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Chapter 4 Clinical Assessment, Diagnosis, and Treatment.

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1 Chapter 4 Clinical Assessment, Diagnosis, and Treatment

2 Clinical Assessment: How and Why Does the Client Behave Abnormally? What is assessment? What is assessment? The collecting of relevant information in an effort to reach a conclusion The collecting of 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 that person may be helped Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped Focus is idiographic – on an individual person Focus is idiographic – on an individual person Also may be used to evaluate treatment progress Also may be used to evaluate treatment progress

3 Clinical Assessment: How and Why Does the Client Behave Abnormally? The specific tools used in an assessment depend on the clinician’s theoretical orientation The 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: Hundreds of clinical assessment tools have been developed and fall into three categories: Clinical interviews Clinical interviews Tests Tests Observations Observations

4 Characteristics of Assessment Tools To be useful, assessment tools must be standardized and have clear reliability and validity To be useful, assessment tools must be standardized and have clear reliability and validity To standardize a technique is to set up common steps to be followed whenever it is administered To standardize a technique is to set up common steps to be followed whenever it is administered One must standardize administration, scoring, and interpretation One must standardize administration, scoring, and interpretation

5 Characteristics of Assessment Tools Reliability refers to the consistency of a test Reliability refers to the consistency of a test A good test will yield the same results in the same situation A good test will yield the same results in the same situation Two main types: Two main types: Test – retest reliability Test – retest reliability To test for this type of reliability, a subject is tested on two different occasions and the scores are correlated – the higher the correlation, the greater the test’s reliability To test for this type of reliability, a subject is tested on two different occasions and the scores are correlated – the higher the correlation, the greater the test’s reliability Interrater reliability Interrater reliability Independent judges agree on the scoring and interpretation of a particular test Independent judges agree on the scoring and interpretation of a particular test

6 Characteristics of Assessment Tools Validity refers to the accuracy of a test’s results Validity refers to the accuracy of a test’s results A good test must accurately measure what it is supposed to be measuring A good test must accurately measure what it is supposed to be measuring Three specific types: Three specific types: Face validity – a test appears to measure what it is supposed to measure; does not necessarily indicate true validity Face validity – a test appears to measure what it is supposed to measure; does not necessarily indicate true validity Predictive validity – a test accurately predicts future characteristics or behavior Predictive validity – a test accurately predicts future characteristics or behavior Concurrent validity – a test’s results agree with independent measures assessing similar characteristics or behavior Concurrent validity – a test’s results agree with independent measures assessing similar characteristics or behavior

7 Clinical Interviews Face-to-face encounters Face-to-face encounters Often the first contact between a client and a clinician/assessor Often the first contact between a client and a clinician/assessor Used to collect detailed information, especially personal history, about a client Used to collect detailed information, especially personal history, about a client Allow the interviewer to focus on whatever topics they consider most important Allow the interviewer to focus on whatever topics they consider most important

8 Clinical Interviews Conducting the interview Conducting the interview Focus depends on theoretical orientation Focus depends on theoretical orientation Can be either unstructured or structured Can be either unstructured or structured In unstructured interviews, clinicians ask open-ended questions In unstructured interviews, clinicians ask open-ended questions In structured interviews, clinicians ask prepared questions, often from a published interview schedule In structured interviews, clinicians ask prepared questions, often from a published interview schedule May include a mental status exam May include a mental status exam

9 Clinical Interviews Limitations: Limitations: May lack validity or accuracy May lack validity or accuracy Interviewers may be biased or may make mistakes in judgment Interviewers may be biased or may make mistakes in judgment Interviews, particularly unstructured ones, may lack reliability Interviews, particularly unstructured ones, may lack reliability

10 Clinical Tests Devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information can be inferred Devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information can be inferred More than 500 different tests are in use More than 500 different tests are in use They fall into six categories… They fall into six categories…

11 Clinical Tests 1. Projective tests Require that subjects interpret vague and ambiguous stimuli or follow open-ended instruction Require that subjects interpret vague and ambiguous stimuli or follow open-ended instruction Mainly used by psychodynamic practitioners Mainly used by psychodynamic practitioners Most popular: Most popular: Rorschach Test Rorschach Test Thematic Apperception Test Thematic Apperception Test Sentence Completion Test Sentence Completion Test Drawings Drawings

12 Clinical Test: Rorschach Inkblot

13 Clinical Test: Thematic Apperception Test

14 Clinical Test: Sentence-Completion Test “I wish ___________________________” “I wish ___________________________” “My father ________________________” “My father ________________________”

