Factor Practice

I. Mental health professionals as specialists

A. Specializing in treatment for people with mental health problems

1. Anxiety

2. Depression

3. Psychosis

4. Conduct problems

5. Characterological troubles (personality disorders)

6. Psychosomatic illnesses

 

B. Diagnostic nomenclature

1. DSM IV TR diagnostic categories

2. Multiple axis system

Axis 1. Clinical disorders

Axis 2. Personality disorders

Mental retardation

Axis 3. General medical conditions

Axis 4. Psychosocial and environmental problems

Axis 5. Global assessment of functioning

C. Differential diagnosis

1. Identify symptom clusters

2. Define course

3. Identify etiology (presumed cause or origin)

D. Setting treatment goals

1. Identify behaviors we want to change

2. Goals are related to the diagnosis

3. Define success -- how you would know if a goal was met

 

E. Treatment methods

1. Intervention activities necessary to achieve the goals

2. Broad categories of treatment

Inpatient hospital

Day treatment

Crisis intervention

Case management in a community setting

Outpatient services

 

 

F. Outpatient clinic services

1. Psychotherapy

Brief

Psychodynamic

Supportive

Cognitive behavioral

Family systems

Relationship therapy

2. Psychotropic medications

Anxiolytics

Anti-depressants

Anti-psychotics

Mood stabilizers

G. Choice of method (triage)

1. Primary problem

2. Meeting medical necessity

The method chosen is appropriate for the condition

The method chosen cannot be provided in a less restrictive setting

The method chosen is not for someone’s convenience

3. Iatrogenic effects

4. Managing dangerousness

5. Accessibility to funding (use of third party payors)

 

H. Clinical judgment

1. Starting treatment

2. Adjusting course in the middle of treatment

3. Terminating treatment

I. Documentation of services

1. Medical charting

Assessment

Plan

Progress notes

Discharge summary

2. Using the narrative style

J. Professional guild issues

1. Licensing

2. Ethics

3. Scope of practice

4. Authority

K. Standards of care

 

II. Let’s pause and do a process check

So we have

this group of professionals

possessing a set of specific skills

who help people having mental health problems?

A. Check the option that best summarizes your response to this question:

1. True _______

2. False _______

3. Undecided _______

B. If you are one of the many who chose undecided, which of the following best summarizes the reason for making this choice?

1. The question is ambiguous _______

2. You respect some mental health professionals but not others ______

3. Some people get better, others don’t ______

C. If you chose item #2 above, did you lose respect for the mental health professional because:

1. He wouldn’t talk to me? ______

 

2. He was too inexperienced? _______

3. I did not agree with him? _______

4. I couldn’t understand him? ______

D. If you chose item #3 above, what was the reason the person(s) didn’t get better?

1. The client was worried about the cost of services _____

2. The client was dissatisfied with the service provider ______

3. The client didn’t want the services offered______

4. The services didn’t focus on the important stuff _______

E. Continuing this exercise, answer the following questions:

1. Who is the customer? Is it the client, or the referral source?

2. How might the goals of the client and the referral source be different?

 

 

 

3. How might the goals of the client and the mental health professional be different?

 

 

 

4. Might the payment structure affect accessibility to the mental health professional?

 

 

 

 

 

5. How can accountability among these players be established to resolve some of these differences?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. Thinking rationally to solve problems

A. Defining rationality

1. Rationality has a perceptual component (perceiving accurately) and an action component (taking effective action).

2. Rationality is use of a reasoning process to improve reality testing and to guide problem solving. It is a powerful tool for living better.

3. The capacity for reasoning is present in all of us, but we do not always use it.

4. Spectacular examples of failure of reasoning include:

a. Beliefs in demons and devils

b. Belief that space aliens visit earth

c. The Salem witch trials

d. Fear of predators

e. Mass hysteria

f. History is replete with many acts of senseless destruction

5. Rational processes are a part of our everyday lives. These processes are present in the following activities:

a. When an automobile mechanic fixes our car

b. When we plan an activity

c. When we are considerate to others

d. When we respond to a challenge and overcome it

6. Rationality is only one tool for better living. Other tools include:

a. Curiosity

b. Creativity

c. Spirituality

d. Play

 

7. Rational process is the foundation of our jurisprudence system, and of the scientific enterprise, although failures in process occur frequently in each of these arenas. Both of these systems have installed error correcting machinery to limit the damage of process errors.

