clinical psychology

1. METHODS OFMETHODS OF
INTERVENTION ANDINTERVENTION AND
CHANGE IN COMMUNITYCHANGE IN COMMUNITY
PSYCHOLOGYPSYCHOLOGY
Lecture 38Lecture 38

2. CONSULTATIONCONSULTATION
What is consultationWhat is consultation?? Orford (1992) offers theOrford (1992) offers the
following definition:following definition:
‘’‘’Consultation is the process whereby anConsultation is the process whereby an
individual (the consultee) who has responsi­individual (the consultee) who has responsi­
bility for providing a service to others (thebility for providing a service to others (the
clients) voluntarily consults another personclients) voluntarily consults another person
(the consultant) who is believed to possess(the consultant) who is believed to possess
some special expertise which will help thesome special expertise which will help the
consultee provide a better service to his orconsultee provide a better service to his or
her clients’’.her clients’’.

3.  The basic advantage of consultation is that itsThe basic advantage of consultation is that its
effects are multiplied like the ripples from aeffects are multiplied like the ripples from a
stone thrown into a pond.stone thrown into a pond.
 Using individual techniques of intervention, theUsing individual techniques of intervention, the
mental health specialist can reach only a verymental health specialist can reach only a very
limited number of clients. But by consulting withlimited number of clients. But by consulting with
other service providers, such as teachers,other service providers, such as teachers,
police, and ministers, he or she can reachpolice, and ministers, he or she can reach
many more clients indirectly.many more clients indirectly.
 Consultation can be viewed from severalConsultation can be viewed from several
orientations:orientations:

4.  First, there is mental health consultation.First, there is mental health consultation.
 It was often practiced in rural orIt was often practiced in rural or
underdeveloped areasunderdeveloped areas
 A second orientation developed out of theA second orientation developed out of the
behavioral tradition. In order to implement thebehavioral tradition. In order to implement the
technology of behavior modification that hadtechnology of behavior modification that had
been so successful in laboratory settings, it wasbeen so successful in laboratory settings, it was
necessary to move into real-life situations. Tonecessary to move into real-life situations. To
do that, people in the patient's environmentdo that, people in the patient's environment
(such as home or school) had to be trained to(such as home or school) had to be trained to
properly dispense reinforcements for theproperly dispense reinforcements for the
desired behavior. Consultation became a waydesired behavior. Consultation became a way
of providing such training.of providing such training.

5.  The third orientation is an organizational oneThe third orientation is an organizational one
that emphasizes consultation to industry.that emphasizes consultation to industry.
Specialists work with management or workSpecialists work with management or work
group leaders to improve morale, jobgroup leaders to improve morale, job
satisfaction, and productivity or to reducesatisfaction, and productivity or to reduce
inefficiency, absenteeism, alcoholism, or otherinefficiency, absenteeism, alcoholism, or other
problems.problems.

6. TYPES OF MENTAL HEALTHTYPES OF MENTAL HEALTH
CONSULTATIONSCONSULTATIONS
Caplan's (1970) classification.Caplan's (1970) classification.
 1.1. Client-centered case consultation.Client-centered case consultation.
 2.2. Consultee-centered case consultationConsultee-centered case consultation..
 33. Program-centered administrative. Program-centered administrative
consultationconsultation..
 4.4. Consultee-centered administrativeConsultee-centered administrative
consultation.consultation.

7. TECHNIQUES AND PHASESTECHNIQUES AND PHASES
 In most cases, the consultation process willIn most cases, the consultation process will
pass through the following phases:pass through the following phases:
 11.. The entry or preparatory phaseThe entry or preparatory phase..
 2. The beginning or warming­up phase2. The beginning or warming­up phase..
 3. The alternative action phase.3. The alternative action phase.
 4.4. Termination.Termination.
 Unfortunately, community mental healthUnfortunately, community mental health
centers have had difficulty providingcenters have had difficulty providing
consultation services, especially to schools andconsultation services, especially to schools and
community agencies;community agencies;
 The budgetary support has just not been there.The budgetary support has just not been there.

