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As client begins to anxiety symptoms in women order 50 mg imipramine feel better about self and identifies positive self-attributes anxiety symptoms 4 days buy imipramine 50mg overnight delivery, and develops the ability to anxiety funny purchase imipramine 25 mg accept certain personal inadequacies anxiety 7 question test purchase imipramine 75 mg with visa, the need for unrealistic achievements should diminish. Help client claim ownership of angry feelings and recognize that expressing them is acceptable if done so in an appropriate manner. Unexpressed anger is often turned inward on the self, resulting in depreciation of self-esteem. Client expresses interest in welfare of others and less preoccupation with own appearance. Client verbalizes that image of body as “fat” was misperception and demonstrates ability to take control of own life without resorting to maladaptive eating behaviors. Common Nursing Diagnoses and Interventions (for Obesity) (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Long-term Goal Client will demonstrate change in eating patterns resulting in a steady weight loss. A food diary provides the opportunity for the client to gain a realistic picture of the amount of food ingested and provides data on which to base the dietary program. This helps to identify when client is eating to satisfy an emotional need rather than a physiological one. With input from the client, formulate an eating plan that includes food from the required food groups with emphasis on low-fat intake. It is helpful to keep the plan as similar to the client’s usual eating pattern as possible. Client is more likely to stay on the eating plan if he or she is able to participate in its creation and if it deviates as little as possible from usual types of foods. Reasonable weight loss (1 to 2 pounds per week) results in more lasting effects. Excessive, rapid weight loss may result in fatigue and irritability and may ultimately lead to failure in meeting goals for weight loss. Exercise may enhance weight loss by burning calories and reducing appetite, increasing energy, toning muscles, and enhancing a sense of well-being and accomplishment. Discuss the probability of reaching plateaus when weight remains stable for extended periods. Plateaus cause frustration, and client may need additional support during these times to remain on the weight-loss program. Provide instruction about medications to assist with weight loss if ordered by the physician. Drugs should be used for this purpose for only a short period while the individual attempts to adjust to the new pattern of eating. Client has established a healthy pattern of eating for weight control with weight loss progressing toward a desired goal. Low self-esteem is defined as negative self-evaluating/feelings about self or self-capabilities (p. Possible Etiologies (“related to”) [Dissatisfaction with appearance] [Unmet dependency needs] [Lack of adequate nurturing by maternal figure] Defining Characteristics (“evidenced by”) Negative feelings about body. Obesity and compulsive eating behaviors may have deep-rooted psychological implications, such as compensation for lack of love and nurturing or a defense against intimacy. Have client recall coping patterns related to food in family of origin, and explore how these may affect current situation. Maladaptive eating behaviors are learned within the family system and are supported through positive reinforcement. Food may be substituted by the parent for affection and love, and eating is associated with a feeling of satisfaction, becoming the primary defense. The individual may harbor repressed feelings of hostility, which may be expressed inward on the self. Because of a poor selfconcept, the person often has difficulty with relationships. When the motivation is to lose weight for someone else, successful weight loss is less likely to occur. The client needs to recognize that obesity need not interfere with positive feelings regarding self-concept and self-worth. Support groups can provide companionship, increase motivation, decrease loneliness and social ostracism, and give practical solutions to common problems. Client attends regular support group for social interaction and for assistance with weight management. These clusters, and the disorders classifed under each, are described as follows: 1. Obsessive-compulsive personality disorder A description of these personality disorders is presented in the following sections. The essential feature is a pervasive and unwarranted suspiciousness and mistrust of people. There is a general expectation of being exploited or harmed by others in some way. Symptoms include guardedness in relationships with others, pathological jealousy, hypersensitivity, inability to relax, unemotionality, and lack of a sense of humor. These individuals are very critical of others but have much difficulty accepting criticism themselves. This disorder is characterized by an inability to form close, personal relationships. Symptoms include social isolation; absence of warm, tender feelings for others; indifference to praise, criticism, or the feelings of others; and flat, dull affect (appears cold and aloof). This disorder is characterized by peculiarities of ideation, appearance, and behavior and by deficits in interpersonal relatedness that are not severe enough to meet the criteria for schizophrenia. Symptoms include magical thinking; ideas of reference; social isolation; illusions; odd speech patterns; aloof, cold, suspicious behavior; and undue social anxiety. This disorder is characterized