AMA About Clinical Psychology (and RPGs!)

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Re: AMA About Clinical Psychology (and RPGs!)

Postby Magmoo » Mon Oct 27, 2014 6:33 pm

What are the methods and standards for determining if some one is competent to stand trial or to commit them against their will? Also what are the short term and long term implications of such events.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Infrared » Tue Oct 28, 2014 10:03 am

Thanks a lot! Informative indeed!
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Burning » Tue Oct 28, 2014 11:40 am

In your intro you list some conditions you've worked with. Could you describe what these conditions are?
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Citizen Joe » Tue Oct 28, 2014 11:40 am

How qualified are psychologists to make assessments outside of their own social structure? How granular does that social structure need to be to draw that line?

Examples: Can Americans really assess Japanese (or more coz-worthy, middle eastern descent)? What about assessing police or soldiers? Do you need to serve in order to get proper perspective?

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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Oct 29, 2014 5:20 pm

Alright! Round 2 (maybe 3? 2.5?) of questions going forward now! Let’s do this thing! It’s on like Carl Jung.

What are the methods and standards for determining if someone is competent to stand trial or to commit them against their will? Also what are the short term and long term implications of such events.
So here’s an interesting thing, if someone isn’t competent to stand trial they plead an Insanity defense, right? Well, Insanity isn’t something that is defined by psychology, it is defined by lawyers! So if a psychologist on the stand is ever asked ‘Is the defendant insane?’ they ought to respond with a denial that they can answer that question. Indeed, psychologists don’t determine if someone is competent to stand trial, they only appear as expert witnesses.
That said, they are called in pretty much any time someone attempts to run a Not Guilty by Reason of Insanity plea. Generally psychologists are called in and asked (by one or both sides) to do a whole battery of personality assessments. These will likely include the MMPI, possibly the Hare Scale, and will ideally involve some structured interviewing. They also may do a risk assessment, but that’s more often used AFTER someone is or isn’t in prison. In any case, they will gather information and then basically go into court to give a diagnosis. What the lawyer is looking for is deniability which could be gained through schizophrenia, fugue states, dissociative identity disorder (which honestly likely deserves a post of itself, but I’ll hold off for now), or advanced levels of psychosis coming along with some other disorder. I’ve heard of an Autism diagnosis being attempted, but it got thrown out so hard the lawyer bounced.
Honestly, insanity pleas are really hard to get to succeed and come with a whole host of risks. One of these is that people can’t be held in prison forever, but they /can/ be held in mental health institutions. There was a case back in the 80s of a man who had been incarcerated for sexually abusing children. While he was in prison, he talked about how he was going to do it again as soon as he got out. Well, he got out, sexually abused a child and killed him, and the US society swung back against this. A law was enacted that allowed extension of involuntary commitment if the patient was believed to be a serious risk to themselves or others. What this means is that it is possible for hospitals to keep people in a hospital essentially forever, though there are some things in place to hopefully prevent this from happening. It was a major problem during the 90s, but appears to be slowly improving with extension of patients rights.

