8-31 Hx & Current Issues

8-31 Hx & Current Issues - Clinical Psychology...

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Unformatted text preview: Clinical Psychology Clinical Psych 486 Current Issues and Current Diagnostic Categories Review Current Issues: Managed Care Current Managed care—systems in which providers of health Managed care programs give control to a third party with the goals of reducing costs and improving quality. goals • Health care costs now account for over 14% of US Health gross national product, up from 4.5% in 1950. gross • Participating psychologists must have their Participating credentials and plans of care approved by the managed care system. managed • Fees are set for specific services, and limits are set Fees for number of sessions and allowable services. Current Issues: Managed Care Current Drawbacks of managed care— • Focus on reducing costs tends to reduce Focus treatment(e.g., fewer sessions and shorter inpatient stays). stays). • Clinicians face ethical dilemma when treatment is Clinicians needed but will not reimbursed. needed • Clients may be encouraged/forced to see clinicians Clients with less training because they are cheaper. • Decisions regarding what treatment is allowed may Decisions be driven by political considerations rather than scientific evidence. • Requirements to share information with managed Requirements care companies infringes on client confidentiality. care • 79% of practitioners report managed care has 79% negatively affected their clinical work. Current Issues: Managed Care Current Benefits of managed care— • Because of focus on accountability, Because managed care has encouraged use of empirically supported treatment (ESTs (ESTs —techniques found effective in —techniques research studies). • Requirements of managed care have Requirements improved clinical documentation. improved Current Issues: Evidence-Based Practice Involves using available research data to select treatment interventions likely to work for a specific client with specific issues. Involves using clinical expertise to… • Determine what are the empiricallysupported treatments for the client’s supported disorder. disorder. • Evaluate client factors that might affect Evaluate preferences/treatment success. preferences/treatment • Choose and implement treatment in a Choose manner most likely to work for that client. Current Issues: Evidence-Based Practice Evidence-Based Best Best available research evidence research EvidenceEvidence- Clinical Clinical Based Based expertise Client Practice Practice preferences and values and Dennis McChargue, 2008 Dennis Current Issues: Evidence-Based Practice • What is considered an EST best determined What through use of Radomized Controlled Trials(RCTs)— Trials(RCTs)— Involves randomly assigning subjects to receive Involves one of a number of possible interventions. State of the art for clinical research. State – – • • Replaces doing what you were taught to do/ prefer to do with what you have reason to prefer believe is actually likely to work. Contributes to greater eclecticism among Contributes psychologists. Current Issues: Multiculturalism Current Multicultural counseling—providing services to people Multicultural who differ from the therapist in terms of ethnicity, religion, socioeconomic status, education level, sexual orientation, and physical ability. sexual • In 2000, ethnic minorities comprised 17% of US In population; anticipated by 2050, ethnic minorities will make up half of US population. • Cultural factors affect identity and behavior. • Members of ethnic minorities often are not served Members or are inappropriately served by the mental health system, commonly because clinicians are poorly informed regarding how to provide culturallyinformed sensitive treatment (e.g., misdiagnose normal/ sensitive adaptive behaviors as pathology). Current Issues: Multiculturalism Current • Importance of cultural issues in treatment may be Importance affected by client’s degree of… affected – Cultural identification: importance of background to client. – Acculturation assimilation into the majority Acculturation culture. Differences in degree of acculturation can affect Differences family dynamics—e.g., if a child is the only English speaker. speaker. Clinicians need to be careful not to engage in Clinicians cultural overgeneralization—e.g., assuming all the cultural e.g., client’s problems are due to his/her membership in a minority group. • • Current Issues: Turf Wars Current Turf wars— Turf • Masters level clinicians vs. psychologists— Nebraska now allows independent practice (can Nebraska treat major mental illness without supervision) for masters’ level clinicians who can document sufficient training and supervised experience. sufficient • Specialists vs. non-specialists—should should psychologists not be allowed to work with certain issues (e.g., neuropsychology, drug and alcohol treatment, domestic violence, sexual offenses) unless they have received special training/supervised/experience? training/supervised/experience? Current Issues: Turf Wars Current • Mental health vs. medical care—mental mental health parity: movement to ensure individuals have same access to mental health care as to medical care – Bill passed US Congress in 2008 – APA reports payment for services has APA increased increased • Psychologists vs. psychiatrists—movement movement towards prescription privileges for appropriately trained psychologists. appropriately Psychologists need to keep informed regarding Psychologists changes in licensure/ reimbursement in their areas. Current Issues: Medicalization of Mental Health Medicalization Greater understanding of neurological basis of Greater behavior, plus advancements in psychiatric medications, have increased focus on medical explanations for mental illness. • Part of movement to place mental illnesses Part on a par with physical illness. on • Encourages a more passive role for clients Encourages in treatment. in • May