8. COMMUNITY ALTERNATIVES TOCOMMUNITY ALTERNATIVES TO
HOSPITALIZATIONHOSPITALIZATION
 Despite the fact that there is a core ofDespite the fact that there is a core of
"undischargeable" patients, there are"undischargeable" patients, there are
alternatives to our current hospital system-alternatives to our current hospital system-
alternatives that will provide environmentsalternatives that will provide environments
geared to the goal of enabling patients togeared to the goal of enabling patients to
resume a responsible place in society.resume a responsible place in society.
 Examples of alternatives include the communityExamples of alternatives include the community
lodge. This is akin to a halfway house wherelodge. This is akin to a halfway house where
formerly chronic, hospitalized patients can learnformerly chronic, hospitalized patients can learn
independent living skills.independent living skills.

9.  The Mendota Program was a pioneeringThe Mendota Program was a pioneering
attempt to help formerly "un-dischargeable"attempt to help formerly "un-dischargeable"
patients find jobs, learn cooking and shoppingpatients find jobs, learn cooking and shopping
skills, and so on.skills, and so on.
 Finally, there is the growing popularity of dayFinally, there is the growing popularity of day
hospitals that are often more effective and lesshospitals that are often more effective and less
expensive than traditional 24-hourexpensive than traditional 24-hour
hospitalization.hospitalization.

10. CRISIS INTERVENTIONCRISIS INTERVENTION
 The basic goal of crisisThe basic goal of crisis intervention isintervention is to reachto reach
people in an acute state of stress and topeople in an acute state of stress and to
provide them with enough support to preventprovide them with enough support to prevent
them from becoming the chronically mentally illthem from becoming the chronically mentally ill
of the futureof the future
 Persons in crisis are often in a uniquelyPersons in crisis are often in a uniquely
"reachable" state that can pave the way for"reachable" state that can pave the way for
future long-term interventions.future long-term interventions.
 Crisis intervention requires the relinquishing ofCrisis intervention requires the relinquishing of
traditional procedures and prerogatives.traditional procedures and prerogatives.
 Finally, crises tend to obliterate customaryFinally, crises tend to obliterate customary
professional roles, pecking orders, andprofessional roles, pecking orders, and
prerogatives.prerogatives.

11.  Crisis intervention requires a versatility andCrisis intervention requires a versatility and
flexibility that are not often found in traditionalflexibility that are not often found in traditional
clinics or hospitals.clinics or hospitals.
 The emphasis is now on 24-hour servicesThe emphasis is now on 24-hour services
staffed by workers who personally take calls.staffed by workers who personally take calls.
 Current interventions emphasize follow-up bothCurrent interventions emphasize follow-up both
to check on the well-being of the client and toto check on the well-being of the client and to
assess the adequacy of the services providedassess the adequacy of the services provided
by the agency to which the client was referred.by the agency to which the client was referred.
 Current intervention procedures alsoCurrent intervention procedures also
encourage face-to-face contact rather than theencourage face-to-face contact rather than the
earlier over reliance on the telephoneearlier over reliance on the telephone

12.  Suicide prevention centers.Suicide prevention centers.
 Development of the Suicide and CrisisDevelopment of the Suicide and Crisis
Intervention Service (SCIS) in Gainesville,Intervention Service (SCIS) in Gainesville,
Florida.Florida.
 The policy of SCIS was simply "to respond toThe policy of SCIS was simply "to respond to
every request to participate in the solution ofevery request to participate in the solution of
any human problem whenever and wherever itany human problem whenever and wherever it
occurs“.occurs“.
 People in crisis were to be given immediate,People in crisis were to be given immediate,
active, and aggressive services.active, and aggressive services.
 SCIS regarded people in crisis as theSCIS regarded people in crisis as the
responsibility of the community and felt that, asresponsibility of the community and felt that, as
citizens, they had a right to expect such acitizens, they had a right to expect such a
community service.community service.

13.  The SCIS-type crisis center is organized withThe SCIS-type crisis center is organized with
the idea of community Control.the idea of community Control.
 Are these interventions really helpful?. MuchAre these interventions really helpful?. Much
depends on the questions asked.depends on the questions asked.
 For example Decker and Stubblebine (1972)For example Decker and Stubblebine (1972)
found that psychiatric hospitalizations werefound that psychiatric hospitalizations were
reduced when crisis intervention proceduresreduced when crisis intervention procedures
were used.were used.