Involuntary Commitment
This is a really complicated issue, but I’ll try my very best to cover it as best as I can without writing for pages and pages.
Involuntary commitment is generally reserved for people who need intensive treatment for one reason or another. This is most often because the patient is a danger to themselves or others. There are two major ways in which this risk is assessed. The first is the kind of obvious one; people who have attempted suicide, engaged in highly risky behavior that went poorly for them (injured with violent behavior, para-suicidal behavior), or people who are being brought in from the justice system. The other risk assessment method tends to use structured interviews and a combination of past history and current statements to make as objective a judgment as possible whether someone is indeed at risk. Additionally, the school, work, or family members of the person may have more or less brought them in for assessment and commitment. Again, risk is the big factor, though immediate violent behavior can enough. While I was working with in-patient children the most common pathway had been the school demanding that the child be brought in for treatment. People also check themselves into treatment for a variety of reasons and honestly, there are some disorders that are nearly impossible to manage with just a single hour of out-patient treatment a week. There is also a slice of the population that is in for medical adjustments after a previous in-patient experience.
Where it gets complicated is that depending upon the state, the previous diagnoses of the patient, and sometimes how much money the family has kicking around, there isn’t a lot of consistency in who can get treatment and for how long. Insurance companies only want people to be hospitalized for the very shortest they can be before being reintroduced to society. A fair amount of people actually even have trouble /getting/ hospitalized because the insurance companies don’t feel they are severe enough to warrant it. If they do get in, they may get bounced at the first sign of any improvement rather than once they have gained the skills they need to thrive.
Although I saw more problems with people being kicked out of hospitals than being let in, I am aware of several cases in which a jilted ex-lover has managed to get someone institutionalized by claiming that threats were made. In these cases, the hospitalized person doesn’t tend to have a very long stay; anyone can check themselves out with 72 hour notice, barring the agreement and filing of two doctors saying that they are a risk to themselves or others. Sometimes these cases even go to court if the hospital and doctors feel strongly that the person is in very real risk.
The implications of being put in an inpatient hospital are a somewhat mixed bag. On the one hand, in-patient treatment allows intensive work to be done over the course of several weeks in a safer environment. This allows for much larger amounts of skill building than is usually possible with standard once-a-week treatment; For every 1 hour that someone who is not hospitalized spends working with their therapist, there are another 167 hours in the week! This also can allow for work with planning to use coping skills when reintroduced to the stressors of life. And, as stated, there are elements of psychological treatment that are really gratifying!
On the other hand, some in-patient treatment settings can be scary places. Different hospitals specialize in different disorders and level of dysfunction which means they can have very different feels. One hospital that I worked at was an immediate suicide response hospital; the patients there were almost never violent towards others and (apart from often times being on strong medications) generally didn’t seem dissimilar in casual interaction from someone you may meet on the street. Another I worked at had a more severe population and violence (against staff, other patients, and self) had to be stopped often. This could get really disturbing, especially for someone who already is dealing with trauma! The work of the mental health workers at a hospital is frequently trying to keep things therapeutic.
Another interesting story from back in the day! A prominent researcher in psychopaths back in… I want to say the 80s checked himself into a psychiatric hospital. He faked being a psychopath (now more DSM-proper as antisocial personality disorder) for the assessment and then began acting like his normal self. Frighteningly enough, he couldn’t get out of the hospital for a couple of months!
In your intro you list some conditions you've worked with. Could you describe what these conditions are?
Absolutely!
Autism Spectrum Disorder is probably pretty familiar to people. That said, there are a whole bunch of misunderstandings about what exactly ASD is. Autism is, perhaps duh given how I’m writing this, viewed as a spectrum. People can demonstrate with a variety of different symptoms to a variety of different severities. In part because of this, it is really poorly understood by a lot of people. (Aspergers also complicates things, but I’ll get to that when I’m done with ASD) Autism is a developmental disorder that tends to become obvious anywhere from about 2-5 years of age. It is marked by slower developing (or rewinding of) language abilities, an apparent blankness of emotion (or inappropriate emotions), difficulty with understanding social cues, less interest in people than other young children, and obsessive interest in some topic (often mechanically or mathematically based). Something like 4 or 5 times as many boys are diagnosed with Autism than girls, though a lot of researchers and clinicians believe this is because women’s tendency for improved social skills over men allows them to slip under the radar. There’s some kind of cool stuff with autistic transgendered people and the Radical Male Brain Theory of Autism, but that’s probably out of the scope of this question at least.
