, but highly effective emotion regulation strategies The development and maintenance of a sense of self - Emotional consistency and predictability across time and situations are prerequisites of identity development Ineffective interpersonal relationships - Interpersonal relationships depend on • A stable sense of self • A capacity for self-regulation of emotions • Tolerance of emotionally painful stimuli

Clinical Applications: Weight Management

In the U.S., the prevalence for obesity and being overweight are at an all-time high - 67% of adult Americans are overweight or obese - These numbers continue to rise each year in both adult and children Risks are numerous and well-documented - Obesity is estimated to cause more than 400,000 deaths annually • 16.6% of total deaths in the U.S. - Health care costs related to obesity are estimated at $117 billon • 6% to 10% of our national health care expenditures Health psychologists play an important role in efforts to stem this national crisis - Proper nutrition and physical fitness are key in achieving and maintaining a healthy weight - Recent research suggests that the problem is not that Americans are ignorant... • Instead, it's that they have a difficult time committing to these behaviors in the long term - For this reason, cognitive-behavioral therapy has become an important component of successful weight management ABCDS of weight loss - Activity increase - Behavior change - Cognitive change - Dietary change - Social support Collectively, these components represent a multifaceted, long-term approach to maintaining a healthy weight Values affirmation - An approach in which clients are encouraged to clarify and affirm, often in writing, their own personal values, which often contrast with their unhealthy behaviors Sherman and Cohen (2006) • By writing about the things they value most in life (e.g. relationships, service to others), patients focus their attention on their sense of - Personal identity - Self-worth • These affirmations bolster self-control - Concentrating on long-term goals decreases impulsive behavior that is inconsistent with those goals

Psychotherapy With Children and Adolescents

In what ways does psychotherapy with children and adolescents differ from psychotherapy with adults? The techniques used by both types of therapists often originate from the same underlying theories - Major approaches to therapy have generated applications for children as well as adults • These include psychodynamic, humanistic, behavioral, and cognitive orientations However, children should not be mistaken for miniature adults Many factors may differ - Willingness to be in therapy - Motivation to change - Ability to sit relatively calmly - Ability to express feelings for prolonged periods of time When working with an adult, the client is typically the only one involved in sessions - Children don't come to therapy alone • Parents, relatives, teachers, etc. may be involved - This means that you'll need to form more than one alliance

Quitting smoking: ABCs of Relapse Prevention

Involves and examination by the client and the health psychologist of the events that occur before and after smoking - B: Behavior (smoking) - A: Antecedent - C: Consequence A health psychologist can be helpful in facilitating a client's efforts by • Helping recognize antecedents and consequences • Suggesting alternative behaviors

Resilience and Vulnerability

It matters whether children believe they can change their personality traits A child's "implicit theory" can be • Fixed: "I'm shy, and there's nothing I can do about it" Often called an "entity" theory • Malleable: "I'm shy, but I can overcome it" Often called an "incremental" theory A "fixed" approach is more likely to lead to mental health problems Schleider et al. (2015) • Conducted a meta-analysis of 17 studies on kids aged 4-19 • Found that kids who held a fixed/entity theory had more frequent and more severe psychological diagnoses than those who held a malleable/incremental theory about themselves

How does social support protect our health?

It's not entirely clear Some hypotheses The positive feelings associated with having social support allow us to perceive our stressors in a more manageable light • Those who have strong social networks are more likely to confide in others Pennebaker (1990) » Has done work on the effects of confiding in others on the immune system » "Not disclosing our thoughts and feelings can be unhealthy. Divulging them can be healthy." (p. 82.) The sensation of touch - This was born out of the work of Harry Harlow

Clinical Applications: Smoking

Like obesity, smoking is a massive public health problem in America - Currently our single greatest cause of preventable death in the U.S. each year Major risk factor in heart disease, cancer, vascular disease, stroke, and major depressive disorder Like obesity, the primary problem isn't ignorance - It is implementing a very difficult behavior change: quitting Once smoking becomes an addiction... - It exerts a very strong control over the physiological, psychological, and social aspects of the smoker's life Some strong weapons in the battle against smoking - Nicotine replacement - Social support - Stress management - Relapse prevention