15 Clinical Test: Drawings Draw-a-Person (DAP) test: Draw-a-Person (DAP) test: “Draw a person” “Draw a person” “Draw another person of the opposite sex” “Draw another person of the opposite sex”

16 Clinical Tests 1. Projective tests Strengths and weaknesses: Strengths and weaknesses: Helpful for providing “supplementary” information Helpful for providing “supplementary” information Have rarely demonstrated much reliability or validity Have rarely demonstrated much reliability or validity May be biased against minority ethnic groups May be biased against minority ethnic groups

17 Clinical Tests 2. Personality inventories Designed to measure broad personality characteristics Designed to measure broad personality characteristics Focus on behaviors, beliefs, and feelings Focus on behaviors, beliefs, and feelings Usually based on self-reported responses Usually based on self-reported responses Most widely used: Minnesota Multiphasic Personality Inventory Most widely used: Minnesota Multiphasic Personality Inventory For Adults: MMPI (original) or MMPI-2 (1989 revision) For Adults: MMPI (original) or MMPI-2 (1989 revision) For Adolescents: MMPI-A For Adolescents: MMPI-A

18 Clinical Test: MMPI Minnesota Multiphasic Personality Inventory Consists of 550 self-statements that can be answered “true,” “false,” or “cannot say” Consists of 550 self-statements that can be answered “true,” “false,” or “cannot say” Statements describe physical concerns; mood; morale; attitudes toward religion, sex, and social activities; and psychological symptoms Statements describe physical concerns; mood; morale; attitudes toward religion, sex, and social activities; and psychological symptoms Assesses careless responding & lying Assesses careless responding & lying

19 Clinical Test: MMPI Minnesota Multiphasic Personality Inventory Comprised of ten clinical scales: Comprised of ten clinical scales: Hypochondriasis (HS) Hypochondriasis (HS) Depression (D) Depression (D) Conversion hysteria (Hy) Conversion hysteria (Hy) Psychopathic deviate (PD) Psychopathic deviate (PD) Masculinity-femininity (Mf) Masculinity-femininity (Mf) Scores range from 0 – 120 Scores range from 0 – 120 Above 70 = deviant Above 70 = deviant Graphed to create a “profile” Graphed to create a “profile” Paranoia (P) Paranoia (P) Psychasthenia (Pt) Psychasthenia (Pt) Schizophrenia (Sc) Schizophrenia (Sc) Hypomania (Ma) Hypomania (Ma) Social introversion (Si) Social introversion (Si)

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21 Clinical Tests 2. Personality inventories Strengths and weaknesses: Strengths and weaknesses: Easier, cheaper, and faster to administer than projective tests Easier, cheaper, and faster to administer than projective tests Objectively scored and standardized Objectively scored and standardized Appear to have greater validity than projective tests Appear to have greater validity than projective tests Measured traits often cannot be directly examined – how can we really know the assessment is correct? Measured traits often cannot be directly examined – how can we really know the assessment is correct? Tests fail to allow for cultural differences in responses Tests fail to allow for cultural differences in responses

22 Clinical Tests 3. Response inventories Usually based on self-reported responses Usually based on self-reported responses Focus on one specific area of functioning Focus on one specific area of functioning Affective inventories (example: Beck Depression Inventory) Affective inventories (example: Beck Depression Inventory) Social skills inventories Social skills inventories Cognitive inventories Cognitive inventories

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24 Clinical Tests 3. Response inventories Strengths and weaknesses: Strengths and weaknesses: Have strong face validity Have strong face validity Rarely include questions to assess careless or inaccurate responding Rarely include questions to assess careless or inaccurate responding Not all have been subjected to careful standardization, reliability, and/or validity procedures (BDI and a few others are exceptions) Not all have been subjected to careful standardization, reliability, and/or validity procedures (BDI and a few others are exceptions)

25 Clinical Tests 4. Psychophysiological tests Measure physiological response as an indication of psychological problems Measure physiological response as an indication of psychological problems Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction Most popular is the polygraph (lie detector) Most popular is the polygraph (lie detector)

26 Clinical Tests 4. Psychophysiological tests Strengths and weaknesses: Strengths and weaknesses: Require expensive equipment that must be tuned and maintained Require expensive equipment that must be tuned and maintained Can be inaccurate and unreliable Can be inaccurate and unreliable

