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Chapter 3 Clinical Assessment. “ An evidence-based approach to clinical assessment necessitates the recognition that even when evidence- based instruments.

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Presentation on theme: "Chapter 3 Clinical Assessment. “ An evidence-based approach to clinical assessment necessitates the recognition that even when evidence- based instruments."— Presentation transcript:

1 Chapter 3 Clinical Assessment

2 “ An evidence-based approach to clinical assessment necessitates the recognition that even when evidence- based instruments are used, the assessment process is a decision-making task in which hypotheses must be iteratively formulated and tested.” - Hunsley and Mash, 2010, p. 76

3 Which Theoretical Orientations Are Practiced in The Field? 2010 survey and earlier surveys conducted over 50 years with members of the Society of Clinical Psychologists (Norcross & Karpiak, 2012). The most predominant theoretical orientation was: cognitive (31%), eclectic-integrative (22%) psychodynamic (18%) behavioural (15%) humanistic (4%)

4 Therapeutic Assessment The basic premise of therapeutic assessment: assessment itself can be therapeutic. It can provide new insights, a sense of relief, a more mindful approach to cope with life challenges, or simply the sense that someone is taking an interest and cares.

5 Therapeutic Assessment Examples of Therapeutic Assessment…. Finn and Tonsager (1992) found that providing personality score feedback to students awaiting therapy lowered their distress and raised self-esteem. After receiving the Minnesota Multiphasic Personality Inventory : Newman and Greenway (1997) reported that students who received feedback had significant reductions in distress and significant increases in self-esteem relative to those students who did not receive feedback about their test results. Telling perfectionistic students about their perfectionism reduced emotional reactivity and psychological distress (Aldea, Rice, Gormley, & Rojas, 2010).

6 Therapeutic Assessment Finn (2007) suggested a key early session is the assessment interview that takes place shortly after test results are available. Here the client will discuss his or her problems in living as the assessor/therapist begins the process of relating these problems to test feedback.

7 Therapeutic Assessment This session is following by a summary and discussion session, which involves a focus on Level 1 findings (i.e., findings that are congruent with how people see themselves) Level 2 findings (i.e., findings that amplify or reframe how people typically see themselves) Level 3 findings (i.e., information findings that conflict with self-views)

8 Reliability And Validity In Assessment Reliability the cornerstone of any diagnostic system refers to consistency of measurement. Reliability is assessed via correlation (a measure of how closely two variables are related). The higher the correlation, the better the reliability.

9 Subtypes of Reliability Inter-rater reliability refers to the degree to which two independent observers or judges agree.

10 Subtypes of Reliability Test-retest reliability measures the extent to which people being observed twice or taking the same test twice score in generally the same way. Only makes sense when the theory assumes that people will not change appreciably between testings on the variable being measured Alternate-form reliability The use two forms of a test Internal Consistency Reliability Assesses if the items on a test are related to one another.

11 Validity Central question to validity: Does a measure fulfills its intended purpose? Validity is related to reliability: unreliable measures will not have good validity

12 Subtypes Of Validity Content validity refers to whether a measure adequately samples the domain of interest Criterion validity is evaluated by determining whether a measure is associated in an expected way with some other measure (the criterion). concurrent validity (same point in time) predictive validity (a point in the future) Construct validity Is a test a measure of some characteristic or construct that is not simply defined (Cronbach & Meehl, 1955). evaluated by looking at a wide variety of data from multiple sources.

13 Validity Validity of diagnostic categories? Construct validity

14 Case Validity Suggested recently by Teglasi, Nebbergall, and Newman (2012). the focus is on validity of the interpretations and decisions made with respect to a particular person. Case validity would be demonstrated when the person is accurately assessed in their life context in a way that takes into account interactions between the person and situations as well as interactions of the person’s schemas Case validity requires considering the person in typical situations versus maximal situations (i.e., the difference between how a person usually is versus what they are capable of in atypical or extreme situations).

15 Psychological Assessment Psychological assessment techniques are designed to determine cognitive, emotional, personality, and behavioural factors in psychopathological functioning.