by a pattern of socially irresponsible, exploitative, and guiltless behavior, as evidenced by the tendency to fail to conform to the law, to sustain consistent employment, to exploit and manipulate others for personal gain, to deceive, and to fail to develop stable relationships. The individual must be at least 18 years of age and have a history of conduct disorder before the age of 15. The features of this disorder are described as marked instability in interpersonal relationships, mood, and self-image. The instability is significant to the extent that the individual seems to hover on the border between neurosis and psychosis. Symptoms include exaggerated expression of emotions, incessant drawing of attention to oneself, overreaction to minor events, constantly seeking approval from others, egocentricity, vain and demanding behavior, extreme concern with physical appearance, and inappropriately sexually seductive appearance or behavior. This disorder is characterized by a grandiose sense of self-importance; preoccupation with fantasies of success, power, brilliance, beauty, or ideal love; a constant need for admiration and attention; exploitation of others for fulfillment of own desires; lack of empathy; response to criticism or failure with indifference or humiliation and rage; and preoccupation with feelings of envy. This disorder is characterized by social withdrawal brought about by extreme sensitivity to rejection. Symptoms include unwillingness to enter into relationships unless given unusually strong guarantees of uncritical acceptance; low self-esteem; and social withdrawal in spite of a desire for affection and acceptance. Individuals with this disorder passively allow others to assume responsibility for major areas of life because of their inability to function independently. They lack self-confidence, are unable to make decisions, perceive themselves as helpless and stupid, possess fear of being alone or abandoned, and seek constant reassurance and approval from others. This disorder is characterized by a pervasive pattern of perfectionism and inflexibility. Interpersonal relationships have a formal and serious quality, and others often perceive these individuals as stilted or “stiff. Many of the behaviors associated with the various personality disorders may be manifested by clients with virtually every psychiatric diagnosis, as well as by those individuals described as “healthy. Individuals with personality disorders may be encountered in all types of treatment settings. They are not often treated in acute care settings, but because of the instability of the borderline client, hospitalization is necessary from time to time. The individual with antisocial personality disorder also may be hospitalized as an alternative to imprisonment when a legal determination is made that psychiatric intervention may be helpful. Because of these reasons, suggestions for inpatient care of individuals with these disorders are included in this chapter; however, these interventions may be used in other types of treatment settings as well. Undoubtedly, these clients represent the ultimate challenge for the psychiatric nurse.

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Parents are advised to anxiety symptoms ocd buy 75 mg imipramine otc learn basic frst aid and resuscitation as well as the following: Y Always supervise a swimming child and teach children water and basic resuscitation skills anxiety in relationships order 50mg imipramine mastercard. Encourage children to anxiety symptoms severe buy 25mg imipramine be cautious about removing food from microwaves and to anxiety yellow pill 75mg imipramine otc stir food thoroughly and test the temperature prior to eating. This section: Y Identifes factors that increase the risk of a child fve to twelve years experiencing sub-optimal health outcomes, and Y Provides guidelines on how child health professionals can work with children and their families where these factors exist, including additional targeted services and referral and care coordination with other service providers. Services will depend on the local community, resources and context of health care. Targeted services aim to increase parenting skills, support parents to respond efectively to their child’s needs and decrease risk factors impacting on family functioning. These services may be provided within a variety of settings to promote engagement of families. Depending on the local model of care, this may include: z Appointments for short term individual structured intervention z Group programs. For exampe, they have twice the number of decayed teeth by the time they are six years old, compared to families with higher incomes 144. Growth retardation and obesity are risks when nutritional requirements are not met and illness more common. Overcrowded living circumstances results in higher incidence of communicable illnesses 24. A range of vulnerabilities exist for children of these families – the more disruption to family life, the more the likelihood of a detrimental impact on the child’s emotional and physical wellbeing 169. Their children are also at greater risk of maltreatment, child abuse and being developmentally delayed 170. Single parent families may be at greater risk of alcohol-related harm to children 171. The key factor for children of parents with a disability is whether the parent can provide adequate care for the child. This will depend on the type and severity of their disability and the level of support they have. Evidence suggests that parents with intellectual disability can provide adequate parenting when appropriate