14.  Yet when other researchers compared crisisYet when other researchers compared crisis
patients with patients who had been randomlypatients with patients who had been randomly
assigned to a waiting list, they could find noassigned to a waiting list, they could find no
differences in several indices of psychiatricdifferences in several indices of psychiatric
improvement.improvement.
 Other reports are much more optimistic.Other reports are much more optimistic.
 Not all research shows the efficacy of crisisNot all research shows the efficacy of crisis
intervention.intervention.
 However, others argue that additionalHowever, others argue that additional
preventive measures could well reduce thepreventive measures could well reduce the
number of deaths from suicide.number of deaths from suicide.

15.  Clearly, crisis interventions can help reduce distress.Clearly, crisis interventions can help reduce distress.
 When a school bus collides with a train, the survivorsWhen a school bus collides with a train, the survivors
must be helped to cope.must be helped to cope.
 Public health workers and mental health workers havePublic health workers and mental health workers have
long been aware of the educational disadvantageslong been aware of the educational disadvantages
experienced by the poor.experienced by the poor.
 Of great concern is the fear that early deprivation inOf great concern is the fear that early deprivation in
crucial developmental periods will mark the child forcrucial developmental periods will mark the child for
life.life.
 Impoverished preschool environments andImpoverished preschool environments and
experiences may almost guarantee that the child willexperiences may almost guarantee that the child will
do poorly in school and thus become vulnerable to ado poorly in school and thus become vulnerable to a
wide variety of mental health, legal, and socialwide variety of mental health, legal, and social
problems.problems.
 But if successful preschool interventions can beBut if successful preschool interventions can be
developed, then a truly preventive course of action willdeveloped, then a truly preventive course of action will
have been taken.have been taken.

16. HEAD START PROGRAMSHEAD START PROGRAMS
 The best-known early childhood program isThe best-known early childhood program is HeadHead
Start.Start.
 Head Start was one of the programs targetedHead Start was one of the programs targeted
specifically for disadvantaged children.specifically for disadvantaged children.
 It was designed to prepare preschool children fromIt was designed to prepare preschool children from
disadvantaged back-grounds for elementary school.disadvantaged back-grounds for elementary school.
 Head Start programs are locally controlled butHead Start programs are locally controlled but
required to conform to general federal guidelines.required to conform to general federal guidelines.
 Local programs vary in number of hours ofLocal programs vary in number of hours of
attendance, number of month, background ofattendance, number of month, background of
teachers, and so on.teachers, and so on.
 The specific techniques used also vary, but basicThe specific techniques used also vary, but basic
learning skills are usually stressed.learning skills are usually stressed.
 Physical and medical needs are also addressed, asPhysical and medical needs are also addressed, as
are general school preparation and adjustment.are general school preparation and adjustment.

17. EVALUATION:EVALUATION: --
 It was found useful to distinguish between child-It was found useful to distinguish between child-
focused programs and family-focused programs.focused programs and family-focused programs.
 In the former case, interventions are administeredIn the former case, interventions are administered
directly to the child;directly to the child;
 in the latter case, family members (such as parents)in the latter case, family members (such as parents)
receive the intervention or training.receive the intervention or training.
 Participation in a child-focused program results in anParticipation in a child-focused program results in an
average IQ gain of about 8 points immediately afteraverage IQ gain of about 8 points immediately after
program completion (although these relative gainsprogram completion (although these relative gains
dissipate over time), makes it less likely that the childdissipate over time), makes it less likely that the child
will be placed in special education or retained inwill be placed in special education or retained in
grade, and makes it more likely that the child willgrade, and makes it more likely that the child will
graduate from high school .graduate from high school .

18.  Positive social outcomes resulting fromPositive social outcomes resulting from
program participation have also been reported,program participation have also been reported,
including fewer contacts with the criminalincluding fewer contacts with the criminal
justice system, fewer out-of-wedlock births, andjustice system, fewer out-of-wedlock births, and
higher average earnings than non participants.higher average earnings than non participants.
 Although family-focused programs appear toAlthough family-focused programs appear to
have more impact on parents' behaviors thanhave more impact on parents' behaviors than
do child-focused programs,do child-focused programs,
 It is not clear how much positive impact theyIt is not clear how much positive impact they
have on children.have on children.
 Not only is the focus of the interventionNot only is the focus of the intervention
different, but so is its intensity and frequency. Indifferent, but so is its intensity and frequency. In
the case of family focused interventions,the case of family focused interventions,
services may be rendered only once a weekservices may be rendered only once a week

