CHAPTER 5

Ethical Issues in Clinical Psychology

American Psychological Association Code of
Ethics
 First published in 1953
 Nine subsequent revisions
 Applies to all specialties
 Especially relevant to clinical psychologists

Aspirational and Enforceable

 Aspirational – General Principles
 Enforceable – Ethical Standards
•General Principles: Describe an ideal level of
ethical functioning or how psychologists should
strive to conduct themselves. They don’t include
specific definitions of ethical violations; instead,
they offer more broad descriptions of exemplary
ethical behavior.
1.Beneficence and Nonmaleficence.
2.Fidelity and Responsibility.
3.Integrity.
4.Justice.  Celia Fisher’s model for ethical decision
making:
5.Respect for People’s Rights and Dignity.
1.Prior to any ethical dilemma arising, make a
•Ethical Standards: If a psychologist is found
commitment to doing what is ethically appropriate.
guilty of an ethical violation, it is a standard (not a
principle) that has been violated. These standards 2.Become familiar with the American Psychological
are written broadly enough to cover the great range Association ethical code.
of activities in which psychologists engage, but they
are nonetheless more specific than the general 3.Consult any law or professional guidelines
principles. Although each general principle could relevant to the situation at hand.
apply to almost any task a psychologist performs, 4.Try to understand the perspectives of various
each ethical standard typically applies to a more parties affected by the actions you may take.
targeted aspect of professional activity. Consult with colleagues (always protecting
1.Resolving Ethical Issues. confidentiality) for additional input and discussion.

2.Competence. 5.Generate and evaluate your alternatives.

3.Human Relations. 6.Select and implement the course of action that

4.Privacy and Confidentiality.
5.Advertising and Other Public Statements.
6.Record Keeping and Fees.
7.Education and Training.
8.Research and Publication.
9.Assessment.
10.Therapy
Ethical Decision Making
 The American Psychological Association’s
(2002) ethical code does not offer any such
decision-making models per se, but such
models have been recommended by a
number of experts in the field
 Models have been recommended by experts
 Celia Fisher’s model
 Best preparation to deal with
dilemmas
seems most ethically appropriate.
7.Monitor and evaluate the effectiveness of your
course of action.
8.Modify and continue to evaluate the ethical plan
as necessary.
Psychologists’ Ethical Beliefs
 Based on survey of American Psychological
Association members
 Based on studies by other researchers
 One study found that psychologists’ ethical
beliefs may vary according to the point in
time or the region of the country in which
they are collected
Confidentiality
 Confidentiality is specifically mentioned
among the general principles (in Principle E:
Respect for People’s Rights and Dignity)
and in numerous specific ethical standards
—including Standard 4.01, “Maintaining
Confidentiality,” which begins,
“Psychologists have a primary obligation and take
reasonable precautions to protect confidential
information”
 Specifically mentioned in
 General principles
 Ethical standards
 Reason for emphasis
Tarasoff and the Duty to Warn (PROTECT)
 Tarasoff case
 Duty to warn and duty to protect
 Challenges faced by clinical psychologists
 As stated in the Tarasoff ruling, “The
confidential character of patient-
psychotherapist communications must yield
to the extent to which disclosure is essential
to avert danger to others.
 Interpretations vary from state to state
When the Client Is a Child or Adolescent
 More confidentiality-related challenges arise
when clinical psychologists provide services
to minors.
 Dilemma: How much to reveal to parents?
 Possible arrangements
 Cases involving child abuse
Informed Consent
 Facilitates an educated decision
 Required during
– Research
– Assessment
– Therapy
 it affords individuals the opportunity to
refuse to consent if they so choose.
Boundaries and Multiple Relationships
 Multiple relationships - friend, business
partner, or romantic partner
 Can be problematic
 The claim of their nonexistence would be
false
Defining Multiple Relationships
 So multiple relationships can form not only
when a psychologist knows one person both
professionally and nonprofessionally but
also when a psychologist has a relationship
with someone “closely associated with or
related to” someone the psychologist knows
professionally.
 Ethical Standard states that a multiple
relationship occurs when a psychologist is in
a professional role with a person and
(1) at the same time is in another role with the
same person,
(2) at the same time is in a relationship with a
person closely associated with or related to the
person with whom the psychologist has the
professional relationship, or
(3) promises to enter into another relationship in
the future with the person or a person closely
associated with or related to the person.
 Sexual multiple relationships: sexual
partner of the client.
 Nonsexual multiple relationships:
friendships, business or financial
relationships, coworker or supervisory
relationships, affiliations through religious
activities, and many others
What Makes Multiple Relationships Unethical?
 Two Criteria for impropriety
1. Involves the impairment in the psychologist
• if the dual role with the client makes it difficult for
the psychologist to remain objective, competent, or
effective, then it should be avoided.
2. Exploitation or harm to the client
• Need for caution and foresight
Competence
 Competent clinical psychologists are those
who are sufficiently capable, skilled,
experienced, and expert to adequately
complete the professional tasks they
undertake.
 Boundaries of competence:
“Psychologists provide services, teach, and conduct
research with populations and in areas only within
the boundaries of their competence, based on their
education, training, supervised experience,
consultation, study, or professional experience”.
Ethics in Clinical Assessment
 Test selection should entail a number of
factors, including the psychologist’s
competence; the client’s culture, language,
and age; and the test’s reliability and
validity.
 Test security represents another specific
area of focus of the American Psychological
Association’s (2002) ethical code.
Psychologists should make efforts to protect
the security and integrity of the test
materials they use. In other words,
psychologists should prevent the questions,
items, and other stimuli included in
psychological tests from entering the public
domain
 Test data refers to the raw data the client
provided during the assessment—responses,
answers, and other notes the psychologist
may have made.
Ethics in Clinical Research
 The American Psychological Association’s
code of ethics includes numerous standards
that apply to research of all kinds, including
clinical research.
 So, just like psychologists from other
specialty areas, clinical psychologists who
conduct research are ethically obligated to
minimize harm to participants, steer clear of
plagiarism, and avoid fabrication of data,
among other things.
Managed Care and Ethics
 Psychologists are ethically committed to
“strive to benefit” and “safeguard the
welfare” of their client’s clinical
psychologists may find themselves in a tug-
of-war between the managed-care
companies’ profits and their clients’
psychological wellbeing