Asperger’s Disorder: Alright, so I should note first of all that according to the DSM-V (the latest of the Diagnostic and Statistical Manuals most often used in the United States) Asperger’s Disorder no longer exists. It now is wrapped up in with ASD and generally viewed as high functioning autism. I’ve got some major issues with this, because there are high functioning autistics who are very different from people with Asperger’s, and because there are low functioning people with Asperger’s. Not only that, quite a few people who have been diagnosed with Asperger’s are horrified to receive the ‘worse’ diagnosis of ASD. Moving on to what Asperger’s is. Dr. Asperger identified children that he described as ‘tiny professors’ and this is really a great image to picture. While people with ASD frequently have slowed language development, people with Asperger’s tend to instead have really pedantic and odd speech. It also can have a lack of understanding of social cues, less interest in people, and obsessive interest, but interactions are rather different. Frequently people with Asperger’s are actually quite good at language and many have a biting or amusing wit. That said, Asperger’s is probably the most erroneously claimed disorder (YOU CAN’T JUDGE ME I HAVE UNDIAGNOSED ASPERGERS) because it has some appeal to people who don’t have it (though needless to say, it’s not as badass as Benedict Cumberbatch’s Sherlock’s of High Functioning Sociopath. Actually, Sherlock Holmes? Asperger’s.)
Selective Mutism: Selective Mutism is pretty much exactly what it sounds like. A child (I’ve worked a lot with kids) around preschool or Kindergarten age will simply not talk outside of certain contexts. Usually the child will speak at home, but not at school or in public. This is most common in boys (working with hospitalized kids is practically working with only boys) who come from a non-English speaking family and have high levels of social anxiety. In the US, this is especially common in Hispanic families; the cultural tendency for Hispanics to want to maintain Latino culture in the home tends to encourage first generation immigrants to not talk much English at home. These high anxiety kids do tend to come out of it by 2nd or 3rd grade, but therapy can help. I actually just yesterday heard of the oldest Selective Mute a friend of mine worked with who was 18 freaking years old. He hadn’t said a word in school. Ever.
Generalized Anxiety Disorder: Anxiety Disorders are really common. Like really, really common. Stupidly common. I can talk about treatment for them another time if people are interested (and maybe give some skills work or meditations people could play with!) but I’m going to keep this kind of short because it’s just an overview. More likely in women than in men, tends to follow a path of Separation Anxiety->Social Anxiety->GAD->Panic Disorder though it can be stopped (or simply stop developing) at any level of it. Treatment can often be done outpatient, CBT or ACT seem to be the most efficacious treatments. It’s so common that I’d bet 20 bucks that someone in this thread has clinically significant anxiety. It may also be better conceptualized as a rumination disorder, as it is in many ways REALLY similar to Depression which is also highly ruminative. Can talk more about that if people have specific interest in anxiety!
Borderline Personality Disorder: This is a really hard disorder to have or to treat. Many (I’m tempted to write most) therapists will refer people who come in and appear to have Borderline. I’ve heard this described as being ‘Borderline Psychotic,’ though that terminology tends to be used rather quietly. People with Borderline tend to be highly impulsive, very emotional, and clingy in a really destructive way. They form relationships that they are highly dependent upon; this person (sometimes including the therapist) means EVERYTHING to them and if they get even a hint of being abandoned, they react strongly. People with Borderline frequently get involved in abusive relationships in part because of this, are highly likely to be suicidal (or parasuicidal), and get involved in a lot of bad stuff (drugs, violence, etc). They are frequently mistaken for people with Bipolar (which I’ll bring up in a second!), but the key differences to look for are people with BPD cycle between moods faster, they are highly reactive to their environments, and their mood swings are more specific rather than simply ‘up’ and ‘down.’ The big treatment for BPD is Dialectical Behavior Therapy which was developed by Marsha Linehan and I’ll likely end up talking about at some point because I really, really like it.
Bipolar Personality Disorder: Again, this one is claimed ALL the time by people who don’t actually have it. The main reason that it is so popular for people to say they have is that pretty much everybody has times when they are happy and times when they are unhappy. This is a big simplification of what bipolar is. Formerly manic-depressive disorder, people cycle through times of extreme mania and depression (hence the old name). These cycles have little to do with life events and can happen unexpectedly. Cycles happen at different speeds, but tend not to go super quickly (one could be manic or depressed for days-weeks). In a manic state, people often can sleep as little as less than 3 hours a night and still be energetic, though obviously while they are in a downswing they act like they have depression.
I have some others as well, but those are probably the big categories I’ve worked with! I’d be happy to talk other disorders as well if anyone has interest in specific ones!
Worth noting: Psychologists don’t treat disorders in the same way that medical doctors treat illnesses. It is very important in psychological treatment to remember that you are treating a person who has been (sometimes in a slightly arbitrary way) given a diagnosis that attempts to describe their behavior. People can qualify for more than one psychological disorder, can have behavior outside of their disorders, and individual differences that should be kept in mind for most appropriate treatment.