 

 

 

 

 

 

 

IV. The human cognitive apparatus

A. The power of hallucinations

1. Normal dreams

a. Regarded as real in childhood. The life of dreams and the life in the outside world are learned distinctions with advancements in development. These distinctions are never 100% attained.

 

b. Nightmares occur in adults that induce panic, as do dreams while awake -- due to vividness and compelling affective intensity.

c. Dreams are characterized by fantasy and imagination. As such they express our conflicts and wishes.

d. Fantasies create anxiety that has survival value, in that we can imagine dangers that may exist. Thus, children are afraid of monsters.

2. Sleep paralysis

a. It occurs in the twilight world between being fully awake and fully asleep -- a form of reverie. In this state we may experience auditory and visual hallucinations. In the right setting this experience can have the full force and impact of reality.

 

b. We show stronger propensities toward fantasy production and are more likely to interpret them as real events rather than imaginings when they were associated with restricted sensory environments (night and sleep).

3. Psychophysiological research findings on hallucinations

 

a. Electrical stimulation of the brain can induce hallucinations that are indistinguishable from reality.

4. Shared hallucinations

 

a. Hallucinations can be a social phenomena when conditions promote social suggestibility.

b. Reports of UFO sightings began at the turn of the century after the author Percival Lowell wrote about martian cultures.

c. Crop circles in England

d. Product tampering cases in America

e. Alien abduction stories

f. Repressed memories

5. "A credulous mind . . . finds most delight in believing strange things, and the stranger they are the easier they pass with him; but never regards those that are plain and feasible, for every man can believe such."

Samuel Butler, 1667.

6. The distinction between imagination and memory is often blurred.

 

7. To many people the guide to which something is true is the power or intensity with which something is felt.

8. Misremembering is the rule not the exception. Memories are shaped and reshaped with time and with response to interpersonal demands. We retrospectively rework our past lives. This just goes with the territory.

B. Skeptical thinking

1. Require strong evidence. Not all claims to knowledge have equal merit.

2. Develop a baloney detection kit.

a. Start with data, observations, measurements (facts).

b. Then invent an array of explanations.

c. Confront each explanation with the facts.

d. Develop the ability to construct and understand a reasoned argument, and to recognize a fallacious or fraudulent argument.

e. Draw a conclusion from the train of reasoning. Instead of choosing the conclusion we like, choose the conclusion that follows from the premise or the starting point.

f. Check to make sure the premise is valid or accurate. Reasoning based on an unsound premise leads to error. If there’s a chain of argument, every link in the chain must work, including the premise.

g. Independently verify the facts whenever possible; corroborate them.

h. Encourage others to participate in a debate on the evidence. Substantive debate on the evidence by knowledgeable proponents of all points of view allows us to test our hypotheses.

i. Don’t get overly attached to a hypothesis just because it is yours.

j. Use Occam’s razor -- If two hypotheses explain the data equally well, choose the simpler.

k. Think of ways in which the hypothesis can be falsified (disproved), then test the hypothesis. Check assertions out.

l. Share your reasoning with other skeptics. Give them a chance to follow your reasoning to see if they arrive at the same conclusion.

m. Identify fallacious arguments (see appendix A).

 

3. Maintain an openness to new ideas, and the most ruthless skeptical scrutiny of all ideas, old and new. Creative thinking and skeptical thinking are a collective enterprise. If you are only skeptical then new ideas cannot make it through to you, but the vast majority of ideas are simply wrong. If you are gullible, have not a whit of skeptical sense, then you cannot distinguish promising ideas from the worthless ones.