What is Cognitive Behavior Therapy?: Beyond Beck

Many forms of CBT exist that share characteristics of Beck's therapy, but whose conceptualizations and emphases vary - Rational Emotional Behavior Therapy: Ellis (1962) - Dialectical Behavior Therapy: Linehan (1993) - Problem-Solving Therapy: D'Zurilla & Nezu (2006) - Acceptance and Commitment Therapy: Resick & Schnicke (1993) - Exposure Therapy: Foa & Rothbaum (1998) - Cognitive Processing Therapy: Resick & Schnicke (1993) - Cognitive Behavioral Analysis System of Psychotherap: McCullough (1999) - Cognitive Behavior Modification: Meichenbaum (1977) - And others... Cognitive Behavior Therapy - Has been adapted for patients with diverse • Levels of income • Cultural groups • Ages (from young children to older adults) - Is used in • Primary care and other medical offices • Schools • Vocational programs • Prisons • Among other settings... - Is used in several formats • Group, couple, and family therapy

A Comprehensive Assessment: Merrell (2008)

Merrell (2008) advocates a... - Multisource, Multimethod, Multi-setting approach: An approach involving multiple sources of information, multiple methods of obtaining information, and multiple settings in which information is solicited Multisource: Involves parties such as parents, relatives, teachers, and the child Multimethod: Involves the use of different methods of data collection such as interviews, pencil-and-paper instruments, and direct observation Multi-setting: Sometimes children's problems pervade all facets of their lives • Sometimes children's problems are specific to certain situations -For this reason, it's wise to get data from the home, school, clinician's office, and any other relevant setting

Forensic Psychology: Assessment Activities

Most common assessments are in the areas of - Child custody - Competency - Presentencing evaluations Assessments are also conducted in - Some parole decisions - Personal injury lawsuits - Worker's compensation hearings - Preemployment screenings of legal personnel - Social security disability evaluations Always important to consider ethical issues - The role of the psychologist is not as clear as in more common clinical situations Example • When a psychologist conducts a police officer preemployment screening evaluation - The police department is the client » Not the applicant - The information is shared with the police department senior staff "Who is the client?" • This should be clarified by the clinical psychologist from the outset • Could be the person being assessed, the court system, or another party Limits of confidentiality should be made clear to the individual being evaluated by way of a written and oral informed consent process - The clinical psychologist can't ensure complete confidentiality of the report once it is shared • So, care is taken to exclude personal information that is not relevant to the reason the evaluation is being conducted - The report and test data are intended to remain confidential • However, an evaluation conducted for the courts or other legal entities may become publicly available once it leaves the hands of the clinical psychologist Mike Tyson was denied a license to box in Nevada in 2002 by the Nevada Athletic Commission • Afterwards, a comprehensive psychological evaluation was conducted to evaluate anger management problems • Tyson attempted to have the report kept private - However, it was made public and posted on various websites Similar situations have happened to college football players - Their I.Q. tests evaluated by the NFL have been leaked to the press

Stress and coping: Nature

Nature - Mellins et al. (1996) • Study involving 44 identical and 30 fraternal twins • Found that genetic factors accounted for the majority of the variance in 57% of the coping variables studied This biological vulnerability manifests itself in a tendency to overreact to or become depressed in response to stress Researchers have hypothesized there is a disease-prone personality • One that predisposes people to stress-related illnesses such as arthritis, ulcers, and coronary heart disease • This personality profile is one of marked anxiety, depression, pessimism, and defensive hostility

Quitting smoking: Nicotine Replacement

Nicotine replacement - Involves the use of over-the-counter or prescription alternatives to cigarettes e.g. gum or transdermal patches - Mechanism of change is two-fold • Breaks the oral habit of smoking • Slowly weans the body off nicotine dependence through controlled dosing that decreases over time - Comprehensive reviews of the efficacy of nicotine replacement therapy have supported it as an agent that produces significant smoking cessation

Treatment of Forensic Clients: Targeted Programs

Often used with problems such as alcohol and other drug treatments and sex offender treatments These have the advantages of allowing for more contact hours with clients

Predicting Dangerousness: Base Rate

One of the most significant challenges with predicting dangerousness is the... - Base rate: the rate at which a behavior occurs, whereby phenomena with a low base rate (low frequency) are more difficult to predict Example of Schizophrenia • 1% of the population meets criteria for Schizophrenia - Base rate of 1% • The higher the base rate is, the more likely a prediction will be accurate based solely on chance occurrence • Trying to predict whether a person will have schizophrenia is very difficult - even with full knowledge of all possible predictor variables

