The Handbook of Adult Clinical Psychology
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The Handbook of Adult Clinical Psychology

An Evidence Based Practice Approach

Alan Carr, Muireann McNulty, Alan Carr, Muireann McNulty

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eBook - ePub

The Handbook of Adult Clinical Psychology

An Evidence Based Practice Approach

Alan Carr, Muireann McNulty, Alan Carr, Muireann McNulty

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About This Book

The second edition of the Handbook of Adult Clinical Psychology: An Evidence Based Practice Approach like its predecessor provides clinical psychologists in training with a comprehensive practice handbook to help build the skills necessary to complete a clinical placement in the field of adult mental health. While practical in orientation, the book is based solidly on empirical evidence.Building on the success of the previous edition this handbook has been extensively revised in a number of ways. Throughout the book, the text, references, and website addresses and have been updated to reflect important developments since the publication the first edition. Recent research findings on the epidemiology, aetiology, course, outcome, assessment and treatment of all psychological problems considered in this volume have been incorporated into the text. Account has been taken of changes in the diagnosis and classification of psychological problems reflected in the DSM-5. Chapters on ADHD in adults, emotion focused therapy, radically open dialectical behaviour therapy, and schema therapy have been added.

The book is divided into 6 sections:

Section 1 covers conceptual frameworks for practice (lifespan development; classification and epidemiology; CBT, psychodynamic, emotion focused, systemic and bio-medical models; and general assessment procedures)

Section 2 deals with mood problems (depression, bipolar disorder, suicide risk, and anger management)

Section 3 focuses on anxiety problems (social phobia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, post-traumatic stress disorder and depersonalization disorder)

Section 4 deals with psychological problems linked to physical health (health anxiety, somatization, chronic pain, adjustment to cancer, and eating disorders)

Section 5 focuses on other significant psychological problems that come to the attention of clinical psychologist in adult mental health services (ADHD in adults, alcohol and other drug problems, psychosis, and psychological problems in older adults)

Section 6 contains chapters on therapeutic approaches to psychological distress related to complex childhood trauma (dialectical behaviour therapy for borderline personality disorder, racially open dialectical behaviour for over-controlled presentations, and schema therapy).

Each of the chapters on clinical problems explains how to assess and treat the condition in an evidence-based way with reference to case material. Interventions from cognitive-behavioural, psychodynamic, interpersonal/systemic and biomedical approaches are described, where there is evidence that they are effective for the problem in question. Skill building exercises and further reading for psychologists and patients are included at the end of each chapter.

This book is one of a set of three volumes which cover the lion's share of the curriculum for clinical psychologists in training in the UK and Ireland. The other two volumes are the Handbook of Child and Adolescent Clinical Psychology, Third Edition (by Alan Carr) and the Handbook of Intellectual Disability and Clinical Psychology Practice, Second Edition edited by Alan Carr, Christine Linehan, Gary O'Reilly, Patricia Noonan Walsh, & John McEvoy).

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Section 1

Conceptual frameworks

Chapter 1

Normal psychological development in adulthood

Alan Carr and Muireann McNulty
When adults develop psychological problems, such as depression, anxiety or other difficulties described later in this book, these problems do not occur in a vacuum. They occur within the context of the family lifecycle. Challenges within the lifecycle may contribute to the development of psychological problems and such difficulties may also compromise the capacity to complete important developmental tasks. It is for this reason that the approach to the practice of adult clinical psychology outlined in this volume begins with a consideration of the normal family lifecycle.

Family lifecycle

Most models of the family lifecycle are based upon the norm of the traditional nuclear family with other family forms being conceptualized as deviations from this norm (McGoldrick et al., 2011). One such model is presented in Table 1.1. This model delineates the main tasks to be completed by the family at each stage of development. After considering this model in some detail, other lifecycle models associated with separation and divorce, living a single life, and gay and lesbian sexual orientation will also be considered.

