The clinical psychologist as program consultant: When is enough enough?

One of the most influential roles clinical psychologists play in health care settings is as consultant to medical colleagues. The psychologist consultant typically approaches either clinical or programmatic questions intending to tap both empirical research and clinical judgment perspectives in trying to answer them. This paper describes a specific “program consultation case,” a not atypical consultation situation in which graduate medical education directors asked for advice about their residency training program. The purpose is to use this example to generate ideas and provoke discussion about such consultation processes and their usefulness in the health care training and service delivery world. The psychologist may be faced with questions that have meaningful implications beyond the specific consultation. What if the concerns being posed by this particular program are concerns which have been raised before, have been researched before, and have generated reasonable suggestions, conclusions, and strategies for improvement? And what if no one has paid attention, so that the questions are being raised again? When empirical and clinical data consistently combine to identify problems within health-related training or service delivery systems, and when suggestions or alternatives for their solutions have been presented and, also presumably, ignored, what does the clinical psychologist consultant do next?     

When is enough enough? We are only beginning

Sheridan (1995) presents the problem of the psychologist consulting to a medical residency program as an example of the difficulty one experiences in attempting to challenge, even from a data-based perspective, the calcification inherent in health systems and medical education in particular. This paper responds to her challenging questions, “How much should we get involved in changing health care and medical education, and at what level (local, national) should psychology intervene (if at all)?” It is suggested that psychologists pick up the challenge to bring about change, whenever possible, with the admonition—we are only beginning.     

Auditory comprehension: is multiple choice really good enough?

Auditory comprehension is commonly measured with multiple choice tasks. The sensitivity of these tasks in identifying deficits, however, is limited by credit given for correct guesses by forced choice. In this study, we compare performance on the multiple choice task to an alternative word/picture verification task, in 122 subjects with acute left hemisphere stroke. As predicted, word/picture verification identifies significantly more subjects with deficits in auditory comprehension. Furthermore, the pattern of errors in the two tasks is consistent with a current distributed model of semantic memory, and inconsistent with alternative local models.     

Children and the Test of Memory Malingering: Is one trial enough?

There is a growing body of research suggesting that the first trial of the TOMM may provide an accurate screener of effort in children. During neuropsychological assessments, some circumstances result in only one completed trial of the TOMM. Research on adults reflects that passing scores on Trial 1 (based on Trial 2 cutoff) are highly predictive of passing scores on Trial 2 and the TOMM overall. Pediatric research found that 100% of children and adolescents who passed Trial 1 of the TOMM also passed Trial 2. Our research hypothesis is that children who pass Trial 1 will also pass Trial 2. Data from 75 clinically diagnosed children (ages 6–18 years) found that 64% performed above the published adult TOMM cutoff on Trial 1. All children who passed Trial 1 also passed Trial 2 suggesting support for the research hypothesis. Sensitivity was 1.0, specificity was 0.72, positive predictive value was .33, and negative predictive value was 1.0. These findings suggest that in this sample, the children who performed above the Trial 2 cutoff on Trial 1 also all passed Trial 2 (so there were no false negatives, thus a perfect sensitivity and negative predictive value). Of the 36% of children who did not pass the Trial 1 cutoff, 67% passed on Trial 2. Data clearly support that children passing Trial 1 have a high likelihood of passing Trial 2, thus drawing conclusions about performance validity after passing Trial 1. Conclusions after failing Trial 1 require further investigation.     

Inhibition in aging: What is preserved? What declines? A meta-analysis

Aging has been assumed to go along with deficient inhibitory processes in cognitive performance. According to this inhibition deficit hypothesis, older adults are less able to suppress or ignore irrelevant thoughts and actions than young adults are. This hypothesis has been investigated in a large number of studies. We conducted a meta-analysis to determine whether there is an inhibition deficit in older age and whether this deficit is general or task-specific. We selected 176 studies in which young and older adults were tested on tasks commonly assumed to measure inhibition (i.e., the color Stroop, flanker, Simon, stop-signal, go/no-go, global–local, positive and negative compatibility tasks, as well as the paradigm assessing n-2 repetition costs in task switching). For most tasks (i.e., the color Stroop, flanker, and local tasks, as well as the n-2 repetition costs), the results speak against an inhibition deficit in older age. Only in a few tasks (i.e., the go/no-go and stop-signal tasks), older adults showed impaired inhibition. Moreover, for four tasks (i.e., the Simon, global, positive and negative compatibility tasks), the results suggest that more studies are necessary to draw a firm conclusion. Together, the present findings call into question the hypothesis of a general inhibition deficit in older age.     