How qualified are psychologists to make assessments outside of their own social structure? How granular does that social structure need to be to draw that line?

Examples: Can Americans really assess Japanese (or more coz-worthy, middle eastern descent)? What about assessing police or soldiers? Do you need to serve in order to get proper perspective?

One of these days, I’ll be able to give a short response to something rather than spamming everyone with paragraphs at a time. Today is not that day.
Cultural factors are something that psychologists and other therapists should be keeping in mind when they do assessments, treatment, etc. Treatments I’ll make a quick aside on, you may not want to be super cavalier about sex with an exceptionally Orthodox religious couple who is having marital issues. Similar sorts of things apply to any group that the therapist/assessor is not a part of.
But in a bigger picture sort of way, psychologists should be considering social factors in addition to biological, emotional, cognitive, and behavioral ones. Ignoring culture is ignoring a large part of someone’s background and personality and can prevent getting a full picture. The question as to whether psychologists can even assess people from different cultures actually brings up a couple of interesting points.
Cultures Differ in Rates of Disorders: Before Sybil became common knowledge in America, there were very few people complaining of multiple-personality disorder. Afterwards, rates spiked hard and have slowly been decreasing since then as the media has portrayed more characters questioning whether multiple-personality disorder exists. That may seem like a silly example, but there’s a worse one. After the Truman Show came out, Truman Disorder suddenly became a complaint; people legitimately believed that they were in a Truman Show-esque situation of secretly having their life be a reality TV show. This actually happened and is just the effect of two movies. Consider how much difference there is when an entire culture is different. This can be partially public perception, but likely also has to do with what a culture values; perhaps someone with a Type-A Go-Get’em On-The-Rise personality in America would be viewed as an out of control manic in a more demure culture.
Some Entire Cultures Qualify For Disorders Here: Now, this may seem like a really culturally unaware statement. I’m not saying that everyone in a certain culture /has/ a psychologist disorder. I’m saying that what Americans view as a psychological disorder may be a highly normalized thing in other cultures. Going a little into the realm of anthropology, consider the example of hermaphrodites. While hermaphrodites were viewed with very negative feelings by much of European culture, they were venerated in other parts of the world.
So can someone assess someone outside of their cultural group? Maybe. Certain things are more similar regardless of culture, pretty much everyone agrees that depression is depression.
This can get even more complicated when you consider social-groups and subcultures like police or military. Hell, this could be expanded to gangs, organized crime, the LGBTQ community, first-responders, doctors, psychologists, teachers, or any other group that has a core set of values or ideas that differ from the greater society. Everyone is secretly a member of multiple subcultures (surprise!) and these sub-cultures matter. Often member of the LGBTQ community specifically see psychologists who themselves are members of the LGBTQ community. Police and military often /do/ feel uncomfortable talking about feelings with someone who doesn’t understand, leading psychologists who work with this population to take slightly different techniques. I had a professor who mostly worked with bikers and had to deal with the fact that these rough riders had different views of sexuality and gender roles than the greater culture.
Does this mean that someone can’t treat someone from a different sub-culture? I would say not necessarily. This has two main elements; how well the psychologist can convince the patient to accept them and how willing the patient is to accept them. You may note that these are things that are necessary for the therapeutic environment anyway!
So to sum up:
Culture can be very important. It is an important part of people’s lives and to ignore it is naive and ineffective. Culture is also fluid and multi-layered, two people from different countries but the same SES and career may have more in common than a homeless man and Donald Trump living in the same country. It is important to remember (as I mentioned up above with diagnoses!) that a psychologist doesn’t treat a disorder. A psychologist treats a person who is a part of a culture, a family, a lifestyle, etc, with their own individual problems that don’t necessarily fit into a cookie-cutter solution.

There we go! Caught up! More questions?
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Citizen Joe » Wed Oct 29, 2014 6:32 pm

This was probably asked, or should have been. What's the difference between a psychologist and a psychiatrist?

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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Oct 29, 2014 7:01 pm

This was probably asked, or should have been. What's the difference between a psychologist and a psychiatrist?

Ooo, that's a big one I get asked a lot in real life!

In order to be a psychologist, you have to get a Ph.D (Doctorate in Philosophy) while to be a psychiatrist, you need to have an M.D. (Doctorate in Medicine). These both take an enormous amount of time, needless to say, above and beyond a B.A. They also both require some kind of practical component, I know I've got internship, externship, and a dissertation while psychiatrists have residency and such like any other medical doctor.

In most states in the US, psychiatrists can prescribe medication and psychologists can't. There's been some movement in certain states towards allowing psychologists to prescribe as well, though this is somewhat controversial. Additionally, primary care physicians can prescribe psychiatric medication, so some people avoid needing to see a psychiatrist by going to their primary care doctor for any medication they may need.

The training received by these two groups is needless to say different. Given that psychiatrists spend more time on medication and things like that, they tend to know more about that side of things. That said, psychologists spend just as much time in school, so we learn other things! In general psychologists tend to get more training in assessment and treatment than psychiatrists do.

This also changes what the day to day work of psychologists and psychiatrists tend to be. While there are many psychiatrists who do therapy, it isn’t exceptionally uncommon for psychiatrists to see their individual patients for significantly less time and to really be focused in on medication. People tend to see a psychiatrist less often than a psychologist (if they see both), sometimes just for 15 minutes every month or so to check in that medication isn’t having bad side-effects/is still working. Conversely most people seeing a psychologist see them once a week for 45 minutes or so during which time the psychologists is providing 45 minutes of therapy.