Leaving home

In the first stage of family development, which is marked by young adult children leaving home and developing emotional and financial autonomy, the principal tasks are differentiating from the family of origin, developing an adult-to-adult relationship with parents, developing intimate peer relationships, beginning a career and moving towards financial independence, and establishing the self in community and society.

Forming a couple

The second stage is that of couple formation, where the main process is commitment to a long-term relationship. The principal tasks include selecting a partner and deciding to form a long-term relationship, developing a way to live together based on an appreciation of partners’ real strengths and weaknesses rather than mutual projection, and realigning couple’s relationships with families of origin and peers so as to accommodate partners.
Adams (1986) views mate selection as a complex process that involves four stages. In the first phase partners are selected from among those available for interaction. At this stage people select mates who are physically attractive and similar to themselves in interests, intelligence, personality and other valued behaviours and attributes. In the second phase there is a comparison of values following revelation of identities through self-disclosing conversations. If this leads to a deepening of the original attraction then the relationship will persist. In the third phase, there is an exploration of role compatibility and the degree to which mutual empathy is possible. Once interlocking roles and mutual empathy have developed, the costs of separation begin to outweigh the difficulties and tensions associated with staying together. If the attraction has deepened sufficiently and the barriers to separation are strong enough, consolidation of the relationship occurs. In the fourth and final phase a decision is made about long-term compatibility and commitment. If a positive decision is reached about both of these issues, then marriage or long-term cohabitation may occur. When partners come together they are effectively bringing two family traditions together and setting the stage for the integration of these traditions with their norms and values, rules, roles and routines into a new tradition.
Table 1.1 Stages of the family lifecycle
Stage Emotional transition processes Tasks essential for developmental progression
Leaving home
Developing emotional and financial autonomy
Differentiating from family of origin and developing adult-to-adult relationship with parents
Developing intimate peer relationships
Beginning a career and moving towards financial independence
Establishing the self in community and society
Forming a couple
Committing to a long-term relationship
Selecting a partner and deciding to form a long-term relationship
Developing a way to live together based on reality rather than mutual projection
Realigning couple’s relationships with families of origin and peers to include partners
Families with young children
Accepting new children into the family system
Adjusting couple system to make space for children
Arranging child-rearing, financial and housekeeping responsibilities within the couple
Realigning relationships with families of origin to include parenting and grandparenting roles
Realigning family relationships with community and society to accommodate new family structure
Families with adolescents
Increasing flexibility of family boundaries to accommodate adolescents’ growing independence and grandparents’ increasing constraints
Adjusting parent–child relationships to allow adolescents more autonomy
Adjusting family relationships as couple takes on responsibility of caring for aging parents
Realigning family relationships with community and society to accommodate adolescents’ increasing autonomy and grandparents’ increasing constraints
Launching children and moving into midlife
Accepting many exits from and entries into the family system
Adjusting to living as a couple again
Addressing couple’s midlife issues and possibilities of new interests and projects
Negotiating adult-to-adult relationships between parents and grown children
Adjusting to include in-laws and grandchildren within the family circle
Dealing with disabilities and death of couple’s aging parents
Realigning family relationships with community and society to accommodate new family structure and relationships
Families with parents in late middle age
Accepting new generational roles
Maintaining couple’s functioning and interests, and exploring new family and social roles while coping with physiological decline
Adjusting to children taking a more central role in family maintenance
Making room for the wisdom and experience of the aging couple
Supporting the older generation to live as independently as possible within the constraints of aging
Realigning family relationships with community and society to accommodate new family structure and relationships
Families with parents nearing the end of life
Accepting the constraints of aging and the reality of death
Dealing with loss of partner, siblings and peers
Preparing for death through life review and integration
Adjusting to reversal of roles where children care for parents
Realigning family relationships with community and society to accommodate changing family relationships
Note: Adapted from McGoldrick et al. (2011).
Couple formation and marriage entail the development of a series of important relationships: the marital relationship, kinship relationships and later parent–child relationships, all of which have the potential to contribute to happiness and well-being (Carr, 2011). Marriage and psychological adjustment are intimately linked (Carr, 2012). Psychological disorders can both cause marital conflict, and such conflict can contribute to the aetiology and maintenance of psychological difficulties.