Technology and Ethics
 A quick Internet search will yield a wide
array of so-called “psychological tests” of
one kind or another, claiming to measure
intelligence, personality, and other variables.
 When therapy is done via computer, the
clinical psychologist and client may not be
able to fully appreciate all aspects of
communication (e.g., nonverbals).
 Moreover, online therapy gives rise to
concerns about confidentiality and client
identity that don’t exist when the clinical
psychologist works with the client in person
Ethics in Small Communities
 Clinical psychologists who work and live-in
small communities have always experienced
these challenges (Werth, Hastings, &
Riding- Malon, 2010).
 Rural areas and small towns may be the
most obvious examples of small
communities, but there are many others as
well.
 Even within large cities, clinical
psychologists can find themselves living and
working in small communities defined by
ethnicity, religion, or sexual orientation, or
on military bases, at small colleges, or in
similar settings.
Chapter 6
Conducting Research in Clinical Psychology
Research on treatment outcome
Efficacy Vs Effectiveness
Efficacy
 The success of a particular therapy in a
controlled study conducted with clients who
meet specific criteria. In short, how well a
therapy works “in the lab”.
Effectiveness
 The success of a therapy in actual clinical
settings in which client problems are not
limited to predetermined criteria in short,
how well a therapy works “in the real
world” 1995 Consumer Reports survey of
readers is an example Generally positive
toward psychotherapy, but scientific rigor is
questionable.
Statistical vs. clinical (“real world”) significance
 Statistical significance doesn’t necessarily
mean clinical significance
Internal vs External Validity
 Internal validity refers to the extent to
which the change in the dependent variable
is due solely to the change in the
independent variable. On the other hand,
external validity refers to the
generalizability of the result.
Research on Assessment Methods
 Examples can include: Validation or
expanded use of assessment tools
 Establishing psychometric data for
assessment tools
 Comparing multiple assessment tools to
each other Others
Research on Diagnostic Issues
 Examine reliability or validity of diagnostic
constructs
 Examine relationships between disorders
 Prevalence or course of disorders Others
Research on Professional Issues
 Examples can include psychologists’:
 Beliefs
 Activities
 Practices
 Other aspects of their professional lives
Research on Teaching and Training Issues
 Examples can include:
 Training philosophies
 Specific coursework
 Opportunities for specialized training
 Outcome of training efforts
 Comparison to training in similar
disciplines
 Others
How Do Clinical Psychologists Do Research?
 The Experimental Method
 Observation of events
 Hypothesis
 Define independent and dependent variables
 Empirically test the hypothesis
 Alter hypothesis as necessary per results
Quasi-experiments
 Used in place of true experiments when
practical, ethical, or other issues limit
manipulations.
 Less scientifically sound than true
experiments, but common in clinical
psychology.
Between-group designs
 Participants in different conditions receive
entirely different treatments
 Often, an experimental condition vs. a
control group
Within-group designs
 Compare participants in a single condition to
selves at different points in time
Mixed-group designs
 Combination of between- and within-group
Analogue designs
  Used when actual clinical populations or
situations can’t be accessed
 An approximation or simulation of the “real
thing”
Correlational designs
 Examine relationship between two or more
variables
 Causality cannot be determined
 Often used when experimental or
quasiexperimental designs are not feasible
Case studies
 Detailed examination of a single person or
situation; often very clinically relevant
 Often qualitative rather than quantitative
 Demonstrates the idiographic approach to
research (vs. nomothetic approach)
 Can inspire more systematic research
 ABAB design is one example
 Alternately apply and remove a treatment
Meta-analysis
 Statistical method of combining results of
separate studies into a single summary
finding.
 Findings are translated into effect sizes
 Can quantitatively capture the trends of
many individual studies
 Examples include meta-analyses of
psychotherapy outcome
Cross-sectional designs
 Compare participants at a single point in
time
 More efficient than longitudinal designs
 Longitudinal designs
 Compare participants at different points in
time
 Less efficient than cross-sectional designs,
but can be more valid in assessing change
across time
Ethical Issues in Research in Clinical Psychology
 Numerous APA ethical standards
specifically address research:
 Obtain informed consent
 Don’t coerce participation
 Use deception only when justified and
necessary
 Minimize harm to participants
 Don’t fabricate or falsify data
 Assign authorship appropriately
 Share data with other researchers for
