48 The Scientist Practitioner Model of Professional Psychology
The most valuable natural resource on the planet earth is not diamonds, gold, or energy; it is the potential of every human being to understand and impact upon nature. Development of this potential resulted in the discovery of diamonds, gold, fossil fuels, and nuclear energy; it resulted in the transformation of Manhattan and much of the rest of the earth since the Scientific Revolution. Development of this potential resulted in the beauty and creativity intrinsic to architecture, music, and the arts. Development of this potential resulted in what we know as civilization.
Over the past 11 chapters, we described how the science of psychology helps us understand the many different ways that experience interacts with our genes to influence our thoughts, emotions, and actions. As humans acquired new knowledge and skills, we altered our environment; as we altered our environment, it became necessary to develop new knowledge and skills. Permanently recording human progress sped up the transformation from the Stone Age to the Information Age (Kurzweil, 2001). Humans are at an unprecedented point in time. Application of the scientific method to understanding nature is a two-edged sword. This knowledge and technological capability has enabled humans to extend our reach beyond our planet. At the same time this capability is threatening our very survival on earth. We need to insure that we continue to eat, survive, and reproduce. Otherwise, it will not matter what we think it is all about!
Often, we contrasted the adaptive requirements of the Stone Age with our current human-constructed conditions. The still existing indigenous tribes often have elders believed to have special powers or knowledge to help those suffering from physical or behavioral problems. As a science, psychology has progressed in the accumulation of knowledge and technology since its beginnings in Wundt’s lab. In the previous chapter, we saw how the profession of clinical psychology uses empirically-validated learning-based procedures to successfully ameliorate severe psychiatric and psychological disorders. In the rainforest, parents, relatives, and band members are responsible for raising children to execute their culturally defined roles. In this chapter, we will examine other examples of the application of professional psychology to assist individuals in adapting to their roles within our complex, technologically-enhanced, cultural institutions.
Academic and Research Psychology
College professors in all disciplines conduct scholarly research in their areas of specialization. Empirical research provides the foundation of the scientist-practitioner model of professional psychology . This model emphasizes the complementary connection between basic and applied research and professional practice. We have seen that if the requirements of internal and external validity are satisfied, it is possible to come to cause-effect conclusions regarding the effectiveness of specific therapeutic procedures in modifying specific behavioral problems. Ethical practice requires remaining current and basing one’s clinical strategy on the results of such research. Throughout this book, we have described the findings and implications of correlational and experimental research conducted in the laboratory and field. Most of the individuals carrying out that research are academic and research psychology faculty members possessing doctoral degrees in departments of Psychology and related disciplines (e.g., Cognitive Science, Human Development, Neuroscience, etc.). Much of the research relates to the basic psychological processes described in Chapters 2 through 7 (biological psychology, perception, motivation, learning, and cognition). Other research relates to the holistic issues involved in normal and problematic human personality and social development described in Chapters 8 through 11.
Prior to the Second World War, psychology was almost exclusively an academic discipline with a small number of practitioners. During and after the war, psychiatrists requested help from psychologists in providing treatment for soldiers. The government funded the development of clinical psychology programs to meet this increased demand for services. It became necessary to develop a standardized curriculum to train psychological practitioners (Frank, 1984). In 1949, a conference was held at the University of Colorado at Boulder to achieve this objective (Baker & Benjamin, 2000). A scientist-practitioner model was adopted for American Psychological Association accreditation in clinical psychology. The rationale was that in the same way that medical practice is based upon research findings from the biological sciences, clinical practice should be based upon findings from the content areas of psychology. After the Second World War, significant changes occurred in another APA division beside clinical psychology. In 1951, the name of the Division of Personnel and Guidance Psychologists was changed to the Division of Counseling Psychology. This change reflected the fact that individuals in this division often worked side-by-side with clinical psychologists on other lifestyle issues beside those related to work.