Not Guilty by Reason of Insanity (NGRI)

People who commit crimes should be punished only when they committed the crime of their own free will - This is according to the U.S. legal system If an individual is unable to control his or her actions due to a mental disorder - The individual would not be held for a crime • Even if such actions were criminal in nature Not guilty by reason of insanity (NGRI) -In the U.S. legal system, a possible finding whereby an individual was unable to control his or her criminal actions due to a mental disorder at the time of the offense and is therefore not held responsible for the crime When found NGRI • Defendants are not imprisoned in the usual sense - These penalties were created as a means of deterrence and social control - Imprisonment would not deter someone who did not commit the crime of his or her own free will

Basic Principles of Treatment: Principle No. 10

Principle No. 10: Cognitive behavior therapy uses a variety of techniques to change thinking, mood, and behavior Socratic questioning and behavioral experiments are essential • So are techniques from other orientations that are implemented within a cognitive framework - Gestalt-inspired techniques might help Sally understand how familiar experiences shaped her beliefs - Psychodynamically inspired techniques with some Axis II patient who apply their distorted ideas about people to the therapeutic relationship The emphasis in treatment also depends on the patient's particular disorder • CBT for panic disorder involves testing the patient's catastrophic misinterpretations of bodily or mental sensations • Anorexia requires modification of beliefs about personal worth and control • Substance abuse focuses on negative beliefs about the self and facilitating or permission-granting beliefs about substance use

Basic Principles of Treatment: Principle No. 1

Principle No. 1: Cognitive behavior therapy is based on an everevolving formulation of patients' problems and an individual conceptualization of each patient in cognitive terms Consider Sally's difficulties in three time-frames • Her current thinking contributes to her feelings of sadness - "I'm a failure, I can't do anything right, I'll never be happy" • Her current problematic behaviors - Isolating herself, spending a great deal of unproductive time in her room, avoiding asking for help - These a) flow from and b) reinforce Sally's dysfunctional thinking Identify precipitating factors that influenced Sally's perceptions at the onset of her depression • e.g. being away from home for the first time and struggling in her studies contributed to her belief she was incompetent Hypothesize about key developmental events and her enduring patterns of interpreting these events that may have predisposed her to depression • e.g. Sally has had a lifelong tendency to attribute personal strengths and achievements to luck, but views her weaknesses as a reflection of her "true" self

Basic Principles of Treatment: Principle No. 2

Principle No. 2: Cognitive behavior therapy requires a sound therapeutic alliance I strive to demonstrate all the basic ingredients necessary in a counseling situation • Warmth, empathy, caring, genuine regard, and competence I show my regard by • Making empathic statements • Listening closely and carefully • Accurately summarizing her thoughts and feelings

Basic Principles of Treatment: Principle No. 3

Principle No. 3: Cognitive behavior therapy emphasizes collaboration and active participation I encourage Sally to view therapy as teamwork. Together, we decide • What to work on each session • How often we should meet • What Sally can do between sessions for therapy homework At first, I am more active in directing therapy sessions and summarizing what we've discussed As Sally becomes less depressed and more socialized to treatment • I encourage her to become increasingly active in the therapy session • e.g., deciding which problems to talk about, identifying distortions in thinking, summarizing important points, devising homework assignments, etc.

Basic Principles of Treatment: Principle No. 4

Principle No. 4: Cognitive behavior therapy is goal oriented and problem focused I ask Sally in our first session to • Enumerate her problems • Set specific goals • This is essential because it gives a shared understanding of what we are working toward These goals should be in behavioral terms • Example: If Sally says that she is feeling isolated - We then set the goal to initiate new friendships and spend more time with current friends - The goal should also be in Sally's control I help Sally evaluate and respond to thoughts that may interfere with her goal • e.g., "My friends won't want to hang out with me. I'm too tired to go out with them."

