4Psychological Disorder: Experiences of Client and Clinician The Client:The person seeking psychological treatment.Patient refers to someone who is ill and passively waits to be treated.Client refers to the person seeking psychological treatment, to reflect the fact that psychotherapy is a collaborative endeavor. Other terms suggested in recent years include resident, consumer, and member.
5Psychological Disorder: Experiences of Client and Clinician The Client:The person seeking psychological treatment.Prevalence of Psychological Disorders:1 in 5 during past yearThe Surgeon General’s report on mental health (U.S. Department of Health and Human Services, 1999) cites the statistic that 21 percent of all Americans have experienced a mental disorder during the preceding year.Researchers at the National Institute of Mental Health NIMH) designed the Epidemiological Catchment Area (ECA) study, which found that lifetime prevalence across all mental disorders was 32%, and about 20% of the sample had experienced symptoms within the previous year.
6Psychological Disorder: Experiences of Client and Clinician The Client:The person seeking psychological treatment.Prevalence of Psychological Disorders:1 in 5 during past yearComorbidity: NIMH found in their National Comorbidity Survey that 54% of respondents with one psychiatric disorder reported had received a second diagnosis as well at some point in life.Comorbidity:Co-existence of mental disorders
7Psychological Disorder: Experiences of Client and Clinician The Clinician:Mental health professional. There are many types taking many approaches.Psychiatrists: Medical doctors (MDs) with advanced training in treating people with psychological disorders.An important distinction between them and psychologists is that psychiatrists are licensed to administer medical treatment, prescribing medications, and psychologists are not.Psychiatrists (MD)
8Psychological Disorder: Experiences of Client and Clinician The Clinician:Mental health professional. There are many types taking many approaches.Clinical psychologists: Along with the growth of PhD programs has been the development of programs that are called “professional schools” of psychology some of which offer a PhD and some of which offer a newer degree, the doctor of psychology (PsyD).Some psychologists are trained within the field of counseling psychology, where the emphasis is on normal adjustment and development, rather than on the psychological disorders.Clinical psychologists are trained in conducting psychological testing, a broad range of measurement techniques, all of which involve having people provide scorable information about their psychological functioning.Clinical Psychologists (PhD or PsyD)
9The Diagnostic and Statistical Manual of Mental Disorders The DSM-IVThe Diagnostic and Statistical Manual of Mental Disorderspublished by theAmerican Psychiatric AssociationIn making a diagnosis, mental health professionals use the standard terms and definitions contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM).The DSM-IV (the fourth edition) or DSM-IV-TR (fourth edition, text revision) contains descriptions of all psychological disorders, alternatively referred to as mental disorders.
11How the DSM Developed DSM (a.k.a. DSM-I) DSM-II (based on ICD) DSM-III The first edition of the American Psychiatric Association’s DSM was the first official psychiatric manual to describe psychological disorders and was a major step forward in the search for a standard set of diagnosic criteria. However, criteria were vague, had poor reliability, and were based on faculty assumptions about origins of disorders.The second edition, DSM-II, based its classification of mental disorders on the system contained in the International Classication of Diseases (ICD).DSM-III provided precise criteria and definitions for each disorder, enabling clinicians to be more quantitative and objective.
12How the DSM Developed DSM (a.k.a. DSM-I) DSM-II (based on ICD) DSM-III DSM-III-RTo specify criteria further, DSM-III-R was published as an interim manual until a more complete overhaul.The DSM-IV relied on comprehensive reviews, thorough analyses of research data, and field trials to test reliability and validity further.A “text revision,” the DSM-IV-TR, included editorial revisions to the DSM-IV. Many professionals simply refer to it as the DSM-IV.DSM-IVDSM-IV-TR
13Mental DisorderClinically significant behavioral or psychological syndrome or patternDistress or disabilitySignificant riskNot expectable, culturally sanctioned response to a particular eventA syndrome is a collection of symptoms that forms a definable pattern.Mental disorder: A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.
14Assumptions of the DSM-IV Classification system based on medical modelDescriptive rather than explanatoryAtheoretical orientationCategorical approachMultiaxial systemOne of the most prominent assumptions of the DSM-IV is that this classification system is based on a medical model orientation, in which disorders, whether physical or psychological, are viewed as diseases.Atheoretical orientation: The DSM-IV simply classifies and describes a set of symptoms for each disorder without regard for explaining their cause, without theoretical orientation.Categorical approach: Implicit in the medical model is the assumption that diseases fit into distinct categories.Multiaxial system: Each axis is a class of information regarding an aspect of an individual’s functioning.