Although it was not an objective at the time, this grounding in the scientific method was an important first step in the development of the movement to evidence-based practice four decades later. Grounding clinical practice in psychological science was also key to the development of alternatives to the then (by default) prevalent psychodynamic therapeutic model. The Freudian model assumed that psychiatric disorders stemmed from unconscious conflict between impulsive demands of the id and the moral standards of the superego (see Chapter 8). The model postulated the existence of defense mechanisms, such as repression, that prevented the sources of conflict from becoming conscious. Assessment and treatment techniques flowed from this model; it was necessary to circumvent the defense mechanisms in order to bring the sources of conflict to consciousness. The logic of assessment instruments such as the Rorshach inkblots and Thematic Apperception Test was that due to their ambiguity, they would not activate defense mechanisms, thereby enabling individuals to “project” their unconscious thoughts onto the inkblots or pictures. For this reason they are referred to as projective techniques.
The reliability of scoring for the Rorshach inkblots has been questioned (Lillenfeld, Wood, & Garb, 2000) and their use challenged in court cases (Gacono & Evans, 2008; Gacono, Evans, & Viglione, 2002). After an enormously influential review of case studies addressing the effectiveness of psychodynamic therapy, it was concluded that they provided no benefit beyond the passage of time (Eysenck, 1952). The time was right after the Second World War to develop an alternative, science-based approach to psychodynamic psychotherapy. This void was filled by learning-principle based behavior modification, applied behavior analysis, and cognitive-behavior modification interventions (Martin & Pear, 2011, chapter 29). Detailed applications of these approaches will be described below.
Contemporary professional psychologists implement evidence-based psychological procedures to assist individuals in developing their potential. Before we consider applications in schools and at the workplace, we will consider those individuals challenged by serious issues. In the prior chapter, applied behavior analysis and cognitive-behavioral procedures were frequently cited as being effective for treating DSM diagnosed psychiatric disorders. We will now provide more detailed descriptions for these procedures and how they are applied.
A Psychological Model of Maladaptive Behavior
DSM disorder labels still constitute the most used terminology for describing behavioral disorders. As we saw in the last chapter, a DSM diagnosis may provide useful information regarding the likely prognosis for behavioral change in the absence of treatment. However, DSM diagnosis provides minimal information regarding specific interventions for specific thoughts, feelings, or behaviors. Despite this, DSM disorder terms are frequently misunderstood as pseudo-explanations in a way which is not usually characteristic of other non-explanatory illness terms. For example, one is unlikely to conclude that high blood pressure readings are caused by hypertension; in comparison, it is common to conclude that hallucinations are caused by schizophrenia. This problem has led some psychologists to suggest an entirely different approach to describing behavioral disorders. Rather than attempting to identify an underlying “mental illness” (e.g., Autism Spectrum Disorder, Major Depressive Disorder, etc.), the behavior itself is considered the target for treatment. Rather than providing DSM diagnoses for different disorders, problematic behavior is categorized according to the following listing:
- Behavioral Excesses (e.g., head-banging, repetitive hand movements, crying, etc.)
- Behavioral Deficits (e.g., lack of speech, failure to imitate, failure to get out of bed in the morning, etc.)
- Inappropriate External Stimulus Control (e.g., speaking out loud at the library, not paying attention to “Stop” signs, etc.)
- Inappropriate Internal Stimulus Control (e.g., thinking that one is a failure, not thinking of someone else’s needs, etc.)
- Inappropriate Reinforcement (e.g., problem drinking, not caring about performance in school, etc.)
One’s thoughts, emotions, or behaviors are maladaptive when they interfere with or prevent achieving personal objectives. A psychological model of maladaptive behavior avoids the issues of pseudo-explanation, reliability, and validity that plague DSM diagnoses. There is no disease to be determined or considered an explanation. Diagnosis consists of a detailed description of the individual’s behaviors and environmental circumstances. Psychologists explain such disorders as resulting from nature/nurture interactions and rely upon experiential treatment approaches (e.g., talking therapies and homework assignments). An underlying assumption is that no matter what the “cause” of maladaptive behavior, it can usually be modified by providing appropriate learning experiences. Assessment of the effectiveness of treatment is based on objective measures of improved adaptation to specific environmental conditions (e.g., performance in school, job performance, interpersonal relations, etc.).
