AP8 Lecture 4

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Clinical Assessment: How and Why Does the

Client Behave Abnormally?

Assessment is collecting relevant information in

an effort to reach a conclusion Clinical assessment is used to determine how

and why a person is behaving abnormally and how thatperson may be helped Focus is idiographic i!e!" on an individual person#

Also may be used to evaluate treatment progress

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Clinical Assessment: How and Why Does the

Client Behave Abnormally?

$he specific tools used in an assessment depend

on the clinician%s theoretical orientation

Hundreds of clinical assessment tools have been

developed and fall into three categories: Clinical interviews

$ests

&bservations

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Characteristics of Assessment $ools

$o be useful" assessment tools must be

standardi'ed and have clear reliability and validity $o standardi'e a techni(ue is to set up common steps

to be followed whenever it is administered &ne must standardi'e administration" scoring" and

interpretation

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)eliability refers to the consistency of an

assessment measure A good tool will always yield the same results in the

same situation $wo main types:

$est*retest reliability * yields the same results every time it is

given to the same people

+nterrater reliability * different ,udges independently agree on

how to score and interpret a particular tool

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Validityrefers to the accuracy of a tool%s results A good assessment tool must accurately measure what

it is supposed to measure

$hree specific types: Face validity* a tool appears to measure what it is supposed to

measure- does not necessarily indicate true validity

Predictive validity* a tool accurately predicts future

characteristics or behavior

Concurrent validity* a tool%s results agree with independentmeasures assessing similar characteristics or behavior

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Clinical +nterviews

$hese face.to.face encounters often are the first

contact between a client and a clinician/assessor 0sed to collect detailed information" especially personal

history" about a clientAllow the interviewer to focus on whatever topics

they consider most important Focus depends on theoretical orientation

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Clinical +nterviews

Conducting the interview Can be either unstructured or structured

+n an unstructured interview" clinicians as1 open.ended

(uestions

+n a structured interview" clinicians as1 prepared (uestions" often

from a published interview schedule 2ay include a mental status e3am

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Clinical +nterviews

4imitations: 2ay lac1 validity or accuracy

+ndividuals may be intentionally misleading

+nterviewers may be biased or may ma1e mista1es in,udgment

+nterviews" particularly unstructured ones" may lac1

reliability

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Clinical $ests

$ests are devices for gathering information about

a few aspects of a person%s psychological

functioning" from which broader information can

be inferred 2ore than 566 clinical tests are currently in use

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Clinical $ests

7ro,ective tests )e(uire that clients interpret vague and ambiguous

stimuli or follow open.ended instruction

2ainly used by psychodynamic practitioners 2ost popular:

)orschach $est

$hematic Apperception $est

8entence completion tests

Drawings

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Clinical $est: )orschach +n1blot

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Clinical $est: 8entence.Completion $est

9+ wish ;

92y father ;

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Clinical $est: Drawings

Draw.a.7erson DA7# test: 9Draw a person;

9Draw another person of the opposite se3;

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Clinical $ests

7ro,ective tests 8trengths and wea1nesses:

Helpful for providing 9supplementary; information

Have rarely demonstrated much reliability or validity

2ay be biased against minority ethnic groups

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Clinical $ests

7ersonality inventories Designed to measure broad personality characteristics

Focus on behaviors" beliefs" and feelings

0sually based on self.reported responses 2ost widely used: 2innesota 2ultiphasic 7ersonality

+nventory For adults: 227+ original# or 227+.< =>> revision#

For adolescents: 227+.A

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Clinical $est: 2innesota 2ultiphasic 7ersonality

+nventory 227+#

Consists of more than 566 self.statements that

can be answered 9true"; 9false"; or 9cannot say; 8tatements describe physical concerns" mood" morale"

attitudes toward religion" se3" and social activities" and

psychological symptoms

Assesses careless responding and lying

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Clinical $est: 2innesota 2ultiphasic 7ersonality

+nventory 227+#

Comprised of ten clinicalscales: Hypochondriasis H8# Depression D#

Conversion hysteria Hy# 7sychopathic deviate 7D# 2asculinity.femininity 2f#

8cores range from 6 to=

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Clinical $ests

7ersonality inventories 8trengths and wea1nesses:

asier" cheaper" and faster to administer than pro,ective tests

&b,ectively scored and standardi'ed

Appear to have greater validity than pro,ective tests However" they cannot be considered highly valid * measured traits

often cannot be directly e3amined * how can we really 1now the

assessment is correct?