supports are in place and the child is likely to develop in line with their peers from similar socio-demographic backgrounds 144,173. Under these conditions children may be emotionally or physically compromised with some children developing a carer role to the parent, or developing behavioural problems 173. The development of secure attachment relies on the child’s attachment fgure to be ‘a safe haven’; when the parent is able to provide consistent comfort and a secure base for the child, he/she feels able to explore the world. This optimises the child’s chance of developing social skills that will assist him/her in successfully navigating life 69. If a parent is sufering a mental illness this may impact on their availability to their child as well as their consistency in parenting behaviours that support child-parental attachment. Children with parents sufering from a mental illness are more likely to have an altered attachment, socio-emotional and behavioural problems 69. Children living in remote areas encounter more than twice the number of decayed teeth as children in major cities. Obesity in these areas is a greater risk with 27% of children aged 5-14 years, being overweight or obese compared to 21% in city areas. The use of additional resources may be required to facilitate a comprehensive family health assessment, such as an interpreter. Services will be tailored in partnership with families and guided by the local Hospital and Health Service protocol and models of care. This may include, for example: z universal service provision with brief structured interventions and/or z referral to additional support services within or external to the service 1. Aboriginal and Torres Strait Islander families It is important to invite a child and their family members to identify as Aboriginal and Torres Strait Islanders, to ensure their cultural needs can be considered. Health in the context of an Aboriginal and Torres Strait Islander is a holistic concept, encompassing physical, social, emotional, spiritual and cultural wellbeing of the individual as well as their community. Men’s and Women’s Business remains a fundamental cultural practice within Aboriginal and Torres Strait Islander families and kinship and family responsibilities hold a higher priority than personal health needs. Additional factors that the health care professional can consider when working with Aboriginal and Torres Strait Islander families are outlined in the following tables: 206 Child and Youth Health Practice Manual 2014 Section 3 Five to twelve years 25, 158-160 Cultural needs Why there may be additional need Y Aboriginal and Torres Strait Islander clans difer in their belief systems across Australia; stereotyping cultural needs and cultural misunderstanding continues to exist. This may induce feelings of disconnection and being overwhelmed, and fear of the unknown or of being judged. Recommendations Y Invest time into establishing a therapeutic relationship with children and their families; this is thought to increase ongoing engagement of the family. Child and Youth Health Practice Manual 207 Section 3 Five to twelve years For health professionals Aboriginal and Torres Strait Islander patient care guideline (Queensland Government, 2014) It supports classroom activities by raising cultural awareness of Indigenous values, customs, language and food-related practices. Middle ear infection is common and has been diagnosed in infants as young as 2 weeks of age. The associated conductive hearing loss may have a profound impact on their development. Of these presentations, 44% were found to be potentially preventable either by the nature of the concern or that a primary care provider could have treated the presenting concern. Recommendations Y It is recommended that preventative measures and targeted health promotion programs are ofered to reduce these common health concerns, as well as appropriate access to primary health care facilities in non-emergency settings. This should include Otoscopy, Tympanometry and Audiometry as the clinician deems appropriate to the specifc situation. Refer to Primary Clinical Care Manual Topics: Acute otitis media, chronic suppurative otitis media, otitis externa Refer to Chronic Conditions Manual Child and Youth Health Practice Manual 209 Section 3 Five to twelve years 51, 161, 165 Family wellbeing Why there may be additional need Y Aboriginal and Torres Strait Islander children are 8-9 times more likely to be in the child protection system and they are over-represented in ‘out of home’ care services. For example: Y In a report on social and emotional wellbeing, over one third of Torres Strait Islander people reported high to very high levels of psychological distress and had experienced at least one life stressor (death of a family member / close friend, serious illness, inability to get work) in the previous 12 months of their life. Recommendations Y Promote parental wellbeing by ofering psychosocial support strategies including: z Promoting peer support. Cooperative Research Centre for Aboriginal Health) Referral for Active Intervention services Refugee young people are at heightened risk of developing co-morbid substance use disorders, with many using alcohol and other drugs as a means of coping with stressors relating to both pre-migration and settlement experiences. Whilst it is illegal in Australia it may still be practiced in some cultural groups. What to do Principles to underpin good clinical practice: Y Welcoming cultural diversity as a strength helps eliminate discrimination and strengthens community cohesion. Child and Youth Health Practice