Marital satisfaction

The following demographic factors are associated with marital satisfaction (Conger et al., 2010; Fincham & Beach, 2010; Gottman & Notarius, 2002; Newman & Newman, 2015):
  • High level of education
  • High socio-economic status
  • Similarity of spouses’ interests, intelligence and personality
  • Early or late stage of family lifecycle
  • Sexual compatibility
  • For women, later marriage.
The precise mechanisms linking these factors to marital satisfaction are not fully understood. However, the following speculations seem plausible. Higher educational level and higher socio-economic status probably lead to greater marital satisfaction because where these factors are present people probably have better problem-solving skills and fewer chronic life stresses such as crowding. Although there is a cultural belief that opposites attract, the research results show that similarity is associated with marital satisfaction, probably because of the greater ease with which similar people can empathize with each other and pursue shared interests. Marital satisfaction drops during the child-rearing years and satisfaction is highest before children are born and when they leave home. During these periods, it may be that greater satisfaction occurs because partners can devote more time and energy to joint pursuits and there are fewer opportunities for conflict involving child management. Most surveys find wide variability in the frequency with which couples engage in sexual activity but confirm that it is sexual compatibility rather than frequency of sexual activity that is associated with marital satisfaction.

Marital interaction

Studies of belief systems and interaction patterns of well-adjusted couples show that they have distinctive features (Casey et al., 2010; Fincham et al., 2007; Gottman & Notarius, 2002; Gurman, 2008; Ozer & Benet-Martínez, 2006). These include:
  • Respect
  • Acceptance
  • Commitment
  • Spirituality
  • Dispositional attributions for positive behaviour
  • More positive than negative interactions
  • Focusing conflicts on specific issues
  • Rapidly repairing relationship ruptures and forgiving transgressions
  • Managing differing male and female conversational styles
  • Addressing needs for intimacy and power
  • Emotional intelligence, emotional stability and agreeableness.
Happy couples tend to attribute their partners’ positive behaviours to dispositional rather than situational factors. For example, ‘She helped me because she is such a kind person,’ not ‘She helped me because it was convenient at the time.’ The ratio of positive to negative exchanges has been found to be about 5:1 in happy couples (Gottman, 1993). So even though happy couples have disagreements, this is balanced out by five times as many positive interactions. When happy couples disagree, they focus their disagreement on a specific issue rather than globally criticizing or insulting their partner. This type of behaviour is a reflection of a general attitude of respect which characterizes happy couples. Happy couples tend to rapidly repair their relationship ruptures arising from conflict. Where transgressions occur and one partner is hurt, there is a willingness to forgive, and to prevent long episodes of non-communication, sulking or stonewalling to occur (Fincham et al., 2007). Sometimes happy couples resolve conflicts by agreeing to differ. The specific process of agreeing to differ reflects a general attitude of acceptance. There is good evidence that men and women have different conversational styles, and these differences are probably determined more by social than biological factors (Cameron, 2010). Men use conversation predominantly to convey task-focused information and to resolve task-related problems. Women use conversation predominantly to make and maintain relationships. In their communication with each other, happy couples find ways to manage these differing conversational styles so that psychological intimacy may be fostered rather than compromised. So males in such relationships make efforts to use conversation to make and maintain their relationship with their partner and females are tolerant of the challenge that this poses. Difficulties and disagreements about communication and intimacy on the one hand, and the power balance or role structure of the relationship on the other, are central themes for distressed couples (Gurman, 2008). With respect to intimacy, usually males demand greater psychological distance and females insist on greater psychological intimacy. With respect to power, males commonly wish to retain the power and benefits of traditional gender roles while females wish to evolve more egalitarian relationships. In happy coup...

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