Let us take the example of Major Depressive Disorder. The medical model dictates assessing the extent to which an individual’s symptoms fulfill the requirement of a DSM-5 diagnosis. Different individuals vary, however, in terms of the patterns of their depressed behaviors. Some may not get out of bed in the morning; others might. Some might groom and dress themselves; others not. Some might cry a lot; others not; some may be lethargic; others not. Some may no longer enjoy their hobbies; others might. Some may no longer perform adequately on their jobs; others might; and so on. Given the infinite combination of possibilities, it is not surprising that arriving at a DSM diagnosis requires a good deal of interpretation and prioritization by the psychiatrist. Reliability issues are inevitable. In contrast, the psychological assessment model results in a detailed behavioral and environmental description tailored to each individual. One would not expect differences in interpretation of whether or not someone gets out of bed in the morning, grooms and dresses themselves, cries, etc. It is clear that these behavioral descriptions are defined exclusively on the behavioral (dependent variable) side. No one would make the mistake of concluding that a person fails to get out of bed because they fail to get out of bed; this is obviously circular. A DSM diagnosis, however, is seductive. It is tempting to conclude that the person fails to get out of bed as the result of major depressive disorder. We will now see how a psychological model can be applied to help non-verbal individuals with direct learning-based interventions. This will be followed by an application of the model to verbal individuals using indirect-learning procedures.
Treating Behavioral Problems with Non-Verbal Individuals:
Applied Behavior Analysis with Autistic Children
Autism is a severe developmental disorder. It is characterized by an apparent lack of interest in other people, including parents and siblings. A behavioral excess such as head banging, not only is likely to result in serious injury, but will interfere with a child’s acquiring important linguistic and social skills. That is, an extreme behavioral excess may result in serious behavioral deficits. Autistic children often display excesses and/or deficits of attention. For example, they may stare at the same object for an entire day (stimulus over-selectivity) or seem unable to focus upon anything for more than a few seconds (stimulus under-selectivity). In the absence of treatment, an autistic child may fail to acquire the most basic self-help skills such as dressing or feeding oneself, or looking before crossing the street. They require constant attention from care-givers in order to survive, let alone to acquire the social and intellectual skills requisite to making friends and preparing for school.
The principles of direct learning described in Chapter 5 were predominantly established under controlled conditions with non-verbal animals. It should therefore come as no surprise that procedures based upon these principles have been applied to non-verbal children diagnosed with neurodevelopmental disorders. Ivar Lovaas (1967) pioneered the development and implementation of Applied Behavior Analysis (ABA) as a comprehensive learning program for autistic children. In the absence of effective biological treatment approaches, ABA continues to be the treatment of choice for individuals diagnosed with autism spectrum disorder. An excellent summary of this early work (Lovaas & Newsom, 1976) describes his success in reducing self-destructive behavior (e.g., head-banging) and teaching language using control learning procedures. Reinforcement Therapy, a still inspiring film (Lovaas, 1969), portrays this seminal research.
In Lovaas’s words, “What one usually sees when first meeting an autistic child who is 2, 3, or even 10 years of age is a child who has all the external physical characteristics of a normal child – that is, he has hair, and he has eyes and a nose, and he may be dressed in a shirt and trousers – but who really has no behaviors that one can single out as distinctively “human.” The major job then for a therapist – whether he’s behaviorally oriented or not – would seem to be a very intriguing one, namely the creation or construction of a truly human behavioral repertoire where none exists” (Lovaas & Newsom, 1976, p. 310). Since they are non-verbal and do not imitate, teaching an autistic child can have much in common with training a laboratory animal in a Skinner-box. Initially, one needs to rely on direct learning procedures. Unconditioned reinforcers and punishers (i.e., biologically significant stimuli such as food or shock) serve as consequences for arbitrary (to the child) behaviors.