15The Five Axes of the DSM-IV Axis I: Clinical DisordersAxis II: Personality Disorders and Mental RetardationAxis III: General Medical ConditionsAxis IV: Psychosocial and Environmental ProblemsAxis V: Global Assessment of Functioning(helps assess prognosis)The major clinical disorders and adjustment disorders are on Axis I.Axis II disorders (personality disorders and mental retardation) represent enduring characteristics of an individual’s personality or abilities.Personality disorders: Personality traits that are inflexible and maladaptive and that cause either subjective distress or considerable impairment in a person’s ability to carry out the tasks of daily living.On Axis III, the diagnostician notes the individual’s medical conditions, which may or may not be connected to the person’s psychological condition.On Axis IV, the clinician documents events or pressures that may effect the diagnosis, treatment, or outcome of a client’s psychological disorder.Axis V is used to document the clinician’s overall judgment of a client’s psychological, social, and occupational functioning.The rating of the client’s functioning during the preceding year provides the clinician with important information about the client’s prognosis, or likelihood of recovering from the disorder.
16The Diagnostic Process The Client’s Reported and Observable SymptomsDiagnostic Criteria and Differential DiagnosisFinal DiagnosisCase FormulationCultural FormulationWhen clinicians use multiple diagnoses, they typically consider one of the diagnoses to be the principal diagnosis, the disorder that is considered to be the primary reason the individual is seeking professional help.In certain cultures, psychological disorders may be expressed as particular patterns of behavior, perhaps reflecting predominant cultural themes that date back for centuries, known as culture-bound syndromes. For example, “ghost sickness” is a preoccupation with death and the deceased that is reported by members of American Indian tribes.
17Planning Treatment Establish Treatment Goals Immediate Goals Short-Term GoalsLong-Term GoalsThe first phase of treatment planning is to establish treatment goals, objectives the clinician hopes to accomplish in working with the client. These goals range from the immediate to the long term.First the clinician deals with the crisis at hand, then handles problems in the near future, and finally addresses issues that require extensive work well into the future. However, in other cases, there may be a cyclical unfolding of stages.
18Planning Treatment Determine Treatment Site Hospital or Inpatient Treatment CenterOutpatient ServicesHalfway Houses and Day TreatmentSchool and EAP CounselorsTreatment sites include psychiatric hospitals, outpatient treatment settings, halfway houses and day treatment centers, and other treatment sites such as the school or workplace, that provide mental health services. The more serious the client’s disturbance, the more controlled the environment that is needed and the more intense the services.Hospitalization is also recommended for clients who have disorders that require medical interventions and intensive forms of psychotherapeutic interventions.Because hospitalization is such a radical and expensive intervention, most clients receive outpatient treatment in which they are treated in a private professional office or clinic.Community mental health centers (CMHCs) are outpatient clinics that provide psychological services on a sliding fee scale for individuals who live within a certain geographic area.Halfway houses are designed for clients who have been discharged from psychiatric facilities but ho are not yet ready for independent living.Day treatment programs are designed for formerly hospitalized clients as well as clients who do not need hospitalization but do need a structured program during the day, similar to that provided by a hospital.Psychological treatment is also provided in settings not traditionally associated with the provision of mental health services, such as the schools and workplace.
19Treatment Modality Individual Psychotherapy Family Therapy Group TherapyMilieu TherapyTheoretical Perspective on Which Treatment Is BasedThe modality, or form in which psychotherapy is offered, is another crucial component of the treatment plan. In individual psychotherapy, the therapist works with the client on a one-to-one basis.In family therapy, several or all of the family members are involved in the treatment.Group therapy provides a modality in which troubled people can openly share their problems with others, receive feedback, develop trust, and improve interpersonal skills.Milieu therapy, is based on the premise that the milieu, or environment, is a major component of the treatment; a new setting, in which a team of professionals works with the client to improve his or her mental health, is considered to be better than the client’s home and work environments.Whatever modality of treatment a clinician recommends, it must be based on the choice of the most appropriate theoretical perspective or the most appropriate aspects of several different perspectives.
20Treatment Implementation The Course of TreatmentThe Role of ClinicianThe Role of ClientThe Outcome of TreatmentIn optimal situations, psychotherapy is a joint enterprise in which the client plays an active role. It is largely up to the client to describe and identify the nature of his or her disorder, to describe personal reactions as the treatment progresses, and to initiate and follow through on whatever changes are going to be made.Some obstacles that clinicians face in their efforts to help clients include some curious and frustrating realities. The most frustrating involve the client who is unwilling to change.
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