Manual 211 Section 3 Five to twelve years 24, 149, 163, 166, 167, 206 Children from culturally and linguistically diverse families What to do cont. This may enhance your ability to gain information and develop rapport with the family. It may be necessary to complete a ‘Report of Suspected Child in Need of Protection’ See page 222. For the purpose of this manual, the following three issues have been discussed: z weight faltering / malnutrition z childhood obesity z behavioural difculties. The healthcare context A comprehensive health assessment will provide the foundation for clinical decision making by the child health professional when additional needs are identifed. Immediate action will be required in the event that an acute health issue is identifed by the child health professional, for example: z concerns for the immediate safety of the child / family. In situations such as these, the child health professional will take immediate action to alert the relevant emergency services. Ambulance, Police, Acute Mental Health Services, Royal Flying Doctor Service, Queensland Government Department of Communities, Child Safety and Disability Services. Primary Clinical Care Manual Topics: Patient assessment, emergencies Child and Youth Health Practice Manual 213 Section 3 Five to twelve years Case management To manage and coordinate service provision for families with identifed needs where a number of health care providers are involved, a case manager may be assigned to the family to coordinate the overall care. Key elements of case management include: Y family partnership Y comprehensive and ongoing family assessment Y cultural safety Y working with and utilising community resources (it is important for the case manager to be aware of local services available to meet additional needs of families) Y participating in interdisciplinary consultation and collaboration Y monitoring and evaluating client and service delivery outcomes Y advocating on behalf of a child with an identifed need Y documenting client encounters and case manager activities with a focus on family centred practice Y scheduling of follow-up and review, outlined in the care plan. This includes: z from the community to hospital and back to community afer inpatient events z between general practitioners, agencies and other services z for children placed with diferent carers z between health care professionals in the same organisation. Clinical practice points Y Conduct a comprehensive family health assessment to identify specifc needs of the individual child/ family, this should include: z Food intake, what and how much, how ofen z Cultural and social context of meal times z Impact of family budget on food availability z Impact of rural environment on food choices z Sleep patterns (poor sleep can disturb metabolic processes and disrupt appetite control z Activity assessment. Higher level services Case management strategies may include: Y Have a multidisciplinary team approach with the involvement of health professionals with varied specialties. The management strategy should include: z A diet plan for provision of adequate calories, protein and other nutrients; z Nutritional counselling; z Monitoring of growth and nutritional status; z Treatment for the underlying cause of malnutrition; z Specifc treatment of complications or defciencies. Clinical practice points Y Conduct a comprehensive family health assessment to identify specifc needs of the individual child / family, this should include: z Dietary intake, what and how much. Child and Youth Health Practice Manual 217 Section 3 Five to twelve years 24, 84, 87, 141, 140 Obesity in childhood z Discourage habits such as using foods for reward, and giving foods as a form of comfort.

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Problems With the Types the goal of delineating types or subtypes of a disorder is to anxiety symptoms 247 purchase 50mg imipramine fast delivery identify and organize useful information anxiety zone ms fears 75 mg imipramine otc, such as distinguishing the prognosis or course of one type from another anxiety symptoms in 13 year old buy 50mg imipramine amex. Patients diagnosed with one type often shift to anxiety symptoms throat purchase imipramine 75mg without a prescription the other type over time (Eddy et al. For example, at an 8-year follow-up, one study found that 62% of those with the restricting type had changed to the binge-eating/purging type; in fact, only 12% of those who had been restrictors never developed any binge/purge symptoms. These findings suggests that the restricting type may be an earlier phase of the disorder for some patients (Eddy et al. Other criteria include an associated with general medical status, prognosis, or outcome. Other symptoms include irritability, headaches, faor not her eating-related symptoms meet all of the criteria for tigue, and restlessness. Specifically, list which criteria apply and which ics, laxatives, and enemas—can cause dehydration because they do not. If you would like more information to determine her primarily eliminate water, not calories, from the body. Bulimia Nervosa Marya Hornbacher describes her descent into bulimia nervosa: I woke up one morning with a body that seemed to fill the room. Long since having decided I was fat, it was a complete crisis when my body, like all girls’ bodies, acquired a significantly greater number of actual fat cells than it had ever possessed. At puberty, what had been a nagging, underlying discomfort with my body became a full-blown, constant obsession. When I returned [from the bathroom after throwing up], everything was