Basic Principles of Treatment: Principle No. 7

Principle No. 7: Cognitive behavior therapy aims to be time limited - Many straightforward patients with depression and anxiety disorders are treated for 6 to 14 sessions Therapists goals are to • Provide symptom relief • Facilitate a remission of the disorder • Help patients resolve their most pressing problems • Teach them skills to avoid relapse

Basic Principles of Treatment: Principle No. 8

Principle No. 8: Cognitive behavior therapy sessions are structured - This is true no matter what the diagnosis or stage of treatment - Following a structure in each session maximized efficiency and effectiveness Structure • Introductory part: Doing a mood check, briefly reviewing the week, collaboratively setting an agenda for the session • Middle part: Reviewing homework, discussing problems on the agenda, setting new homework, summarizing • A final part: Eliciting feedback This format • Makes the process of therapy more understandable to patients • Increases the likelihood that they will be able to do self-therapy after termination

Basic Principles of Treatment:

Principle No. 9: Cognitive behavior therapy teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs - Patients can have many dozens or even hundreds of automatic thoughts a day that affect their mood, behavior, and/or physiology Therapists help patients • Identify key cognitions • Adopt more realistic, adaptive perspectives These leads patients to • Behave more functionally • Decrease their physiological arousal Guided discovery • Using questioning to evaluate their thinking - Often labeled or mislabeled as "Socratic questioning" - This is opposed to persuasion, debate, or lecturing Behavioral experiments • Experiences the therapist creates for patients to directly test their thinking - e.g., "If I even look at a picture of a spider, I'll get so anxious I won't be able to think."

Play Therapy: Humanistic

Rather than interpreting clients' behavior, humanistic play therapists tend to reflect their client's feelings • These may be expressed either directly or indirectly through their play activities

Comprehensive assesment: Schroeder & Gordeon

Schroeder & Gordeon (2002) have some suggestions... -The presenting problem:What, exactly, is the presenting problem? Do all parties (parents, child, teachers, etc.) agree on the definition of the problem? When did the problem arise? For whom is this problem most troubling -Development: What is the child's current state of physical, cognitive, linguistic, and social development? Have there been any developmental abnormalities during childhood or during the prenatal period? Has the child reached all developmental milestones at the expected points in time? -Parents/Family: What are the relevant characteristics of the child's parent or parents? What style of parenting is used? What parent factors (psychological, medical, other) might play a role in the child's problem? How might siblings, grandparents, or other family members influence the child -Environment: What is the child's larger environment outside the family? What relevant ethnic or cultural factors play a role in the child's behavior? Are there recent major events in the child's life that may factor into the current problem? A clinical child psychologist may receive different answers from different people in the child's life - For this reason, it's important to rely on more than one source of information

Dialectical Perspectives on the Nature of Reality - Three Characteristics (#2)

Second, reality is not seen as static - It is made up of internal opposing forces (thesis and antithesis) out of whose synthesis evolves a new set of opposing forces All propositions contain within them their own oppositions - "I assume that truth is paradoxical, that each article of wisdom contains within it its own contradictions, that truths stand side by side". - Goldberg Dichotomous and extreme thinking, behavior, and emotions are viewed as dialectical failures - They leave the individual • Stuck in polarities • Unable to move to syntheses The therapist must pay attention to polarity and assist each client in moving toward a workable synthesis Polarities -Need for clients to accept themselves as they are in the moment and the need for them to change - This is the most fundamental tension in any psychotherapy - Therapist must negotiate this skillfully if change is to occur • Clients' getting what they need to become more competent and losing what they need if they become more competent • Clients' maintaining personal integrity and validating their own views of their difficulties versus learning new skills that will help them emerge - If clients get better by learning new skills, they validate their view that they were the problem and didn't have sufficient skills » It may appear to prove that others were right all along or that the client was the problem • Dialectics focuses attention on these polarities and suggests ways out of them

Cognitive-Behavioral Therapies for Children: Social Skills Training

Social Skills Training: a cognitive-behavioral approach in which therapists teach kids behaviors that improve their interactions with others - Works well for kids with a wide range or problems - Used most often in kids who have autism spectrum disorder, social anxiety disorder, or ADHD Targets many skills • How to start a conversation • How to join other kids who are already interacting • How to express feelings appropriately • How to handle frustration • How to manage eye contact and other nonverbal behavior • How to manage volume and tone of voice Skills are • Modeled by the therapist and reinforced during the session • Reinforced with rewards that are meaningful to the child

Quitting smoking: Social Support

Social support - Having smokers in one's social group has been shown to be • A significant detriment to smoking cessation • A significant predictor of relapse