Video
Watch the following video for a description of applied behavior analysis (ABA):
Behavioral Excesses – Eliminating Self-Injurious Behavior
Some early attempts at eliminating self-injurious behaviors by withdrawing attention (Wolf, Risley, & Mees, 1964) or placing the child in social isolation (Hamilton, Stephens, & Allen, 1967) were successful. However, such procedures tend to be slow-acting and risky in extreme cases. In such instances, presentation of an aversive stimulus (a brief mild shock) may be necessary. Lovaas, Schaeffer, and Simmons (1965) were the first to demonstrate the immediate long-lasting suppressive effect of contingent shock on tantrums and self-destructive acts with two 5-year-old children. These findings have been frequently replicated using a device known as the SIBIS (Self-Injurious Behavior Inhibiting System) . The SIBIS was developed through collaboration between psychological researchers, engineers, autism advocates, and medical manufacturers. A sensor module that straps onto the head is attached to a radio transmitter. The sensor can be adjusted for different intensities of impact and contingent shock can immediately be delivered to the arm or leg. Rapid substantial reductions in self-injurious behavior were obtained with five previously untreatable older children and young adults using brief mild shocks (Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990).
Behavioral Deficits – Establishing Imitation and Speech
Once interfering behavioral excesses are reduced to being manageable, it is possible to address behavioral deficits and establish the capability of indirect learning through imitation and language. Perhaps the most disheartening aspect of working with an autistic child is her/his indifference to signs of affection. Smiles, coos, hugs, and kisses are often ignored or rejected. Autistic children are typically physically healthy and good eaters. Therefore, Lovaas and his co-workers were able to work at meal time, making food contingent on specific behaviors. A shaping procedure including prompting and fading was used at first to teach the child to emit different sounds. For example, in teaching the child to say “mama”, the teacher would hold the child’s lips closed and then let go when the child tried to vocalize. This would result in the initial “mmm” (You can try this on yourself). Once this was achieved, the teacher would touch the child’s lips without holding them shut, asking him/her to say “mmm.” Eventually the physical prompt could be eliminated and the verbal prompt would be sufficient. At this point one would ask the child to say “ma”, holding the child’s lips closed while he/she is saying “mmm” and suddenly letting go. This will result in an approximation of “ma” that can be refined on subsequent trials. Repeating “ma”, produces the desired “mama.” With additional examples, the child gradually acquires the ability to imitate different sounds and words and the pace of learning picks up considerably.
Once the child is able to imitate what she/he hears, procedures are implemented to teach meaningful speech. Predictive learning procedures are used in which words are paired with the objects they represent, resulting in verbal comprehension. Verbal expression is achieved by rewarding the child for pointing to objects and saying their name. The child is taught to ask questions (e.g., “Is this a book?”) and make requests (e.g., “May I have ice cream?”). After a vocabulary of nouns is established, the child learns about relationships among objects (e.g., “on top of”, “inside of”, etc.) and other parts of speech are taught (e.g., pronouns, adjectives, etc.). Eventually the child becomes capable of describing his/her life (e.g., “What did you have for breakfast?”) and creative storytelling.
Lovaas assessed the extent to which the treatment gains acquired in his program were maintained over a 4-year follow-up in other environments. If the children were discharged to a state institution, they lost the benefit of training. Self-injurious behavior, language, and social skills all returned to pre-treatment levels. Fortunately, providing “booster” sessions rapidly reinstated the treatment gains. Those children remaining with their parents (who received instruction in the basic procedures) maintained their treatment gains and continued to improve in some instances (Lovaas, Koegel, Simmons, & Long, 1973). An intellectual development disorder often accompanies autism, so it is unrealistic to aspire to the age-appropriate grade level for all children. Still, Lovaas (1987) has achieved this impressive ideal with 50 percent of the children started prior to 30 months of age.