verification
CHAPTER 7
Diagnosis and Classification Issues
 Defining abnormality has been a primary
task of clinical psychologists since the
inception of the field
– What defines abnormality?
– Who defines abnormality?
– Why is the definition of abnormality important?
 What Defines Abnormality?
Various theories have suggested:
– Personal distress
– Deviance from cultural norms
– Statistical infrequency
– Impaired social functioning
– Others
 Harmful Dysfunction—a current theory
– Jerome Wakefield
– Considers both scientific data
(dysfunction) and social context (harmful)
• Can behaviors be culturally typical yet also
abnormal?
 Who Defines Abnormality?
-Authors of DSM make official definitions of
disorders
-Leading researchers in psychopathology
-Many of these authors have been psychiatrists
(DSM published by American Psychiatric
Association)
– Medical model of psychopathology
• Categorical definitions with specific symptoms
– Increasing cultural diversity among these authors
in more recent editions of DSM
 Why Is the Definition of Abnormality
Important?
• Labeling an experience as a disorder can affect
professionals and clients
– Professionals
• Facilitate research, awareness, and treatment
– Clients
• Demystify difficult experience
• Feel like “not the only one”
• Acknowledge significance of problem
• Access treatment
• Stigma damages self-image
• Stereotyping by those who know the client
• Legal consequences
 Before the DSM
• Abnormal behavior was recognized and studied in
ancient civilizations.
• In 19th century, asylums in Europe and U. S.
arose.
• Around 1900, Emil Kraepelin put forth some of
the first specific categories of mental illness.
• Some early categorical systems were for
statistical/census purposes.
 DSM-I and DSM-II
• DSM-I published in 1952
• DSM-II published in 1968
– Similar to each other, but different from later
editions
– Not scientifically or empirically based
• Based on “clinical wisdom” of
psychiatrists
– Psychoanalytic/Freudian influence
– Contained three broad categories of disorders
• Psychoses, neuroses, character disorders
– No specific criteria; just paragraphs with
somewhat vague descriptions
 DSM – More Recent Editions
• DSM-III
• DSM-III
– Published in 1980
– Very different from DSM-I and DSM-II
• More reliant on empirical data
• Specific criteria defined disorders
• Multi-axial assessment (5 axes)
• Much longer—included many more disorders
• DSM-III-R (minor changes from DSM-III) was
published in 1987
 DSM-IV was published in 1994
• DSM-IV-TR was published in 2000
– TR stands for “text revision”
– Only text, not diagnostic criteria, differ between
DSM-IV and DSM-IV-TR
• So, these two editions are essentially similar
• DSM-IV included significant cultural advances
– Text describing disorders often included culturally
specific information
– Culture-Bound Syndromes were listed
• Not official diagnostic categories, but experiences
common in some cultural groups
– Outline for Cultural Formulation
• Helped clinicians appreciate impact of culture on
symptoms
 DSM-5
• Current edition of the DSM
– Released in 2013
• Task Force led Work Groups, each focusing on a
particular area of mental disorders
• Attempted greater consistency between DSM and
International Classification of Diseases (ICD)
 Changes DSM-5 Didn’t Make
• Paradigm shift to emphasize
neuropsychology/biological roots of mental disorder
• Dimensional definition of all mental disorders
• Dimensional approach for personality disorders
• Remove five of the 10 personality disorders
leading • Proposed disorders
– Attenuated psychosis syndrome
– Mixed anxiety-depressive disorder
– Internet gaming disorder
 New Features in DSM-5
• Naming shift from Roman numerals (e.g., DSM-
IV) to Arabic numerals (e.g., DSM-5)
– Minor updates will be denoted as new versions
(e.g., DSM-5.1, DSM-5.2, etc.)
 New Disorders in DSM-5
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
• Binge eating disorder
• Mild neurocognitive disorder
• Somatic symptom disorder
• Hoarding disorder
 Revised Disorder in DSM-5
• Major depressive episode
– “Bereavement exclusion” dropped
• Autism spectrum disorder (new scope in
DSM5)
– Encompasses autistic disorder, Asperger’s
disorder, and related developmental disorders from
DSMIV
• Attention-Deficit/Hyperactivity Disorder
– Age at which symptoms must first appear raised
from 7 to 12
• Bulimia nervosa  Rapport
– Frequency of binge eating decreased from twice -Positive, comfortable relationship between
to once per week interviewer and client
• Anorexia nervosa -How an interviewer is with clients
– Removed requirement that menstrual periods stop  Technique
– “Low body weight” changed from numeric -What an interviewer does with clients
definition to less specific description
- Directive vs. nondirective styles
• Substance use disorder (new scope in DSM-5)
– Encompasses substance abuse and substance
dependence disorders from DSM-IV
• Intellectual disability disorder
– Mental retardation from DSM-IV
• Specific learning disorder
– Covers separate learning disorders in reading,
writing, and math from DSM-IV.