Social Suppor

Social support - The perception that one has relationships with others who can both • Provide support in a time of crisis • Share in good fortune One of the most documented phenomena in health psychology • Benefits to physical health are ample and undeniable Some argue that social support is the single most vital resource against stress Thomas Padus - "The breakdown in social support structure precipitates a breakdown in the body's immune system. House, Kahn, McLeod, and Williams (1985): Social resources are composed of three components • Social network: the broad scope of all social contacts one has. Within this large pool is a smaller pool of those with whom one has more meaningful... • Social relationships • Social support: the quantity and quality of care and assistance those relationships bring Someone with a small social network who has a single meaningful social relationship with a large degree of social support might be better off than a "social butterfly" with a broad social network but no intimate friends Interesting... • Married men report that their main source of social support is their wives • Married women rely more heavily on other family members and friends • Some say this is why men are more likely than women to suffer physically from stress-related ailments after a divorce

Stress and Physical Illness

Stress has been linked to myriad symptoms and diseases - Migraine headaches - Osteoporosis - Chronic back pain - Cardiovascular disease - Ulcers - Diarrhea - Acne - Fertility problems The same bodily responses - Saved us from an immediate danger - In our current society, become a maladaptive condition that has led to illness in many people The American Institute of Stress (1997) estimate that • 75% to 90% of all visits to health care providers result from stress-related disorders • Those who are stressed are six times more likely to be hospitalized for a physical ailment than those who are not Chronic stress can lead to (Hafen et al., 1996) - Increased levels of thyroid hormones resulting in insomnia and weight loss - Depleted endorphins, resulting in bodily pain - Reduced sex hormones, leading to amenorrhea or infertility - The shutting down of the digestive system resulting in nausea, bloating, and dry mouth - An excess of cholesterol release than can contribute to blocked arteries, blood pressure increases of up to 400%, stroke, or aneurism Of the most debilitating effects of stress is the weakening of the immune system - Stress activates the hypothalamic-pituitary-adrenal (HPA) axis. This controls the release of our body's stress hormone, cortisol - Cortisol: Beneficial in appropriate amounts. Chronic stress leads to an increased level, which leads to - The deterioration of T-cells, essential cells in the immune system -T-cells attack foreign pathogens and regulate other cells of the immune system - This leads to a weakened immune system Chronic stress can make you sick Sheldon Cohen - Conducted pioneering work on stress and the common cold - Found that those participants with the highest amounts of stress were more than five times as likely to become infected with the common cold virus Psychoneuroimmunology (PNI) - The scientific field of study concerned with the interactions among behavior, the nervous system, and the immune system

Quitting smoking: Stress Management

Stress management - Smokers often report that they smoke because they find it relaxing and stress reducing - An important task is for the client to develop and practice alternate replacement strategies for relaxation and stress reduction • This must be done before the smoker begins the quitting process

Cognitive Theory

The Cognitive Model - Proposes that dysfunctional thinking (which influences the patient's mood and behavior) is common to all psychological disturbances - When people learn to evaluate their thinking in a more realistic and adaptive way, they experience improvement in their • Emotional state • Behavior Example: Let's say that you bounced some checks • You may have an automatic thought - "I can't do anything right." - This is an idea that just popped into your mind • This thought would lead to a particular reaction - You feel sad (emotion) - You retreat to bed (behavior) • If you examined the validity of this idea, you might conclude that you had overgeneralized - You actually do many things well Looking at the experience from a new perspective would probably make you feel better and lead to more functional behavior For lasting improvement in patients' mood and behavior, cognitive therapists work at a deeper level of cognition - Patients' basic beliefs about themselves, their world, and other people - Modification of their underlying dysfunctional beliefs produces more enduring change Example: if you continually underestimate your abilities, you might have an underlying belief of incompetence - Modifying this general belief can alter your perception of specific situations you encounter daily - You will no longer have as many thoughts with the theme "I can't do anything right" - Instead, if you make a mistake you will probably think, "I'm not good at [this specific task]."