27 Clinical Tests 5. Neurological and neuropsychological tests Neurological tests directly assess brain function by assessing brain structure and activity Neurological tests directly assess brain function by assessing brain structure and activity Examples: EEG, PET scans, CAT scans, MRI Examples: EEG, PET scans, CAT scans, MRI Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning Most widely used is the Bender Visual-Motor Gestalt Test Most widely used is the Bender Visual-Motor Gestalt Test

28 CT Scan shows a horizontal slice. Left slide is normal, right side has a tumor on the left side

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30 Clinical Test: Bender Visual-Motor Gestalt Test

31 Clinical Tests 5. Neurological and neuropsychological tests Strengths and weaknesses: Strengths and weaknesses: Can be very accurate Can be very accurate At best, though, these tests are general screening devices At best, though, these tests are general screening devices Best when used in a battery of tests, each targeting a specific skill area Best when used in a battery of tests, each targeting a specific skill area

32 Clinical Tests 6. Intelligence tests Designed to measure intellectual ability Designed to measure intellectual ability Composed of a series of tests assessing both verbal and nonverbal skills Composed of a series of tests assessing both verbal and nonverbal skills Generate an intelligence quotient (IQ) Generate an intelligence quotient (IQ) Most popular: Wechsler Adult Intelligence Scale (WAIS) & Wechsler Intelligence Scale for Children (WISC) Most popular: Wechsler Adult Intelligence Scale (WAIS) & Wechsler Intelligence Scale for Children (WISC)

33 Clinical Tests 6. Intelligence tests Strengths and weaknesses: Strengths and weaknesses: Are among the most carefully produced of all clinical tests Are among the most carefully produced of all clinical tests Highly standardized on large groups of subjects Highly standardized on large groups of subjects Have very high reliability and validity Have very high reliability and validity Because intelligence is an inferred quality, it can only be measured indirectly Because intelligence is an inferred quality, it can only be measured indirectly

34 Clinical Tests 6. Intelligence tests Strengths and weaknesses: Strengths and weaknesses: Performance can be influenced by nonintelligence factors (e.g., motivation, anxiety, test-taking experience) Performance can be influenced by nonintelligence factors (e.g., motivation, anxiety, test-taking experience) Tests may contain cultural biases in language or tasks Tests may contain cultural biases in language or tasks

35 Clinical Observations Systematic observation of behavior Systematic observation of behavior Several kinds: Several kinds: Naturalistic Naturalistic Analog Analog Self-monitoring Self-monitoring

36 Clinical Observations Naturalistic and analog observations Naturalistic and analog observations Naturalistic observations occur in everyday environments Naturalistic observations occur in everyday environments Can occur in homes, schools, institutions (hospitals and prisons), and community settings Can occur in homes, schools, institutions (hospitals and prisons), and community settings Tend to focus on parent – child, sibling – child, or teacher – child interactions Tend to focus on parent – child, sibling – child, or teacher – child interactions Observations are generally made by “participant observers” and reported to a clinician Observations are generally made by “participant observers” and reported to a clinician If naturalistic observation is impractical, analog observations are used in artificial settings If naturalistic observation is impractical, analog observations are used in artificial settings

37 Clinical Observations Naturalistic and analog observations Naturalistic and analog observations Strengths and weaknesses: Strengths and weaknesses: Reliability is a concern Reliability is a concern Different observers may focus on different aspects of behavior Different observers may focus on different aspects of behavior Validity is a concern Validity is a concern Risk of “overload,” “observer drift,” and observer bias Risk of “overload,” “observer drift,” and observer bias Client reactivity may also limit validity Client reactivity may also limit validity Observations may lack cross-situational validity Observations may lack cross-situational validity

38 Clinical Observations Self-monitoring Self-monitoring People observe themselves and carefully record certain behaviors, feelings, or cognitions as they occur over time People observe themselves and carefully record certain behaviors, feelings, or cognitions as they occur over time

39 Clinical Observations Self-monitoring Self-monitoring Strengths and weaknesses: Strengths and weaknesses: Useful in assessing infrequent behaviors Useful in assessing infrequent behaviors Useful for observing overly frequent behaviors Useful for observing overly frequent behaviors Provides a means of measuring private thoughts or perceptions Provides a means of measuring private thoughts or perceptions Validity is often a problem Validity is often a problem Clients may not receive proper training and instruction Clients may not receive proper training and instruction Clients may not record information accurately Clients may not record information accurately When people monitor themselves, they often change their behavior When people monitor themselves, they often change their behavior