4. The method of the ancient hunter is the same as the method of the modern day astronomer who analyzes the "tracks" left by past events on other worlds. The hunters us the clues in the trail to predict the "orbits" of the animals -- to identify who they are -- what their condition is, etc. These hunters have formidable forensic tracking skills. These skills, developed and passed down from generation to generation, are science in action. A proclivity for science is imbedded deeply within us, in all times, places and cultures. It has been the means for survival.

C. Information processing in a clinical setting

1. Basic information processing

a. Take in information from the environment.

b. Relate information to memory (associative and hardwired)

c. Categorize information

d. Assign meaning to information

e. Use meaning to define action

f. Take action

g. Check results

2. Perceptual aspects of information processing

a. Perception is an act of seeing, hearing, or feeling.

b. Perception involves taking in information about events in our immediate environment, events that we imagine, events that we hear about second hand, events in our bodies, events in our minds.

c. Oftentimes the data available to us is vague.

d. We attribute meanings to information that we take in. Some meanings are hardwired, for instance, the perception of depth is available to us at a very early developmental age. However, perception has substantial learning components; that is, as we take in information we assign meanings based on past experience, or our own perceptual biases. One could say we are preset to see what we want to see. Higher cortical functions, as well as sensory apparatuses are involved in perception, i.e., as we take in information through our senses, we assign meaning by going "all the way to the top".

e. To be accurate we have to check in two domains simultaneously, one outside and one inside. Good evidence collection is a learned skill. In considering this issue, remember that often we are in a position of the information coming to us being incomplete, vague, and distorted. Remember that in conditions of sensory deprivation we have a greater tendency to hallucinate.

f. A good evaluator has to develop an investigative mindset to verify events and to assign meanings to those events, remembering that the reporters of those events may be misremembering, or skipping over the most important aspects of the events.

g. A clinician uses information about behavior to identify clinical meanings, such as what factors contributed to the behavior, or organized the behavior, so we can develop a plan or strategy for addressing the behavior. This is analysis of behavior process.

h. To analyze behavior process we have to utilize models of behavior. These models help us organize the information we take in. There are several models of behavior, each with a different explanation of how behavior works. These explanations provide hypotheses.

3. Response aspects of clinical information processing

a. After we "understand" the event, we make decisions about what actions we wish to take. As clinicians are usually dealing with problem behavior, some intervention is usually called for, but not always. Sometimes it is better to not respond.

b. Responses can be organized in different domains, depending on the treatment modality chosen. The choice of treatment modality, the choice of intervention is supposed to "get at" the behavior that is a problem. How we define this behavior, using our models of behavior, is critical to the process of intervening.

c. Intervention plans have to address who, what, when, where, and how.

d. Intervention plans promote hypothesis testing, to determine which model best fits the situation, that is, we organize a response and then see what happens. To measure results we have to go back to the perceptual mode and get information on behavior.

4. Sources of error in information processing by clinicians

a. Broad categories of error

--Errors in description of the problem

--Errors in detecting the extent of covariation of problem behaviors, i.e., oppositional children have low self- esteem.

--Errors in assuming causal relationships

--Errors in prediction

b. The impact of clinical errors

--Failing to offer help that is available and is requested

--Forcing clients to accept "help" they do not want

--Offering help that is not needed

--Using procedures that aggravate rather than alleviate the problem

c. Errors at the level of choice points in processing information

--Overlooking important data or attending to irrelevant data

--Relying on inaccurate information

--Selecting weak rather than strong intervention methods

--Overlooking important factors that organize the problem behavior

--Assuming that gains made will be maintained

--Selecting irrelevant or invalid progress indicators

--Drawing conclusions without adequate testing of the hypotheses

--Failure to use knowledge that is available

--Failure to identify personal, institutional, social, and political sources of bias

--Failure to understand the interpersonal context in which the problem behavior occurs

--Making exaggerated claims of certainty

--Misrepresenting findings for self protection

--Failing to look at client assets

d. Reducing errors in making judgments

--It is not enough to know what kinds of errors are made

--We must look at the causes of these errors, such as selective perception, lack of agreed-on criteria for determining the accuracy of decisions, and the intrusion of everyday language in mediating our choices