The M'Naghten Test

The M'Naghten Test: the first legal standard for the insanity defense in the history of the American legal system Daniel M'Naghten was charged with attempting to kill the prime minister of England • The attempt was because of persecutory delusions M'Nghten held about Britain's Tory party and its leader, Prime Minister Sir Robert Peel • Instead of killing the intended target, he killed the prime minister's secretary, who was nearby English common law had already recognized that "lunatic idiots" who acted as "wild beasts" due to their mental state were not responsible in the eyes of the law • The M'Naghten case developed the formal test of insanity The court ruled - "To establish a defense on the ground of insanity, it must be clearly proved that, at the time of the committing of the act, the party accused was laboring under such a defect of reason, from disease of mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong."

Forensic psychology

The application of psychological methods and principles within the legal system - Dates back nearly to the origins of psychology as a recognized science Examples • Social psychologists: Research and apply psychological science issues such as jury selection and jury dynamics • Cognitive psychologists: Bring their expertise to bear on the issues of eyewitness testimony and its accuracy • Clinical psychologists: The most qualified and most often involved in forensic psychology. Bring their expertise and extensive training in assessment, treatment, and psychopathology

Development of Emotion Dysregulation

The biosocial developmental model proposes the following The development of extreme emotional lability is based on characteristics of the child in transaction with a social context that shapes and maintains the lability Reciprocal reinforcing transactions between biological vulnerabilities and environmental risk factors increase emotion dysregulation and behavioral dyscontrol • These contribute to negative cognitive and social outcomes A constellation of identifiable features and maladaptive coping strategies develops over time These traits and behaviors may exacerbate risk for pervasive emotion dysregulation across development • This is due to the evocative effects on interpersonal relationships and social functioning via interference with healthy emotional development

What Does the Research Say about CBT?

The first outcome study was published in 1977 (Rush et al., 1977) Now, more than 500 outcome studies have demonstrated the efficacy of CBT for a wide range of - Psychiatric disorders - Psychological problems - Medical problems with psychological components Effectiveness of CBT has been demonstrated in community settings Studies have found that computer-assisted CBT is effective Several studies have demonstrated neurobiological changes associated with CBT Hundreds of studies have also validated the cognitive model of depression and of anxiety

Dialectical Behavior Therapy Goal

The overall goal of DBT skills training: To help individuals change behavioral, emotional, thinking, and interpersonal patterns associated with problems in living

The Role of the Invalidating Environment in DBT

The primary function of emotions in humans is to serve as a rapid communication system* - Invalidation of emotions sends the message that the communication was not received • When the message is important, the sender escalates the communication by escalating the emotion • When the receiver does not "get" the communication or disbelieves it, he/she increases efforts to stop the communicatio (Usually by some means of invalidation) - This process goes around and around until one side backs down • It is often the receiver who finally stops and listens... or gives into the demands of the highly emotional sender. This reinforces the escalation in the sender and cements the pattern This pattern is particularly damaging for a child who begins life with high emotional vulnerability - The emotionally vulnerable and reactive individual elicits invalidation from an environment that might have otherwise been supportive Defining characteristic of the invalidating environment - The tendency to • Respond erratically and inappropriately to private experience • Be insensitive to private experience that does not have public accompaniments Invalidating environments also tend to respond in an extreme fashion to private experiences that do have public accompaniments In the optimal family, public validation of private experience is frequent - Example: The child says, "I'm thirsty" • The parents give him or her a drink • This is opposed to saying "No, you're not. You just had a drink." - Example: The child cries • The parents soothe the child or attempt to find out what is wrong • This is opposed to saying, "Stop being a crybaby!" - Example: The child expresses anger or frustration • The parents take it seriously • This is opposed to dismissing it as unimportant - Example: The child says "I did my best" • The parents agree • This is opposed to saying, "No, you didn't" In the invalidating environment - Leads to a big difference between • The emotionally vulnerable child's private experience • The experience the social environment actually supports and responds to - When persistent, leads to the fundamental learning environment necessary for many of the behavioral problems associated with emotion dysregulation

Cognitive-Behavioral Therapies for Children: Bravery Bingo and Mr. OCD

The principles are the same, though the delivery may differ "Bravery Bingo" (Pincus et al., 2011) • Here, a phobic child earns a token, to be placed on a bingo board, for each successful exposure on the anxiety hierarchy "Mr. OCD" (Pincus et al., 2011) • Here, children practice cognitive restructuring by refuting a puppet (Mr. OCD) who exhibits flawed logic - "A monster's gonna get you tonight when you're sleeping" could be countered with "A monster has never gotten me before, and it's not gonna happen tonight, either! There are no monsters in my room!" More deliberate reinforcement for homework assignments is often done • e.g., stickers, candy, privileges, praise, etc