CHAPTER 8
The Clinical Interview
 Assessment is closely linked with the
identity of clinical psychologists.
 None other mental health profession
incorporates assessment into their work as Specific Interviewer Responses
clinical psychologists do.
 Open-ended and closed-ended questions
 An assessment technique has validity to the
extent that it measures what it claims to – Open-ended questions
measure.
 The technique has reliability to the extent  Allow individualized and spontaneous
that it yields consistent, repeatable results. responses from clients
 An element common to all kinds of – Closed-ended questions
psychological assessment is feedback.
 Allow less elaboration and self-expression
by the client
 Clarification
– Question to make sure the interviewer accurately
understands the client’s comments
 Confrontation

The Interviewer – For discrepancies or inconsistencies in a client’s

 A skilled interviewer only is not a master of comments

the technical and practical aspects of the  Paraphrasing
interview but also demonstrates broad-based
wisdom about the human interaction it – Restatement of client’s comments to show they
entails. have been heard
 Listening the primary task of the  Reflection of feeling
interviewer, consisting of numerous building
blocks – Echo client’s emotions, even if not explicitly
mentioned.
• Eye contact
 Summarizing
• Body language
– Tie together various topics, connect statements
• Vocal qualities that may have been made at different points, and
• Verbal tracking identify themes.