This isn’t to say, of course, that psychiatrists never do therapy, many of them do! But they also tend to be more expensive to see when they do therapy. There is a perception among many psychologists that psychiatrists are just pill pushers, but I think that’s a simplification that just points at the worst psychiatrists.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby lostclause » Wed Oct 29, 2014 9:37 pm

To follow on from the previous question, what is your relationship like with psychiatrists? Do particular psychiatrists refer patients to you/your practice? What makes a psychiatrist good/bad to work with? How do you mediate disagreements in management or raise concerns with them?

I'm really not helping you avoid the wall of texts answers here. :lol:

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Re: AMA About Clinical Psychology (and RPGs!)

Postby Peetiedog » Thu Oct 30, 2014 12:31 am

Ok I have a question with a qualifier first...

I work in legal aid for seniors (60+). Numerous clients I represent have perceptions and behaviors that are counter productive to protecting their rights. The client's own behaviors make it difficult (or impossible) to protect the client's rights. This can denial of their actions, paranoia, or acting out against perceived threats (or maybe they do need to break into the managers car to remove the government speaker influences turning the manager against the client). The client realy needs a social worker or mental health help, but emphatically deny that they have mental health challenges.

How can I or others best suggest mental health professionals to someone who needs the help, but they are in denial? Any strategies would help my clients.

Thanks in advance.

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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Thu Oct 30, 2014 11:53 am

To follow on from the previous question, what is your relationship like with psychiatrists? Do particular psychiatrists refer patients to you/your practice? What makes a psychiatrist good/bad to work with? How do you mediate disagreements in management or raise concerns with them?

I'm really not helping you avoid the wall of texts answers here.


I don’t mind writing wall of text answers, I just don’t want to bore people with ridiculously long responses!

I’ve had quite a few different kinds of relationships with psychiatrists over the years. Most of this has to do with which treatment center I was actively involved with at the time. I’ll try to give some good brush-strokes for my experience though!

Psychiatrists tend to be higher ranked in hospital and treatment centers than psychologists. I think this has something to do with there needing to be fewer of them compared to psychologists; a single psychiatrist who is really focused upon medication can see three times as many patients in an hour as a psychologist tends to. This is ignoring the fact that psychiatrists sometimes see patients even less than once a week, I was just speaking to someone who had been getting their medication from a psychiatrist and saw them for 15 minutes (or less) every six months. This potential elevated status can go well or poorly; psychiatrists that recognize that they are experts in different things that psychologists can be REALLY helpful, while those who think they are all-around more qualified tend to be jackasses who get in the way of treatment.

In my own experience, I’ve worked with a couple of really good psychiatrists and a whole slew of pill-pushers. This is obviously purely my own experience and purely my own feelings, but I’ve seen way more bad than good. The psychiatrists that I’ve worked with generally have been old, out of touch, and convinced that pills do the core of the work. They’ve also mostly kind of been pricks, but that’s a bit of an aside. The good ones were people that truly believed in the interaction of medication and treatment and I can’t understate how fantastic they were because of that.

I specifically am currently working out of a University, so we don’t get a whole lot of referrals that way. My understanding is that it’s more common for psychologists to refer to psychiatrists, it’s relatively rare for people be seeing a psychiatrist before seeing a psychologist.

There are two main ways I’ve seen of mediating difference between psychologists and psychiatrists. One of them, dependent fully upon a good milieu of treatment with a treatment team that actually works together, is to sit down and discuss. People in mental health are trained in all kinds of mediation, discussion, etc. so often these things can go pretty well! Honestly, if both parties are coming in good faith, you can make good progress! The other option is when the person “in charge” is being truly unreasonable. I’ve seen this a decent amount from high-ranking psychiatrists who are really out of touch with things involved in the therapeutic field. (“We need to do more Rorschach's!” “Eh, he doesn’t need to be in a group AND individual therapy.” “Let’s just discharge her. It’s not like she’s getting better.”) In this case, the best path I’ve seen is the Screw That Guy, I’m Doing It Anyway. Most of the time, the problem is coming up that the person in charge wants to lower the amount of treatment, and frankly I’m a big believer in doing more to help the patient.

Peetiedog, I'm working on your response! I'm trying to be all thoughtful and helpful on it, so I don't want to just jump in with my random thoughts. But I'll post back soon! Your question is definitely the next one!
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