$ests fail to allow for cultural differences in responses

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Clinical $ests

)esponse inventories 0sually based on self.reported responses

Focus on one specific area of functioningAffective inventories e3ample: Bec1 Depression +nventory#

8ocial s1ills inventories

Cognitive inventories

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Clinical $ests

)esponse inventories 8trengths and wea1nesses:

Have strong face validity

ot all have been sub,ected to careful standardi'ation" reliability"

and/or validity procedures Bec1 Depression +nventory and a few

others are e3ceptions#

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Clinical $ests

7sychophysiological tests 2easure physiological response as an indication of

psychological problems +ncludes heart rate" blood pressure" body temperature" galvanic

s1in response" and muscle contraction

2ost popular is the polygraph lie detector#

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Clinical $ests

7sychophysiological tests 8trengths and wea1nesses:

)e(uire e3pensive e(uipment that must be tuned and

maintained

Can be inaccurate and unreliable

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Clinical $ests

eurological and neuropsychological tests eurological tests directly assess brain function by

assessing brain structure and activity 3amples: " 7$ scans" CA$ scans" 2)+" f2)+

europsychological tests indirectly assess brain

function by assessing cognitive" perceptual" and motor

functioning 2ost widely used is the Bender Eisual.2otor estalt $est

Clinicians often use a battery of tests

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Clinical $ests

eurological and neuropsychological tests 8trengths and wea1nesses:

Can be very accurate

At best" though" these tests are general screening devices Best when used in a battery of tests" each targeting a specific s1ill

area

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Clinical $ests

+ntelligence tests Designed to indirectly measure intellectual ability

$ypically comprised of a series of tests assessing both

verbal and nonverbal s1ills

eneral score is an intelligence (uotient +# )epresents the ratio of a person%s 9mental; age to his or her

9chronological; age

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Clinical $ests

+ntelligence tests 8trengths:

Are among the most carefully produced of all clinical tests Highly standardi'ed on large groups of sub,ects

Have very high reliability and validity

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Clinical $ests

+ntelligence tests Wea1nesses:

7erformance can be influenced by nonintelligence factors e!g!"

motivation" an3iety" test.ta1ing e3perience#

$ests may contain cultural biases in language or tas1s

2embers of minority groups may have less e3perience and be

less comfortable with these types of tests" influencing their

results

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Clinical &bservations

8ystematic observations of behavior

8everal 1inds: aturalistic

Analog 8elf.monitoring

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aturalistic and analog observations aturalistic observations occur in everyday

environments Can occur in homes" schools" institutions hospitals and

prisons#" and community settings

2ost focus on parent*child" sibling*child" or teacher*child

interactions

&bservations are generally made by 9participant observers; and

reported to a clinician

+f naturalistic observation is impractical" analog

observations are used and conducted in artificial

settings

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aturalistic and analog observations 8trengths and wea1nesses:

)eliability is a concern Different observers may focus on different aspects of behavior

Ealidity is a concern )is1 of 9overload"; 9observer drift"; and observer bias

Client reactivity may also limit validity

&bservations may lac1 cross.situational validity

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8elf.monitoring 7eople observe themselves and carefully record the

fre(uency of certain behaviors" feelings" or cognitions

as they occur over time

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8elf.monitoring 8trengths and wea1nesses:

0seful in assessing infre(uent behaviors

0seful for observing overly fre(uent behaviors

7rovides a means of measuring private thoughts or perceptions

Ealidity is often a problem Clients may not record information accurately

When people monitor themselves" they often change their behavior

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Diagnosis: Does the Client%s 8yndrome 2atch a

Gnown Disorder?

0sing all available information" clinicians attempt

to paint a 9clinical picture; +nfluenced by their theoretical orientation

0sing assessment data and the clinical picture"clinicians attempt to ma1e a diagnosis A determination that a person%s psychological problems

constitute a particular disorder

Based on an e3isting classification system

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Classification 8ystems

4ists of categories" disorders" and symptom

descriptions" with guidelines for assignment Focus on clusters of symptoms syndromes#

+n current use in the 0!8!: D82.5

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D82.5

4ists appro3imately 66 disorders

Describes criteria for diagnoses" 1ey clinical

features" and related features that are often" but

not always" present

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4ifetime 7revalence of D82.5 Diagnoses

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Categorical +nformation

D82.5 re(uires clinicians to provide bothcategorical and dimensional information as part of

a proper diagnosis!

Categorical information refers to the name ofthe category disorder# indicated by the clientIs

symptoms!