Question
Treating Behavioral Problems with Verbal Individuals: Cognitive Behavior Therapy
It is clear how the Applied Behavior Analysis procedures used with non-verbal individuals such as autistic children flow directly from Skinnerian reinforcement and punishment procedures developed with non-speaking animals. Less obvious is how cognitive behavior modification talking therapies relate to the psychology research literature. Their origin can be traced to two books published for the general population a year apart by Albert Ellis: A Guide to Rational Living (1961) and Reason and Emotion in Psychotherapy (1962). Ellis was trained in the Freudian psychodynamic approach to psychotherapy and became dissatisfied with the results obtained with his patients. At best, progress was very slow and often did not occur at all. He attributed these poor results to emphasis upon the past rather than the present and a passive/non-directive as opposed to a more active/directive approach he defined as Rational Emotive Therapy (RET) . RET assumed that an individual’s emotional and behavioral reactions to an event resulted from interpretation. For example, if you were walking along a sidewalk and someone bumped into you, you might react with anger until discovering that the person was blind. Ellis developed a systematic approach to therapy based on identifying one’s irrational thoughts and countering them with more adaptive alternatives.
Part of the reason for not connecting Ellis’ verbal approach to psychotherapy with the animal literature is the failure to connect that literature with speech by making the distinction between direct and indirect learning. As described in chapters 5 and 6, word meaning is established through Pavlovian classical conditioning procedures and speech is maintained by its consequences (i.e., may be understood as an operant). Martin Seligman (1975) developed a learned helplessness animal model providing the underpinnings of a cognitive analysis of depression and the psychiatrist Aaron Beck conducted experimental clinical trials comparing the efficacy of cognitive and pharmacologic approaches to the treatment of depression.
Cognitive-Behavioral Treatment of Depression
One might think that if it is possible to socialize an autistic child with extreme behavioral excesses and severely limiting behavioral deficits, treating a healthy verbal cooperative adult for a psychological problem would be easy in comparison. However, we need to appreciate the logistic and treatment implementation issues that arise when working with a free-living individual. Lovaas was able to create a highly controlled environment during the children’s waking hours. It was possible for trained professionals to closely monitor the children’s behavior and immediately provide powerful consequences. In comparison, adult treatment typically consists of weekly 1-hour “talking sessions” and “homework” assignments where the therapist does not have this degree of access or control. Success depends upon the client following through on suggested actions and accurately reporting what transpires.
Learned Helplessness
God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.
The Serenity Prayer, attributed to Friedrich Oetinger (1702-1782) and Reinhold Niebuhr (1892-1971)
From an adaptive learning perspective, there is much wisdom in the serenity prayer. In our continual quest to survive and to thrive, there are physical, behavioral, educational, cultural, economic, political, and other situational factors limiting our options. Research findings suggest that the inability to affect outcomes can have detrimental effects.
In Seligman’s initial research study, dogs were initially placed in a restraining harness with a panel in front of them. One group did not receive shock. A second group received an escape learning contingency in which pressing the panel turned off the shock. A third group was “yoked” to the second group and received inescapable shock. That is, subjects received shock at precisely the same time but could do nothing to control its occurrence. In the second phase, subjects were placed in a shuttle box where they could escape shock by jumping over a hurdle from one side to the other. Dogs not receiving shock or exposed to escapable shock failed to escape on only 10 percent of the trials whereas those exposed to inescapable shock failed to escape on over 50 percent of the trials. Seligman observed that many of these dogs displayed symptoms similar to those characteristic of depressed humans including lethargy, crying, and loss of appetite. Based upon his findings and observations, Seligman formulated a very influential learned helplessness model of clinical depression. He suggested that events such as loss of a loved one or losing a job could result in failure to take appropriate action in non-related circumstances as well as development of depressive symptoms. In entertaining and engaging books, Seligman describes how his learned helplessness model helps us understand the etiology (i.e., cause), treatment (Seligman, Maier, and Geer, 1968), and prevention of depression (Seligman, 1975; 1990).