40 Diagnosis: Does the Client’s Syndrome Match a Known Disorder? Using all available information, clinicians attempt to paint a “clinical picture” Using all available information, clinicians attempt to paint a “clinical picture” Influenced by their theoretical orientation Influenced by their theoretical orientation Using assessment data and the clinical picture, clinicians attempt to make a diagnosis Using assessment data and the clinical picture, clinicians attempt to make a diagnosis A determination that a person’s problems reflect a particular disorder or syndrome A determination that a person’s problems reflect a particular disorder or syndrome Based on an existing classification system Based on an existing classification system

41 Classification Systems Lists of categories, disorders, and symptom descriptions, with guidelines for assignment Lists of categories, disorders, and symptom descriptions, with guidelines for assignment Focus on clusters of symptoms (syndromes) Focus on clusters of symptoms (syndromes) In current use in the US: DSM-IV-TR In current use in the US: DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders (4th edition) Text Revision Diagnostic and Statistical Manual of Mental Disorders (4th edition) Text Revision

42 DSM-IV-TR Published in 1994, revised in 2000 (TR) Published in 1994, revised in 2000 (TR) Lists approximately 400 disorders Lists approximately 400 disorders Listed in the inside back flap of your text Listed in the inside back flap of your text Describes criteria for diagnoses, key clinical features, and related features which are often but not always present Describes criteria for diagnoses, key clinical features, and related features which are often but not always present People can be diagnosed with multiple disorders… People can be diagnosed with multiple disorders…

43 Lifetime Prevalence of DSM-IV-TR Diagnoses

44 The DSM-IV-TR Multiaxial Multiaxial Uses 5 axes (branches of information) to develop a full clinical picture Uses 5 axes (branches of information) to develop a full clinical picture People usually receive a diagnosis on either Axis I or Axis II, but they may receive diagnoses on both People usually receive a diagnosis on either Axis I or Axis II, but they may receive diagnoses on both

45 The DSM-IV-TR Axis I Axis I Most frequently diagnosed disorders, except personality disorders and mental retardation Most frequently diagnosed disorders, except personality disorders and mental retardation

46 Major Axis I Diagnostic Categories Anxiety disorders Mood disorders Disorders first diagnosed in infancy and childhood Substance-related disorders Schizophrenia and other psychotic disorders Delirium, dementia, amnestic, and other cognitive disorders Mental disorders due to a general medical condition Somatoform disorders Factitious disorders Dissociative disorders Other conditions that are the focus of clinical attention Eating disorders Sexual and gender identity disorders Impulse-control disorders Adjustment disorders Sleep disorders

47 The DSM-IV-TR Axis II Axis II Personality disorders and mental retardation Personality disorders and mental retardation Long-standing problems Long-standing problems Axis III Axis III Relevant general medical conditions Relevant general medical conditions Axis IV Axis IV Psychosocial and environmental problems Psychosocial and environmental problems

48 The DSM-IV-TR Axis V Axis V Global assessment of psychological, social, and occupational functioning (GAF) Global assessment of psychological, social, and occupational functioning (GAF) Current functioning and highest functioning in past year Current functioning and highest functioning in past year 0 – 100 scale 0 – 100 scale

49 DSM IV - Multiaxial Diagnosis I Dysthymic Disorder (early onset) Generalized Anxiety Disorder II.1. R/O Borderline Personality Disorder III. IV.Problems related to the social environment - difficulty managing relationships V.Current GAF 70 Highest Past Year 83 ** Each axis (except III) should have a diagnosis with it

50 Are Classifications Reliable and Valid? In this case reliability = different diagnosticians agreeing on a diagnosis using the same classification system In this case reliability = different diagnosticians agreeing on a diagnosis using the same classification system DSM-IV-TR has greater reliability than any previous editions DSM-IV-TR has greater reliability than any previous editions Used field trials to increase reliability Used field trials to increase reliability Reliability is still a concern Reliability is still a concern

51 Are Classifications Reliable and Valid? In this case validity = accuracy of information that the diagnostic categories provide In this case validity = accuracy of information that the diagnostic categories provide Predictive validity is of the most use clinically Predictive validity is of the most use clinically DSM-IV-TR has greater validity than any previous editions DSM-IV-TR has greater validity than any previous editions Conducted extensive literature reviews and ran field studies Conducted extensive literature reviews and ran field studies Validity is still a concern Validity is still a concern