reduce use of psychological May techniques that are effective, proactive, and not associated with the side-effects common to medications. Current Issues: Recovery Model Current Treatment model—focused on curing disease • Traditional mental health treatment. • Works well for curable illnesses, but may Works lead to reduced/poor services for those with incurable conditions. incurable Recovery model—focus is less on “curing” a Recovery disorder than on improving functioning/quality of life. functioning/quality • Includes input from consumers. • Intended to foster empowerment/hope, Intended reduce stigma. • Should be applicable/useful for the range of Should mental health concerns. Current Issues: Psychology and Politics Psychology The American Psychological Association has taken The positions on issues such as… positions Sexual orientation—based on evidence from decades based of research, APA argues that same-gender sexual orientation is a “normal and positive variation of human sexual orientation,” opposes “prejudice, discrimination, and violence” against gays and lesbians, and “has taken a leadership role” in the pursuit of rights for gays and lesbians (APA, 2010). Abortion—resolved in 1969 that “termination of Abortion—resolved pregnancy be considered a civil right of the pregnant woman, to be handled as other medical procedures” (APA, 1969). Torture—in 2007 issued an “absolute prohibition” for Torture—in psychologists to participate in interrogations techniques such as mock executions or drowning. Continued Redefinition of Diagnostic Categories Diagnostic Why do we need a system for classifying Why mental disorders? mental • To enable communication about disorders To between professionals. • To provide a framework for researchers To investigating the nature/causes/treatment of various disorders. • To guide interventions into the issues To clients present for treatment. • May help clients feel understood/give hope May their situations can improve. Diagnostic and Statistical Manual Diagnostic Process of development— DSM—1952. DSM—1952. • Published by the American Psychiatric Published Association. • Glossary of 60 diagnostic categories. DSM-II—1968. • Described 145 diagnostic categories. Described • Generally psychodynamic, involving Generally significant inference of internal states. significant Diagnostic and Statistical Manual Diagnostic Process of development (cont.)— DSM-III—1980. • Intended to be atheoretical. • Provided specific diagnostic criteria to Provided reduce need for inference. • Provided guidelines for differential Provided diagnosis. diagnosis. DSM-IV—1994. • Took advantage of the considerable Took research data available since 1980. • Includes information on and decision rules Includes for over 300 diagnoses. Diagnostic and Statistical Manual Diagnostic DSM-IV-TR—2000. Based on a prototypical approach to classification— Based prototypical approach uses both… • Essential characteristics—factors that must be factors present, and • A range of variation—some of a list of symptoms some are present, but number and combinations vary. are No changes in diagnostic categories from DSM-IV— added information from new research (e.g., course added of disorder, variations across gender/ethnicity). DSM 5—due out in 2013. Major focus on empiricism, validity, and diagnostic utility. validity, Diagnostic and Statistical Manual Diagnostic Criticism of diagnosis— • Labeling is not fixing—knowing you have erectile knowing dysfunction does not cure your erectile dysfunction. • Association with the medical model—suggests the suggests client is diseased. • Lack of reliability—different clinicians working with different the same case may arrive at different diagnoses (less of an issue from DSM-III on). • Diagnoses may be stigmatizing—may feed existing may prejudices towards individuals identified as having mental illnesses. DSM-IV Review DSM-IV Clinical disorders— • Disorders usually first diagnosed in infancy, Disorders childhood, or adolescence— childhood, – Behavioral disorders: e.g., ADHD, conduct, oppositional-defiant. oppositional-defiant. – Disorders of development: e.g., learning, autism. – Other: e.g., Tourette’s, reactive attachment. • • Cognitive disorders—e.g., delirium, e.g., dementia, amnesic disorders. Substance related disorders—intoxication, intoxication, withdrawal, abuse or dependence. withdrawal, DSM-IV Review DSM-IV Clinical disorders (cont.)— • Schizophrenia and other psychotic disorders—e.g., e.g., brief psychotic, schizoaffective, shared psychotic disorder. • Mood disorders—e.g., major depressive, e.g., dysthymic, bipolar. dysthymic, • Anxiety disorders—e.g., panic, phobias, obessivecompulsive disorder, generalized anxiety disorder, compulsive posttraumatic stress disorder. • Somatoform disorders— – Client reports symptoms of physical illness, but Client no or insufficient medical basis can be found. no – E.g., hypochondriasis and pain disorders. DSM-IV Review DSM-IV Clinical disorders (cont.)— • Dissociative disorders—involve disruptions involve in consciousness, identity, memory or perception (e.g., dissociative amnesia, dissociative identity disorder). dissociative • Sexual and gender identity disorders— • • – Sexual dysfunctions: e.g., premature ejaculation, sexual aversion disorder. sexual – Paraphilias: e.g., pedophilia, sadism, fetishism. Eating disorders—anorexia and bulimia anorexia nervosas. Sleep disorders—e.g., insomnia, sleep e.g., terror disorder. DSM-IV Review DSM-IV Clinical disorders (cont.)— • Adjustment disorders—involve symptoms involve significant enough to affect functiong, but not meeting full criteria for another disorder (e.g., adjustment disorder with depressed mood). • Personality disorders— – – Stable, pervasive patterns of behavior and Stable, attitudes that cause distress and dysfunction. Examples include paranoid, antisocial, and Examples borderline (instability in self-image, relationships, and emotions). ...
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