• Referring to client by proper name Pragmatics of the Interview

Components of the Interview  Note-taking

– Little consensus about note-taking
– Provide a reliable written record, but can be
distracting to client and interviewer
 Audio- and Video-recording
– Also provide a reliable record, but can be
inhibiting to clients
– Must obtain permission
 The Interview Room
– Professional yet comfortable
 Confidentiality
– Explain confidentiality and its limits to clients
(e.g., child abuse, intention to harm)
Types of Interviews
 Intake interviews
– To determine whether to “intake” the client into
the agency or refer elsewhere
 Diagnostic interviews
– To provide DSM diagnosis
– Structured interviews often used
 Minimize subjectivity, enhance reliability
 Semi-structured interviews include some
structure but also, some flexibility or
opportunities to improvise
 Mental status exam
– Typically used in medical settings
– To quickly assess how a client is functioning
at that time
 Crisis interviews
– Assess problem and provide immediate
intervention
– Clients are often considering suicide or other
harmful act
Cultural Components
 Appreciating the cultural context
– Knowledge of the client’s culture, as well as the
interviewer’s own culture
– For behavior described or exhibited during
interview
 Acknowledging cultural differences
– Wise to discuss cultural differences rather than
ignore
– Sensitive inquiry about a client’s cultural
experiences can be helpful
CHAPTER 9
Intellectual and Neuropsychological Assessment
 Intelligence tests measure a client’s
intellectual abilities.
 Achievement tests, in contrast, measure
what a client has accomplished with those
intellectual abilities.
 Neuropsychological tests focus on issues of
cognitive or brain dysfunction, including the
effects of brain injuries and illnesses.
Intelligence Testing
 Theories of intelligence
– Is intelligence one thing or many things?
– Charles Spearman—” g” for general (single)
Intelligence is One thing
–Louis Thurstone—intelligence is plural abilities
that may not relate to each other. Intelligence is
Many things
–Hierarchical models of intelligence blend
singular and plural theories. In which specific
abilities (“s”) existed and were important, but they
were all at least somewhat related to one another
and to a global, overall, general intelligence.
More Contemporary Theories of Intelligence
James Cattell
 proposed two separate intelligences: fluid
intelligence—the ability to reason when
faced with novel problems
 crystallized intelligence—the body of
knowledge one has accumulated as a result
of life experiences.
John Carroll’s (2005)
 three-stratum theory of intelligence, in
which intelligence operates at three levels: a
single “g” at the top, eight broad factors
immediately beneath “g,” and more than 60
highly specific abilities beneath these broad
factors.
Wechsler Intelligence Tests
 Originally created by David Wechsler in
early 1900s
 Currently, there are three Wechsler IQ tests
– Wechsler Adult Intelligence Scale— (WAIS-) –
age 16-89
– Wechsler Intelligence Scale for Children—age
6-16
– Wechsler Preschool and Primary Scale of
Intelligence (WPPSI)– age 2-7