52 Are Classifications Reliable and Valid? Beyond concerns about reliability and validity, a growing number of theorists believe that two fundamental problems weaken the DSM-IV-TR: Beyond concerns about reliability and validity, a growing number of theorists believe that two fundamental problems weaken the DSM-IV-TR: Basic assumption that disorders are qualitatively different from normal behavior Basic assumption that disorders are qualitatively different from normal behavior Reliance on discrete diagnostic categories Reliance on discrete diagnostic categories With such concerns, DSM-V certainly will include some key changes, but the new edition is not imminent With such concerns, DSM-V certainly will include some key changes, but the new edition is not imminent

53 Can Diagnosis and Labeling Cause Harm? Misdiagnosis always a concern Misdiagnosis always a concern Major issue is reliance on clinical judgment Major issue is reliance on clinical judgment Also present is the issue of labeling and stigma Also present is the issue of labeling and stigma Diagnosis may be a self-fulfilling prophecy Diagnosis may be a self-fulfilling prophecy Because of these problems, some clinicians would like to cease the practice of diagnosis Because of these problems, some clinicians would like to cease the practice of diagnosis

54 Treatment: How Might the Client Be Helped? Treatment decisions Treatment decisions Begin with assessment information and diagnostic decisions to determine a treatment plan Begin with assessment information and diagnostic decisions to determine a treatment plan Use a combination of idiographic and nomothetic information Use a combination of idiographic and nomothetic information Other factors: Other factors: Therapist’s theoretical orientation Therapist’s theoretical orientation Current research Current research General state of clinical knowledge – currently focusing on empirically supported, evidence-based treatment General state of clinical knowledge – currently focusing on empirically supported, evidence-based treatment

55 The Effectiveness of Treatment More than 400 forms of therapy in practice, but is therapy effective? More than 400 forms of therapy in practice, but is therapy effective? Difficult question to answer: Difficult question to answer: How do you define success? How do you define success? How do you measure improvement? How do you measure improvement? How do you compare treatments – treatments differ in range and complexity; therapists differ in skill and knowledge; clients differ in severity and motivation… How do you compare treatments – treatments differ in range and complexity; therapists differ in skill and knowledge; clients differ in severity and motivation…

56 The Effectiveness of Treatment Controlled clinical research and therapy outcome studies typically assess one of the following questions: Controlled clinical research and therapy outcome studies typically assess one of the following questions: Is therapy in general effective? Is therapy in general effective? Are particular therapies generally effective? Are particular therapies generally effective? Are particular therapies effective for particular problems? Are particular therapies effective for particular problems?

57 The Effectiveness of Treatment Is therapy generally effective? Is therapy generally effective? Research suggests that therapy is generally more effective than no treatment or than placebo Research suggests that therapy is generally more effective than no treatment or than placebo In one major study using meta-analysis, the average person who received treatment was better off than 75% of the untreated subjects In one major study using meta-analysis, the average person who received treatment was better off than 75% of the untreated subjects

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59 The Effectiveness of Treatment Is therapy generally effective? Is therapy generally effective? Some clinicians are concerned with a related question: Can therapy can be harmful? Some clinicians are concerned with a related question: Can therapy can be harmful? Has this potential Has this potential Studies report ~5% get worse with treatment Studies report ~5% get worse with treatment

60 The Effectiveness of Treatment Are particular therapies generally effective? Are particular therapies generally effective? Generally, therapy-outcome studies lump all therapies together to consider their general effectiveness Generally, therapy-outcome studies lump all therapies together to consider their general effectiveness One critic has called this the “uniformity myth” One critic has called this the “uniformity myth” It is argued that scientists must look at the effectiveness of particular therapies It is argued that scientists must look at the effectiveness of particular therapies There is a movement to look at commonalities among therapies There is a movement to look at commonalities among therapies

61 The Effectiveness of Treatment Are particular therapies effective for particular problems? Are particular therapies effective for particular problems? Studies now being conducted to examine effectiveness of specific treatments for specific disorders: Studies now being conducted to examine effectiveness of specific treatments for specific disorders: “What specific treatment, by whom, is the most effective for this individual with that specific problem, and under which set of circumstances?” “What specific treatment, by whom, is the most effective for this individual with that specific problem, and under which set of circumstances?” Recent studies focus on the effectiveness of combined approaches – drug therapy combined with certain forms of psychotherapy – to treat certain disorders Recent studies focus on the effectiveness of combined approaches – drug therapy combined with certain forms of psychotherapy – to treat certain disorders


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