--Knowing the limits of our information processing capacities

--Knowing how countertransferences affect our decision making

--Attempts to simplify the effort may go astray

--Not knowing how to check our accuracy

--Understanding the concepts of probability

 

e. Applying our knowledge gained to reduce errors

--We have to look deeper yet to accomplish this task

--Let’s take only one example of bias in clinical judgment, that is, the dispositional error. This is the error in which we conclude behavior problems are caused by factors inside the person. We fail to consider how the environment, including the immediate surroundings may be driving the behavior, so we "treat" the person and not the environment. There is a huge payoff for accepting this bias. Can you think of these payoffs. Certainly, the individual clinician would have to be willing and able to take the consequences if he/she said the problem lies in the child’s environment.

--Use our error correcting machinery in the work setting

 

D. A model for making rational judgments(Daniel Kahneman)

1. Two modes of thought -- intuition and reasoning

 

 

 

 

 

 

 

 

2. Operations of system 1 (intuition)

Fast, automatic, effortless, associative, implicit (not available to introspection), and often emotionally charged. They are also governed by habit and so are difficult to control and modify. This system allows parallel processing of information. The features are similar to perceptual processes. Intuitive judgments deal with concepts as well as percepts. They can be evoked by language. They generate impressions of the attributes of objects of perception and thought. These impressions are neither voluntary nor verbally explicit. Intuitive judgments may be erroneous, and we may not catch the error. Intuitive judgments can also be powerful and accurate. High skill from prolonged practice leads to performance that is rapid and effortless. Intuitive responses are readily accessible. Intuitive responses are dominated by the operation of perceptual processes such as vividness, selective attention, stimulus salience, specific training, associative activation, and priming.

 

3. Operations of system 2 (reasoning)

Slower, serial, effortful, more likely to be consciously monitored and deliberately controlled. They are also relatively flexible and potentially rule governed. They monitor the quality of both mental operations and overt behavior. Because these operations are effortful they are subject to dual-task interference. System 2 monitors the functions of system 1. This monitoring is usually quite lax and allows many intuitive judgments to be expressed, including some that are erroneous. All of us often yield to immediate impulse in making choices. We often offer a response without checking it for accuracy. System two is not perceptually bounded. It relies on calculations and possibilities, and is not tied to the immediate situation.

4. Considerations for professionals making judgments

a. Integrating the two modes of thought into practice

b. Use this model to reduce errors in judgment

E. The contributions of natural science to understanding the observation problem

1. Observation that interferes with behavior

This is a phenomenon identified in studying subatomic particles.

Scientists wanted to know if subatomic particles acted like wave energies or like material objects. They discovered that the act of measuring the event determined the result, wave or object. If the scientist set up his experiment to measure energy, he got waves. If he set up his experiment to measure substance he got particles. It was weird, like how can the behavior of subatomic particles change in response to what the scientist was seeking? Did the particles know the scientists mind? This is the story of quantum mechanics. Quantum mechanics showed the deficiencies in the Newtonian model of the world.

2. The Newtonian model of the world

Isaac Newton developed the basic mechanical laws of the universe 300 years ago. He envisioned a universe that worked like a machine -- like clockwork. In this model matter acts on other matter through forces of energy. The machine is made up of parts. You can study the operation of parts separately. The scientist is an objective observer of nature’s laws. The laws of nature work linearly.

 

3. The new science model

The result of the discoveries of quantum mechanics and of chaos theory. These discoveries showed that the Newtonian model of the world works in only limited circumstances. Most of the events in nature are non-linear. There are times when the act of observation cannot be separated from the behavior being studied. Everything behaves, even the crust of the earth. Everything is moving. Prediction is not possible except in limited circumstances.

4. The act of clinical observation

Does the behavior of the clinician influence what he observes in the client?

Should we be breaking behavior into parts?

If the organizing principles of subatomic particles are weird, what are the organizing principles of human behavior?

5. Countertransferences