different. I remember devouring piece after piece [of a loaf of bread, toasted with butter], my raging, insatiable hunger, the absolute absence of fullness. Locking the bathroom door, turning the water on, leaning over the toilet, throwing up in a heave of delight. Though the purging was initially rare—maybe once or twice a week—it was right about this time that I began to get in trouble at school. For Hornbacher, as for many people with bulimia, the maladaptive eating behaviors started off as an attempt to cope with negative feelings about weight, appearance, or eating “too much. In this section we examine the criteria for bulimia nervosa, and the medical effects of the disorder; we then discuss criticisms of the diagnostic criteria and consider the disproportionately high prevalence of the related disorder, eating disorder not otherwise specified. A key feature of bulimia nervosa (often simply referred to as bulimia) is repeated episodes of binge eating followed by inappropriate efforts to prevent weight gain. An episode of binge eating is characterized by both to prevent weight gain, such as fasting or exof the following: cessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at with bulimia nervosa are in the normal weight least twice a week for 3 months. Comorbidity • Up to 75% of people with bulimia have at least one other disorder, often an anxiety disorder (Godart et al. Onset • Bulimia usually begins in late adolescence or early adulthood (American Psychiatric Association, 2000). Course • At a 15-month follow-up, almost a third of those diagnosed with bulimia still met the criteria for the diagnosis; at a 5-year follow-up, that proportion dropped to 15% (Fairburn et al. Gender Differences • Approximately 75–90% of those with bulimia nervosa are female (Hoek & van Hoeken, 2003; Hudson et al. Cultural Differences • Some studies find significant differences in prevalence, frequency, and symptoms of eating disorders across ethnic groups within the United States. Specifically, black and Hispanic American women are less likely to be diagnosed with bulimia than are Asian American or white American women (Alegria et al. Other studies find fewer meaningful differences in symptoms and prevalence rates across ethnic groups (see Arriaza & Mann, 2001; Franko et al. Rather, they try to control what they eat, restricting their caloric intake at meals (trying to be “good” and eat less), but later become ravenous and their hunger feels out of control. They then binge eat, which in turn makes them feel physically and emotionally “bad” because they “lost control” of themselves. As a result of such feelings, they may purge and subsequently strive to eat less, restricting their caloric intake at meals and creating a vicious cycle of restricting, bingeing, and usually purging. As one woman notes: “I don’t eat all day and then I come home from work and binge. I always tell myself I’m going to eat a normal dinner, but it usually turns into a binge” (Fitzgibbon & Stolley, 2000). While her mother and father continue to speak Spanish at home and place a high value on maintaining their Mexican traditions, Gabriella wants nothing more than to fit in with her friends at school. She chooses to speak only English, looks to mainstream fashion magazines to guide her clothing and make-up choices, and wants desperately to have a fashion-model figure. In an attempt to lose weight, Gabriella has made a vow to herself to eat only one meal a day—dinner—but on her return home from school, she is rarely able to endure her hunger until dinnertime. For instance, chronic vomiting, a purging method used by Marya Hornbacher, can cause the parotid and salivary glands (in the jaw area) to swell (creating a kind of “chipmunk” look) and can erode dental enamel, making teeth more vulnerable to cavities and other problems. Those who use syrup of ipecac (which is toxic) to induce vomiting may develop heart and muscle problems (Pomeroy, 2004; Silber, 2004). Furthermore, many people with bulimia use laxatives regularly, which can lead to a permanent loss of intestinal functioning as the body comes to depend on the chemical laxatives to digest food and eliminate waste. In such cases, the malfuncFrequent vomiting can permanently erode dental tioning intestinal section must be surgically removed (Pomeroy, 2004). Bulimia can enamel, shown here, and lead to cavities and also produce constipation, abdominal bloating and discomfort, fatigue, and irregular related problems. As noted earlier in the section on anorexia, all forms of purging can cause dehydration and an imbalance of the body’s electrolytes, which disrupt normal neural transmission and heart conductance. I am at risk of having another stroke, and this time I have a high chance of not coming out of it. I’m depressed because I want to eat, and I’m depressed because I know if I do eat, I’ll get fat and gain all the weight back that I have lost. Eating Disorders 445 Everyone around me is terrified that I may die from this, and it has put a lot of stress on my marriage. I have no bedroom life anymore because I refuse to let my husband touch me or even look at my body. My kids are affected greatly by it because I usually have no energy to do anything with them, and when I do have energy, I am staying busy to burn the calories I have put in my body. In fact, research has found that calories consumed during “binge episodes” vary widely from episode to episode and person to person (Rossiter & Agras, 1990); thus, what some consider to be a binge, others might view as an unexceptional meal. To see the implications of this criticism, let’s compare two