19. SELF-HELPSELF-HELP
 Not all help comes from professionals.Not all help comes from professionals.
 Informal groups of helpers can provide valuableInformal groups of helpers can provide valuable
support that may stave off the need for professionalsupport that may stave off the need for professional
intervention.intervention.
 What needs do self-help groups meet? Orford (1992)What needs do self-help groups meet? Orford (1992)
discussed eight primary functions of self -help groups:discussed eight primary functions of self -help groups:
 (1) They provide emotional support to members;(1) They provide emotional support to members;
 (2) They provide role models-indi-viduals who have(2) They provide role models-indi-viduals who have
faced and conquered problems that group membersfaced and conquered problems that group members
are dealing with;are dealing with;
 (3) They provide ways of understanding members'(3) They provide ways of understanding members'
problems;problems;

20.  (4) They provide important and relevant(4) They provide important and relevant
information;information;
 (5) They provide new ideas about how to cope(5) They provide new ideas about how to cope
with existing problems;with existing problems;
 (6) They give members the opportunity to help(6) They give members the opportunity to help
other members;other members;
 (7) They provide social companionship; and(7) They provide social companionship; and
 (8) They give members an increased sense of(8) They give members an increased sense of
mastery and control over their problems.mastery and control over their problems.
 Clearly self-help group serve several importantClearly self-help group serve several important
functions for group members. However, researchfunctions for group members. However, research
suggests that professionals should be availablesuggests that professionals should be available
to serve as consultants to these groups in orderto serve as consultants to these groups in order
for the groups to be maximally effective.for the groups to be maximally effective.

21. PARAPROFESSIONALSPARAPROFESSIONALS
 One of the more visible features of the communityOne of the more visible features of the community
movement is its use of laypersons who have receivedmovement is its use of laypersons who have received
no formal clinical training, orno formal clinical training, or paraprofesparaprofessionals, assionals, as
therapists.therapists.
 The use of paraprofessionals in the mental health fieldThe use of paraprofessionals in the mental health field
has been growing, but this trend has generatedhas been growing, but this trend has generated
controversy.controversy.
 In reviewing 42 studies, Durlak (1979) concluded thatIn reviewing 42 studies, Durlak (1979) concluded that
professional education, training, and experience areprofessional education, training, and experience are
not prerequisites for becoming an effective helpingnot prerequisites for becoming an effective helping
person.person.
 However, Nietzel and Fisher (1981) took issue withHowever, Nietzel and Fisher (1981) took issue with
this conclusion and urged caution in interpreting thethis conclusion and urged caution in interpreting the
results of many of the studies reviewed by Durlak.results of many of the studies reviewed by Durlak.

22.  They argued that many of the studies includedThey argued that many of the studies included
in the Durlak review were methodologicallyin the Durlak review were methodologically
flawed, and objected to Durlak's definitions offlawed, and objected to Durlak's definitions of
"professional" and "paraprofessional.""professional" and "paraprofessional."
 Results fromResults from their meta-analysis-concurred withtheir meta-analysis-concurred with
those ofthose of Durlak. The overall results favoredDurlak. The overall results favored
paraprofessionals, especially those who wereparaprofessionals, especially those who were
more experienced and received greatermore experienced and received greater
amounts of training.amounts of training.
 More recent summaries have also argued thatMore recent summaries have also argued that
thethe available evidence suggests thatavailable evidence suggests that
paraprofessionalsparaprofessionals may be as effective as (andmay be as effective as (and
in some cases morein some cases more effective than)effective than)
professionals.professionals.

23.  Besides effectiveness, there is also the issue ofBesides effectiveness, there is also the issue of
access to those who can provide help.access to those who can provide help.
 Like it or not, most individuals who are in need ofLike it or not, most individuals who are in need of
mental health services do not seek out mental healthmental health services do not seek out mental health
professionals. Instead, informal "therapy" takes placeprofessionals. Instead, informal "therapy" takes place
in many contexts and is provided by a variety ofin many contexts and is provided by a variety of
laypersons.laypersons.
 For example, an interesting and provocative set ofFor example, an interesting and provocative set of
studies, Cowen (1982) 'investigated the "helpingstudies, Cowen (1982) 'investigated the "helping
behavior" of hairdressers and bartenders.behavior" of hairdressers and bartenders.
 Many community psychologists view these and otherMany community psychologists view these and other
studies as evidence supporting the idea thatstudies as evidence supporting the idea that
consultation programs might be aimed at laypersonsconsultation programs might be aimed at laypersons
that naturally come into contact with individuals withthat naturally come into contact with individuals with
mental health needs.mental health needs.