Vulnerability

The tendency to experience psychological problems in the presence of risk factors Factors that contribute to vulnerability to psychological problems - Environmental factors e.g., poverty, serious emotional conflict among parents, single parenthood, an excessive number of children in the home, neighborhood or community factors, and poor schooling - Parental factors e.g., poor parental physical health, poor parent mental health, low parent intelligence quotient (IQ), and hypercritical tendencies in the parent - Child (internal) factors e.g., medical problems, difficult temperament, low IQ, poor academic achievement, and social skills deficits The more psychological problems parents have, the more psychological problems their children are likely to have -Breaux et al., 2014 • Assessed parents and kids (at ages 3, 4, 5, and 6) • Kids whose parents had a mental health illness at age 3 were more likely to have a mental health illness themselves as they got older •This relationship was especially true when the parent's diagnosis was ADHD, depression, an anxiety disorder, or a personality disorder -Hudson et al., 2014 • Studied children being treated for anxiety disorders • Children were much less likely to have a diagnosis both immediately after treatment and 6-months after treatment if their parents were non-anxious (in comparison to anxious) Sibling relationships are also important factors in kids' vulnerability to psychological factors -Buist et al., 2013 • Conducted a meta-analysis of 34 studies on the effect of sibling relationships on children's mental disorders • Found that those with warmer and more loving brothers and sisters had fewer internalizing and externalizing disorders • Those whose relationships with siblings were full of conflict were more likely to have both categories of disorders

Basic Principles of Treatment: Overview

Therapy must be tailored to the individual - There are, however, certain principles that underlie cognitive behavior therapy for all patients Case Example - "'Sally' was an 18-year-old single female when she sought treatment with me during her second semester of college. She had been feeling quite depressed and anxious for the previous 4 months and was having difficulty with her daily activities. She met criteria for a major depressive episode of moderate severity according to DSM-IV-TR."

Not Guilty by Reason of Insanity (NGRI): misconceptions

There are many misconceptions of the NGRI defense - Some stem from publicized court cases in which the public perceives that the defendant may have sought an NGRI label solely to avoid punishment - John Hinckley was found NGRI after the 1981 attempted assassination of President Reagan Four common misconceptions regarding the NGRI defense (Melton et al., 2007) - The general public may think this defense is used frequently - People may think it is often successful • Less than 1% of felony jury trials involve an NGRI defense • Only about 25% of those trials result in an NGRI verdict People may think the NGRI defendant is often released without being institutionalized • This is very uncommon • Typically, the person found NGRI is institutionalized in a mental hospital almost as long as he or she would have been incarcerated if convicted of the crime There is a misperception that individuals found NGRI are more dangerous than they really are

Assessment Methods: Projective/Expressive Techniques

These include many of the same tests used with adults • The Rorschach Inkblot Method • The Thematic Apperception Test (TAT) • Sentence-completion techniques The Children's Apperception Test • This is an adaption of the TAT test for children • Features animal, rather than human, characters

Dialectical Perspectives on the Nature of Reality - Three Characteristics (#3)

Third is the assumption that the fundamental nature of reality is change and process rather than content or structure - This follows from the first two characteristics - The most important implication • Both the individual and the environment are undergoing continuous transition - Therapy does not focus on maintaining a stable, consistent environment • Therapy aims to help the client become comfortable with change - Therapists must keep aware of • How their clients are changing • How they themselves and the treatment they are applying are changing over time

Treatment of Forensic Clients: Crisis Management

This would include situations when someone engages in self-harming or violent behaviors Such treatments are brief • Followed by a referral to long-range treatments

Treatment of Forensic Clients

Treatment in a forensic context can take many forms Generally, the treatment focuses on short-term goals leading toward the person's reintroduction into society Not Guilty by Reason of Insanity • The primary purpose of hospitalization is the treatment of their psychological and psychiatric symptoms • Goals - Reintroduction of into society - Community-based services Not Competent to Stand Trial • The focus of treatment is typically increased their knowledge of the judicial system relevant to their case • Goals: Preparation for trials Heilbrun and Brooks, 2010 - "Practice guidelines" that provide guidance to psychologists on the best treatment options - Four basic therapy tasks either alone or in combination (Mobley, 2006) • Crisis management • Maintenance • Outpatient psychotherapy • Targeted programs