Dimensional information is a rating of how

severe a clientIs symptoms are and howdysfunctional the client is across various

dimensions of personality!

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+s D82.5 an ffective Classification 8ystem?

A classification system" li1e an assessmentmethod" is ,udged by its reliability and validity

Here" reliability means that different clinicians are

li1ely to agree on a diagnosis using the system todiagnose the same client D82.5 appears to have greater reliability than any

previous edition

0sed field trials to increase reliability )eliability is still a concern

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$he validity of a classification system is theaccuracy of the information that its diagnostic

categories provide

7redictive validity is of the most use clinically D82.5 has greater validity than any previous edition

Conducted e3tensive literature reviews and ran field studies

Ealidity is still a concern

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$he framers of D82.5 followed certainprocedures in their development of the new

manual to help ensure that D82.5 would have

greater reliability than the previous D82s

A number of new diagnostic criteria were

developed and categories" e3pecting that the new

criteria and categories were in fact reliable!

8ome critics continue to have concerns about theprocedures used in the development of D82.5

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D82.5 Changes

Adding a new category" 9autism spectrum disorder"; that combinescertain past categories such as 9autistic disorder; and 9AspergerIssyndrome; see Chapter =@#

Eiewing 9obsessive.compulsive disorder; as a problem that isdifferent from the an3iety disorders and grouping it instead along withother compulsive.li1e disorders such as 9hoarding disorder"; 9body

dysmorphic disorder"; 9hair.pulling disorder"; and 9e3coriation s1in.pic1ing# disorder; see Chapter 5#

Eiewing 9posttraumatic stress disorder; as a problem that is distinctfrom the an3iety disorders see Chapter J#

Adding a new category" 9somatic symptom disorder; see Chapter @#

)eplacing the term 9hypochondriasis; with the new term 9illnessan3iety disorder; see Chapter @# Adding a new category" 9premenstrual dysphoric disorder; see

Chapter # Adding a new category" 9disruptive mood dysregulation disorder; see

Chapters and =@#

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D82.5 Changes

Adding a new category" 9binge eating disorder; see Chapter ==# Adding a new category" 9substance use disorder"; that combines past

categories 9substance abuse; and 9substance dependence; see Chapter =

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Can Diagnosis and 4abeling Cause Harm?

2isdiagnosis is always a concern 2a,or issue is the reliance on clinical ,udgment

Also present is the issue of labeling and stigma

Diagnosis may be a self.fulfilling prophecy Because of these problems" some clinicians

would li1e to do away with the practice of

diagnosis

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$reatment: How 2ight the Client Be Helped?

$reatment decisions Begin with assessment information and diagnostic

decisions to determine a treatment plan 0se a combination of idiographic and nomothetic information

&ther factors: $herapist%s theoretical orientation

Current research

eneral state of clinical 1nowledge * currently focusing on

empirically supported" evidence.based treatment

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$he ffectiveness of $reatment

2ore than 66 forms of therapy in practice" but istherapy effective? Difficult (uestion to answer:

How do you define success?

How do you measure improvement?

How do you compare treatments? 7eople differ in their problems" personal styles" and motivations for

therapy

$herapists differ in s1ill" 1nowledge" orientation" and personality

$herapies differ in theory" format" and setting

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$herapy outcome studies typically assess one ofthe following (uestions: +s therapy in general effective?

Are particular therapies generally effective? Are particular therapies effective for particular

problems?

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+s therapy generally effective? )esearch suggests that therapy is generally more

helpful than no treatment or than placebo

+n one ma,or study using meta.analysis" the average

person who received treatment was better off than @5L

of the untreated sub,ects

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Does $herapy Help?

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+s therapy generally effective? 8ome clinicians are concerned with a related (uestion:

Can therapy can be harmful? +t does have this potential

8tudies suggest that 5.=6L of patients get worse with treatment

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Are particular therapies generally effective? enerally" therapy.outcome studies lump all therapies

together to consider their general effectiveness 8ome critics call this the 9uniformity myth;

An alternative approach e3amines the effectiveness of

particular therapies $here is a movement 9rapprochement;# to loo1 at

commonalities among therapies" regardless of clinician

orientation

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Are particular therapies effective for particularproblems? 8tudies now being conducted to e3amine the

effectiveness of specific treatments for specific

disorders: 9What specific treatment" by whom" is the most effective for this

individual with that specific problem" and under which set of

circumstances?;

)ecent studies focus on the effectiveness of combinedapproaches * drug therapy combined with certain forms

of psychotherapy * to treat certain disorders

Documents

AP8 Lecture 4