Stanford-Binet Intelligence Scales—Fifth Edition

Similarities among the three Wechsler IQ tests:
 The first editions of the Stanford-Binet
 Yield a single full-scale intelligence score intelligence test dominated the field in the
early 1900s until Wechsler’s tests began to
•Also yield 4 index scores: Verbal Comprehension,
provide competition.
Perceptual Reasoning, Working Memory,  The Stanford-Binet remains highly respected
Processing Speed and offers an approach to assessing
•Also yield about a dozen specific subtests scores intelligence that is both similar to and
different from that of Wechsler’s tests.
•One-to-one, face-to-face administration  It is administered face-to-face and one-on-
 Share a core of subtests: one. It employs a hierarchical model of
intelligence and therefore yields a singular
• Vocabulary measure of full-scale IQ (or “g”), five factor
scores, and many more specific subtest
• Similarities
scores.
• Information  It features the same means (100) and
standard deviations (15) as the Wechsler
• Comprehension
intelligence tests for its full-scale and factor
• Block Design scores.
 Its psychometric data, including reliability
• Picture Completion and validity, are similarly strong.
• Matrix Reasoning  The Wechsler tests feature four or five
factors, each of which yields an index score,
• Coding the SB5 features exactly five, described
briefly here:
• Symbol Search
1. Fluid Reasoning—the ability to solve novel
problems.
2. Knowledge—general information
accumulated over time via personal
experiences, including education, home, and
environment.
3. Quantitative Reasoning—the ability to
solve numerical problems
4. Visual-Spatial Processing—the ability to
analyze visually presented information,
including relationships between objects,
spatial orientation, assembling pieces to
make a whole, and detecting visual patterns.
 5. Working Memory—the ability to hold and
transform information in short-term
memory.
Additional Tests of Intelligence: Addressing
Cultural Fairness
 Some subtests may place people from
minority cultural groups at a disadvantage.
Universal Nonverbal Intelligence Test (UNIT)
 Recently created (1996)
 Entirely language free
 No speaking necessary for test administrator
or test taker.
•All instructions are hand gestures.
• All responses are manual, not verbal.
 Some drawbacks: only for kids age 5-17,
limited psychometric data, more limited range.
Achievement Testing
 Intelligence is what a person can accomplish
intellectually.
 Achievement is what a person has
accomplished, especially reading, spelling,
writing, or math.
 Achievement tests typically produce
standard scores that can be easily compared
to scores from intelligence tests (e.g., mean
= 100)
– A significant discrepancy between a person’s
achievement and expected levels of achievement is
the basis for specific learning disorder.
 They also typically produce age- or grade
equivalency scores.
 Some achievement tests are specific to math,
reading, or other abilities
 Others are more global
Wechsler Individual Achievement Test—Third
Edition (WIAT-III)
• For ages 4-50
• Administered face-to-face and one-on-one
• Reading, math, written language, oral language
Neuropsychological Testing
 Neuropsychological testing represents a
specialized area of assessment within
clinical psychology, typically practiced by
clinical psychologists whose training
includes extra training in neuropsychology
during graduate school courses, the
predoctoral internship, and the postdoctoral
internship.
 Measure cognitive functioning or
impairment of the brain and its specific
components or structures.
 Additional purposes: to make prognosis,
plan rehab, determine eligibility for
accommodations, etc.
 Often used after a head injury, a brain
illness, or prolonged alcohol or drug use.
 Some neuropsychological tests are lengthy
and comprehensive; others are brief and
targeted.
Full Neuropsychological Batteries
 The Halstead-Reitan Neuropsychological
Battery (HRB) is a battery of eight
standardized neuropsychological tests.
 It is suitable for clients of age 15 years and
above, but alternate versions are available
for younger clients.
 The HRB is administered only as a whole
battery; its components are not to be
administered separately.
 Some of 8 tests involve sight, hearing,
touch, motor skills, and pencil & paper tasks
 A similar comprehensive battery of tests is
the Luria-Nebraska Neuropsychological
Battery (LNNB)
– Similarly long and comprehensive
– Emphasizes qualitative data in addition to
quantitative data
Brief Neuropsychological Measures
 The Bender-Gestalt test, originally
published in 1938 and currently available as
the Bender Visual-Motor Gestalt Test—
Second Edition (Bender-Gestalt-II), is the
most commonly used neuropsychological
screen among clinical psychologists.
 The test is a straightforward copying task:
The client is given a pencil, blank paper, and
nine simple geometric designs (primarily
made of combinations of circles, dots, lines,
angles, and basic shapes) and is asked to
copy each design as accurately as possible.
 It measures visuo-constructive abilities,
which are also commonly known as
perceptual-motor or visual-spatial skills.
Wechsler Memory Scale – Fourth Edition
(WMS-IV)
– Assesses memory problems due to brain injury,
dementia, substance abuse, etc.
– Ages 16-90
– Assesses visual and auditory memory, immediate
and delayed recall