women, Tess, whose symptoms meet the timing criteria, and Jen, whose symptoms do not. Tess binges three times a week for 4 months and has enough of the other symptoms to be diagnosed with bulimia. Jen binges and purges once a week, usually in a 3-hour stint; however, twice every semester, during midterms and finals weeks, she binges and purges almost every day. Her bingeing and purging do not meet the timing criteria, and thus she would not be diagnosed with bulimia; however, her bingeing and purging cannot be considered “normal. That is, the two groups are similar in terms of the disorder’s onset, course, outcome, and other variables. In fact, research has found that whether or not someone with bulimia is impulsive is the characteristic that best predicts course and prognosis, not whether her diagnosis is the purging or nonpurging type (Favaro et al. Examples of behaviors that indicate impulsivity include stealing, running away, and seeking out dangerous situations, as well as abusing substances (Fischer, Smith, & Anderson, 2003; Wonderlich & Mitchell, 2001). Similarly, the types of each eating disorder—restricting and binge-eating/purging types for anorexia and purging and nonpurging types for bulimia—may represent different paths of the same underlying eating disorder. In fact, the characteristics of the binge-eating/purging type of anorexia have more in common with those of bulimia than with those of the restricting type of anorexia (Gleaves, Lowe, Green, et al. All that distinguishes the binge-eating/purging type of anorexia from bulimia is the low weight and consequent amenorrhea. In contrast, the restricting type of anorexia involves both a very different approach to eating (or not eating) and different coping styles, such as extreme self-regulation.

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As noted earlier anxiety disorder in children buy cheap imipramine 50mg online, beginning in the 1950s anxiety hives purchase imipramine 75 mg on-line, the Psychological Assessment effectiveness of psychotherapy was being quesClinical Psychology: Science and Practice tioned anxiety groups order 75 mg imipramine amex. However anxiety symptoms racing heart discount imipramine 50mg line, in 1977, Mary Smith and Gene Journal of Abnormal Psychology Glass published a survey that supported the effiPsychological Bulletin cacy of therapy. This work laid the basis for a Behavior Therapy series of studies that has helped us better underPsychological Science stand the way therapeutic methods affect American Journal of Psychiatry patients. As noted previously, the field of psychotherapy research continues to grow to this day. We nessed an increasing amount of interest among will review this important field in later chapters. Behavioral genetics is a research speall clinical psychology, we will be discussing cialty in which both genetic and environmental research methods, research on particular topics, influences on the development of behavior are and the historical context of research in these evaluated. Many of the regated these influences in a wide range of behavsearch highlights are mentioned in the timeline iors and individual differences, including intelliSignificant Events in Research. Although the membership of the association was still fewer than 100 by the close of the 19th century, the profession had truly begun. The birth of clinical psychology was not far Image not available due to copyright restrictions behind. In 1896, Lightner Witmer established the first psychological clinic at the University of Pennsylvania. Many would date the real beginning of clinical psychology from this time (McReynolds, 1996) (Figure 2-4). That other children, or because of moral defects is, he got the profession under way but really which rendered them difficult to manage added little in the way of new theories or methunder ordinary discipline. Meanwhile, an ever-increasing number of nal of Abnormal Psychology, and in 1907, Witmer psychological clinics were being established. However, World applied clinicians could now begin to form their War I and the growth of the group testing moveidentity. This identity was further reinforced ment did as much as anything to spur the develwhen, in 1909, Healy established the juvenile opment of the new profession. However, clinics, and internships, the profession of cliniby the close of the 1920s, many clinically orical psychology was beginning to take shape. Such rising tide of patients that swept into its clinics events signaled real growth for clinical psycholand hospitals. Another trend also attested the availability of mental health professionals by to the development of the field: Psychological providing financial support for their training. James McKeen Cattell founded the Psychovided financially attractive internships for gradlogical Corporation in 1921 to develop and maruate students in approved university Ph. Neverwillingness to hire clinicians at salaries higher theless, the clinical psychologists of the day were than could generally be obtained elsewhere quite different in terms of both activities and raised the entire pay scale of the profession. They also continued to large-scale screening program to weed out those serve in their familiar capacity as the research who were unfit for military service. By 1949, 42 schools were these skills set them apart from their psychiatric offering the doctorate in clinical psychology, colleagues. Both their technology and their and large numbers of high-quality students were research orientation served psychologists well in applying. The increased confidence in their abilities and a