24.  Although it hardly seems wise to argue thatAlthough it hardly seems wise to argue that
professionally trained clinical psychologists areprofessionally trained clinical psychologists are
unnecessary, it certainly appears that there is aunnecessary, it certainly appears that there is a
vital role for paraprofessionals in the mentalvital role for paraprofessionals in the mental
health field today.health field today.
 Clinical psychologists are needed, at the veryClinical psychologists are needed, at the very
least, to serve as consultants.least, to serve as consultants.
 Further, research may ultimately indicate thatFurther, research may ultimately indicate that
certain types of mental health problemscertain types of mental health problems
respond better to services provided by a mentalrespond better to services provided by a mental
health professional.health professional.
 To date, however, the research questionsTo date, however, the research questions
addressed (for example, are paraprofessionalsaddressed (for example, are paraprofessionals
effective overall?) have been too broad to shedeffective overall?) have been too broad to shed
light on this issue.

25. THE TRAINING OF COMMUNITYTHE TRAINING OF COMMUNITY
PSYCHOLOGISTSPSYCHOLOGISTS
 Community psychology has yet to develop an adequateCommunity psychology has yet to develop an adequate
or identifiable theoretical frame-work apart from those oor identifiable theoretical frame-work apart from those o
other disciplines.other disciplines.
 This, at times, makes for role confusion. The communityThis, at times, makes for role confusion. The community
psychologist is part sociologist, part political scientist,psychologist is part sociologist, part political scientist,
part psychotherapist, part ombudsman, but lacks apart psychotherapist, part ombudsman, but lacks a
specific identity. This ambiguity makes it difficult tospecific identity. This ambiguity makes it difficult to
design appropriate training programs.design appropriate training programs.
 Fortunately, there are some guidelines for training.Fortunately, there are some guidelines for training.
 The recent IOM report (1994) recommends that futureThe recent IOM report (1994) recommends that future
prevention research specialists should have a solidprevention research specialists should have a solid
background in a relevant discipline (such as nursing,background in a relevant discipline (such as nursing,
sociology, social work, public health, epidemiology,sociology, social work, public health, epidemiology,
medicine, or clinical/community psychology).medicine, or clinical/community psychology).
 Training in the design of interventions and the empiricalTraining in the design of interventions and the empirical
evaluations of interventions is essential.evaluations of interventions is essential.

26.  Finally, practicum or internship-like training inFinally, practicum or internship-like training in
prevention is also recommended.prevention is also recommended.
 Educational requirements for prevention fieldEducational requirements for prevention field
specialists (those that actually carry out thespecialists (those that actually carry out the
interventions) are less stringent.interventions) are less stringent.
 Often, a bachelor's degree in a relevant field (such asOften, a bachelor's degree in a relevant field (such as
psychology) is sufficient.psychology) is sufficient.
 Given the increasing cultural and ethnic diversity in theGiven the increasing cultural and ethnic diversity in the
United States, it is also important for communityUnited States, it is also important for community
psychologists to receive training in how diversitypsychologists to receive training in how diversity
issues may impact their work. For example,issues may impact their work. For example,
knowledge of and sensitivity to cultural and ethnicknowledge of and sensitivity to cultural and ethnic
differences will inform the following activities and rolesdifferences will inform the following activities and roles
of a prevention researcher (IOM, 1994):of a prevention researcher (IOM, 1994):

27.  1. Developing relationships with community1. Developing relationships with community
leaders and organizationsleaders and organizations
 2. Conceptualizing and identifying potential risk2. Conceptualizing and identifying potential risk
factors, mechanisms, and antecedents offactors, mechanisms, and antecedents of
problems or disordersproblems or disorders
 3. Developing interventions that will have3. Developing interventions that will have
maximum effect, and deciding how thesemaximum effect, and deciding how these
should be disseminated and delivered to theshould be disseminated and delivered to the
target populationtarget population
 4. Determining the content and format of4. Determining the content and format of
evaluation instrumentsevaluation instruments