The key factor in the learned helplessness phenomenon is prior exposure to uncontrollable events. Goodkin (1976) demonstrated that prior exposure to uncontrolled food presentations would produce similar detrimental effects to uncontrolled shock presentations on the acquisition of an escape response. A “ spoiling effect ” with appetitive events has also been demonstrated under laboratory conditions using the learned helplessness model. Pigeons exposed to non-contingent delivery of food were slower to acquire a key pecking response and demonstrated a lower rate of key pecking once it was acquired (Wasserman & Molina, 1975). It is clear from these studies and others that the serenity proverb applies to other animals as well as humans. Successful adaptation requires learning when one does and does not have the ability to control environmental events.
Video
Watch the following video for a demonstration of learned helplessness:
Question
As an example, let us consider someone who becomes depressed after losing a job. Seligman’s learned helplessness research suggests that depression results from a perceived loss of control over significant events. It is as though the person believes “If I do this, it will not matter.” Depression in humans has been related to attributions on three dimensions: internal-external, stable-unstable, and global-specific (Abramson, Seligman, and Teasdale, 1978). With respect to our example, the person is more likely to become depressed if he/she attributes loss of the job to: a personal deficiency such as not being smart (internal) rather than to a downturn in the economy (external); the belief that not being smart is a permanent deficiency (stable) rather than temporary (unstable); and that not being smart will apply to other jobs (global) rather than just the previous one (specific).
Cognitive-behavior therapy for depression would include attempts by the therapist to modify these attributions during therapeutic sessions as well as providing reality-testing exercises as homework assignments. The therapist might challenge the notion that the person is not smart by asking them to recall past job performance successes. They could review the person’s credentials in preparation for a job search. Severe cases of depression might require assignments related to self-care and “small-step” achievements (e.g., making one’s bed, grooming and getting dressed, going out for a walk, etc.). As mentioned previously, homework assignments constitute an essential component of cognitive-behavioral treatment of depression (Jacobson, Dobson, Truax, Addis, Koerner, Gollan, Gortner, & Prince, 1996). Apparently, therapies are effective to the extent that they result in clients experiencing the consequences of their acts under naturalistic circumstances. This finding is consistent with an adaptive learning model of the psychotherapeutic process. That is, therapy is designed to help the individual acquire the necessary skills to cope with their idiosyncratic environmental demands.
Frequently the therapeutic process consists of determining adaptive rules specifying a contingency between a specific behavior and specific consequence. For example, in treating a severely depressed individual, one might start with “If you get out of bed within 30 minutes after the alarm goes off, you can reward yourself with 30 minutes of TV.” This can then be modified to require getting up within 20 minutes, 10 minutes, and 5 minutes. Once this is accomplished, the person may be required to get up and make their bed, get dressed and wash their face, etc. If the person is not severely depressed, it may be sufficient to establish rules such as “After finding appropriate positions in the newspaper and submitting your resume, you can reward yourself with reading your favorite section of the paper.”
Question
emphasizes the complementary connection between basic and applied research and professional practice; bases psychological interventions on findings from the different content areas (e.g., learning, motivation, etc.)
approach to assessment and treatment based on the assumption that psychiatric disorders stemmed from unconscious conflict between impulsive demands of the id and the moral standards of the superego
psychodynamic assessment tools assuming that, due to their ambiguity, they would not activate defense mechanisms, thereby enabling individuals to “project” their unconscious thoughts onto the inkblots or pictures; examples are Rorshach inkblots and the Thematic Apperception Test
instead of considering problematic behavior an illness and providing a DSM diagnosis, behavior itself is considered the target for assessment and treatment
a device consisting of a sensor module attached to a radio transmitter straps onto the head and is used to punish head banging with a mild electric shock to the arm or leg
Ellis' active/directive language-based approach based on the assumption that an individual’s emotional and behavioral reactions result from cognitive interpretation
detrimental emotional and behavioral effects resulting from the inability to affect outcomes
when prior non-contingent reward interferes with learning new behaviors