Play Therapy

Unique to child clients • Typically used with younger clients (preschool or elementary-school age) • Allows children to communicate via actions with objects rather than with words -e.g., dollhouses, action figures, and toy animals Through play, children can reveal to clinical psychologists their emotional concerns and attempt to resolve them Three basic functions (Brems (2008) - The formation of important relationships - The disclosure of feelings and thoughts e.g., expressing emotions, acting out anxieties - Healing e.g., acquiring coping skills, experimenting with new behavior

Treatment of Forensic Clients: Maintenance Treatments

Used with incarcerated individuals who have more long-standing problems • e.g., intellectual developmental disorder, schizophrenia, etc. Often held and treated in special housing units

Assessment Methods: Behavioral Observations

When a child's behavior can be directly observed (as in most externalizing disorders) child clinical psychologists do so - Behavioral observation: the direct systematic observation of a client's behavior in the natural environment • Also known as naturalistic observation Several published systems can be used • e.g., the Direct Observation Form, the Child Behavior Checklist, the Student Observation System, the Behavior Assessment System for Children, the Dyadic Parent-Child Interaction Coding System, the Social Interaction Scoring System, etc

Assessment Methods: Interviews

When assessing an adult, the adult is often the only person with whom the psychologist speaks This is very different in child assessment • The clinical psychologist typically interviews anyone who, by virtue of their contact with the child, can shed light on the child's problem • Parents and teachers are the most common • May also include siblings, grandparents, other relatives, pediatricians, friends, child-care workers, tutors, etc.

Resilience and Vulnerability

Why do some children develop psychological disorders whereas other children do not? - This is an essential question for clinical child psychologists - Children from similar environments can have very different kinds or degrees of psychological and/or behavioral problems Why do some children develop psychological disorders whereas other children do not? - Resilience: the tendency to remain psychologically healthy despite the presence of risk factors that contribute to psychological problems in others - Vulnerability: The tendency to experience psychological problems in the presence of risk factors

Predicting Dangerousness: Statistical prediction methods

assessors predict dangerousness according to a statistical or actuarial formula compiled from a comparison of an individual's characteristics with known correlations to future dangerousness • Dispositional variables e.g., age, race, sex, social class, and personality variables • Historical variables e.g., history of violence, work history, mental health history, criminal history • Contextual variables e.g., current social supports, presence or availability of weapons, current stress level • Clinical variables e.g., current mental disorders, drug and alcohol abuse, overall level of functioning Statistical methods - Are objective • Thus, more empirically sound - Less flexible Grove et al. (2000) meta-analysis - Found that statistical predictions were about 10% more accurate than clinical predictions

Predicting Dangerousness: Clinical prediction methods

assessors use psychological tests, clinical interviews, clinical experience, and personal judgements to make determinations Clinical methods - Are subjective - Differ from clinician to clinician • These differences tend to make the clinical method less reliable - Leaves room for biases and other forms of human errors common in subjective decision making

Externalizing disorders

disorders in which the child "acts out" and often becomes a disruption to parents, teachers, or other children • These include ADHD, conduct disorder, and oppositional defiant disorder

Internalizing disorders

disorders that involve maladaptive thoughts and feelings more than disruptive outward behavior • These include depression and anxiety disorders

Predicting dangerousness

the practice whereby a forensic psychologist assesses the likelihood that an individual will behave violently or dangerously in the future Two categories of ways that clinical psychologists assess the potential for future danger - Clinical prediction methods - Statistical prediction methods Research has established general guidelines for predicting dangerous behavior - Risk factors • Age: younger people at higher risk • Arrest record: those with more arrests at higher risk • Weapon availability: those who have available weapons at higher risk • Social support: those low in social support at higher risk • Psychological symptoms: those with active psychosis symptoms at higher risk Research literature is clear that there is a small relationship between the presence of mental illness and violence • There are still some key psychological factors that are related - Presence of substance abuse - Psychotic symptoms

Resilience

the tendency to remain psychologically healthy despite the presence of risk factors that contribute to psychological problems in others