When is it time to stop? When good enough becomes bad enough

This article draws on Winnicott’s concept of the good enough mother to discuss how to know whether a therapeutic situation is good enough to continue or bad enough to end. This dilemma is explored in terms of clinical syndromes, such as anorexia and pathological gambling, but focuses mainly on analyst-initiated endings, which are termed the ‘Casablanca dilemma’, based on an amplification of the ending of the film Casablanca. The author goes on to discuss such one-sided endings, drawing on interviews with 40 analysts and therapists about their clinical experience. A typology of bad enough endings is presented. The psychological differences between a good enough analysis as opposed to a bad enough one are explored through the ideas of Winnicott and Neumann.     

Factor structure of the SCL-90-R: is there one?

A review of the literature on the factor structure of the Symptom Check List-90-R (SCL-90-R) and its precursors makes evident the many problems inherent in this clinical assessment tool as a measure of independent dimensions of symptom distress, particularly in psychiatric patients. The many versions of the Symptom Check List are evaluated on several criteria (e.g., factor stability, factor loadings, proportion of variance, etc.). It is concluded that interpreting nine dimensions for clinical purposes is highly questionable. It is perhaps still a better measure of general distress as was intended in its original version approximately three decades ago.     

Decoding emotions from nonverbal vocalizations: How much voice signal is enough?

Motivation and Emotion - How much acoustic signal is enough for an accurate recognition of nonverbal emotional vocalizations? Using a gating paradigm (7 gates from 100 to 700 ms), the...     

Experts,Novices, and the St. Petersburg paradox: Is one solution enough?

Although the controversy over the correct solution to the St. Petersburg paradox continues in the decision making literature, few of the solutions have been empirically evaluated. Via the development of alternative versions of the St. Petersburg game, we were able to empirically test some of these solutions. Experts and novices behaved in accordance with Treisman's expectation heuristic when bidding for the right to play the various versions of the St. Petersburg game. When subjects were asked their preferences among the game versions. novices continued to behave in accordance with the expectation heuristic but a plurality of experts seemed to follow another strategy. This preference reversal and its implications and possible causes are thoroughly discussed. An alternative theory which mimicks the expectation heuristic is considered, and generalizations of the expectation heuristic and the St. Petersburg Paradox for z-sided 'coins' (where z is any integer greater than or equal to 2) are presented. It appears that no one solution is yet rich enough for the St. Petersburg paradox.     

Multiple cues for quantification in infancy: is number one of them?

A review and synthesis of the literature on quantification in infancy and early childhood is provided. In most current conceptualizations, early quantification is assumed to be number based. However, the extant literature provides no clear-cut evidence that infants use number to perform quantitative tasks. Instead, new research suggests that quantification is initially based on nonnumerical cues, such as area and contour length, whether or not a task involves discrete items. The authors discuss the implications of these findings with respect to early quantification and its relation to later numerical development.     

Schizophrenia outpatients' perceptions of their parents: is expressed emotion a factor?

The factors that mediate the association between expressed emotion (EE) and relapse in schizophrenia patients are still unknown. Many researchers hypothesize that interactions with high-EE individuals are stressful for patients, leaving them vulnerable to relapse. It would be useful to investigate whether patients perceive interactions with high-EE parents as stressful. In this study, associations were examined between levels of EE in parents and the types of personal memories patients had about these parents. EE ratings were obtained for both parents of 27 schizophrenia outpatients, and patients were asked to describe "happy, nonstressful" memories and "unhappy, stressful" memories during 2 interviews. Patients recounted fewer nonstressful memories and more stressful memories about high-versus low-EE parents. Implications of these results are discussed.     

Maternal personality and injury in children: is stability a protective factor?

Measures of injury were obtained in a birth cohort of 953 children in Wales along with maternal Eysenck Personality Inventory (EPI) and children's Behaviour Screening Questionnaire (BSQ) data. While there was no relationship between maternal E and child injury, children of low-N mothers had significantly fewer injuries than those of medium of high-N mothers. The magnitude of this trend remained after controlling for the BSQ variables also relating to injury, but was no longer significant in the case of management disorder or of sex. Moreover, while the association was observed for families with only one or two children, this was not the case for families with three or more children.     

Contextual influences of emotional speech prosody on face processing: How much is enough?

The influence of emotional prosody on the evaluation of emotional facial expressions was investigated in an event-related brain potential (ERP) study using a priming paradigm, the facial affective decision task. Emotional prosodic fragments of short (200-msec) and medium (400-msec) duration were presented as primes, followed by an emotionally related or unrelated facial expression (or facial grimace, which does not resemble an emotion). Participants judged whether or not the facial expression represented an emotion. ERP results revealed an N400-like differentiation for emotionally related prime-target pairs when compared with unrelated prime-target pairs. Faces preceded by prosodic primes of medium length led to a normal priming effect (larger negativity for unrelated than for related prime-target pairs), but the reverse ERP pattern (larger negativity for related than for unrelated prime-target pairs) was observed for faces preceded by short prosodic primes. These results demonstrate that brief exposure to prosodic cues can establish a meaningful emotional context that influences related facial processing; however, this context does not always lead to a processing advantage when prosodic information is very short in duration.