aftermath of the war and the general increase in determination to build a profession. In approximately the the publication of the first American Psychologist same period, federal research grants and conin 1946. The focus notwithstanding the opposition from the psyhas shifted from a search for the traits or internal chiatric profession. It was beginning to make reccal condition to an analysis of the situational facommendations for the training of clinical psytors that control their behavior. In the late 1960s, chologists and also to certify clinical training the road to changing undesirable behavior began programs. In 1953, it published Ethical Standards, swerving sharply from psychotherapy (and the a landmark achievement in the codification of insight it was designed to produce) to conditionethical behavior for psychologists and a great ing and altered reinforcement contingencies. The Boulder Conference was a truly signifSome, of course, began to suspect that all this icant event in clinical psychology because it exwas an overreaction. Were traits really fictions plicated the scientist-practitioner model for trainthat had no utilityfi Could behavioral analyses ing clinical psychologists that has served as the and methods address and cure everythingfi In thought not, and by the mid-1970s, cognition succinct terms, this model asserts (a) clinical had begun to creep back onto the scene. The 1970s and 1980s witnessed still further the 1988 Schism growth in the profession. All 50 states, the District of Columbia, occupied with such professional issues as writing Puerto Rico, and several Canadian provinces prescriptions, hospital privileges, reimbursement either license or certify psychologists. Many clinquestions, licensing, legal actions against psychiical psychologists now have hospital privileges, atry, and so on. There academic-scientific needs of a significant numhas also been an increase in the number of clinber of its members. This organization now sional developments are summarized in the has a newsletter, the Observer, a monthly emtimeline Significant Events in the Profession of ployment bulletin, and three scientific journals, Clinical Psychology. Psychological Science, Psychological Science in the Today, the field of clinical psychology is chalPublic Interest, and Current Directions in Psychologlenged by a host of professional issues. Briefly, they include the question of the bers identify themselves as clinical, counseling, optimal training model for contemporary clinior school psychologists. Witmer would scarcely unfortunate for both sidesfihat what the field recognize it. However, although trainmay produce even less integration than now ing and practice are in a state of flux, certain exists. As mentioned earlier, two recent landmark events will influence the profession of clinical psychology. These events will affect the discipline of psychology, preserving its sciennot only the practice of clinical psychology but tific base, and promoting public understanding of also training and research. Behavior therapy usually focuses relative strengths and weaknesses across a number on observable behavior and is typically of relatively of areas. Examples include the community psychology A psychological specialty paranoid, antisocial, and dependent personality that focuses on the prevention and treatment of disorders. The nature play therapy A technique, derived from traditional of the presenting problem determines which orienFreudian principles, that uses expressive play to tation to use in a given case. Psychotherapy research may be used to dethe rationales, goals, and techniques that corretermine which intervention is more effective for spond to each phase of the treatment). He believed that performance that only overt behaviors could be measured and on these tests was associated with intelligence. To visit any of the followng Web sites listed, go structured diagnostic interviews A class of assessto The term structured means 2-1 American Psychological Association that interviewers ask all interviewees the same ques2-2 American Psychological Society tions in the same order and score the answers in 2-3 Society for a Science of Clinical Psychology standard ways. What are the advantages and disadvanModels of Training in Clinical Psychology tages of various models of training for the Scientist-Practitioner clinical psychologistsfi What obstacles face clinical psychologists Programs who specialize in private practicefi How will managed care affect the practice Professional Regulation of clinical psychologyfi What advantages Private Practice might clinical psychologists have in a managed care environmentfi Prescription Privileges How might this pursuit affect graduate Culturally Sensitive Mental Health Services trainingfi What important diversity and ethical issues Competence guide the practice of clinical psychologyfi That chology professors did carry out research and review helped us to appreciate the roots of clinithey did publish. But their critics (often graduate cal psychology, as well as to put current activities students or clinicians in the field) complained in the appropriate historical context. Worse, it the best training models for a clinical psycholoseemed to professors that their own research gistfi What is the best way to ensure professional detracted from their training of clinical students competencefi How should ing, or principles of physiological psychology clinical psychology respond to the increasing and too little about psychotherapy and diagnosdiversity of the population it servesfi

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