16 Clinical Interviews Interview …any interpersonal encounter, conversational in style, in which one person, the interviewer, uses language as the principal means of finding out about another person, the interviewee. Clinical Interview The paradigm within which an interviewer operates influences the type of information sought, how it is obtained, and how it is interpreted. the interviewer pays attention to how the respondent answers—or does not answer— questions.

17 Clinical Interviews Great skill is necessary to carry out good clinical interviews, for they are usually conducted with people who are under considerable stress. It is critical to establish rapport with the client. Most clinicians empathise with their clients in an effort to draw them out, to encourage them to elaborate on their concerns, and to examine different facets of a problem.

18 Clinical Interviews The interview can be a source of considerable information to the clinician. Its importance in abnormal psychology and psychiatry is unquestionable. Whether the information gleaned can always be depended on is not so clear, however. Interviews vary in the degree to which they are structured.

19 Reliability of Unstructured Clinical Interviews to the extent that an interview is unstructured, the interviewer must rely on intuition and general experience. Reliability for initial clinical interviews is probably low.

20 Structured Interviews …an interview where the questions are set out in a prescribed fashion for the interviewer Used when mental health professionals need to collect standardized information, particularly for making diagnostic judgements based on the DSM (the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association). With adequate training of clinicians, inter-rater reliability for structured interviews is generally good (Blanchard & Brown, 1998).

21 Structured Clinical Interview Diagnosis (SCID) The SCID is a branching interview the client’s response to one question determines the next question that is asked. The SCID contains detailed instructions to the interviewer concerning when and how to probe in detail and when to go on to questions bearing on another diagnosis. Most symptoms are rated on a three-point scale of severity, with instructions in the interview schedule for directly translating the symptom ratings into diagnoses.

22 Evidence-Based Assessment Evidence-based assessment selects assessment measures based on extensive criteria including the reliability and validity of the measures and reading level required.

23 Psychological Tests Psychological tests are standardized procedures designed to measure a person’s performance on a particular task or to assess his or her personality, or thoughts, feelings, and behaviour. They may yield important information such as personality characteristics or situational determinants of a person’s problems.

24 Psychological Tests Standardization Test norms Standards that are used to interpret an individual ’s score because the score by itself for an individual is meaningless without a comparison context.

25 Personality Inventories For a personality inventory the person is asked to complete a self-report questionnaire indicating whether statements assessing habitual tendencies apply to him or her. The best-known and most frequently used and researched psychological test in the United States (see Butcher, Nezami, & Exner, 1998) is the Minnesota Multiphasic Personality Inventory (MMPI).

26 Minnesota Multiphasic Personality Inventory (MMPI) Intended to serve as an inexpensive means of detecting psychopathology Called multiphasic because it was designed to detect a number of psychological problems The MMPI has been widely used to screen large groups of people for whom clinical interviews are not feasible.

27 Developing the MMPI Many clinicians provided statements that they considered indicative of various mental problems. These items were rated as self-descriptive or not by clients already diagnosed as having particular disorders and by a large group of individuals considered normal. Items that “discriminated” among the clients were retained Items were selected if clients in one clinical group responded to them more often in a certain way than did those in other groups.

28 Developing the MMPI If an individual answered a large number of the items in a scale in the same way as had a certain diagnostic group, his or her behaviour was expected to resemble that of the particular diagnostic group.


30 Faking on The MMPI A superficial knowledge of contemporary abnormal psychology, for example, would alert even a seriously disturbed person that in order to be regarded as normal, he or she must not admit to worrying a great deal about germs on doorknobs. There is evidence that these tests can be “psyched out.” In most testing circumstances, however, people do not want to falsify their responses, because they want to be helped.

31 Faking on The MMPI The test designers have included as part of the MMPI several so-called validity scales designed to detect deliberately faked responses. In one of these, the lie scale, a series of statements sets a trap for the person who is trying to look too good. An item on the lie scale might be, “I read the newspaper editorials every night.” The assumption is that few people would be able to endorse such a statement honestly. Individuals who endorse a large number of the statements in the lie scale might well be attempting to present themselves in a particularly good light.

32 MMPI-2 Lees-Haley Fake Bad Scale This scale was created to primarily identify people in personal litigation lawsuits who claim to have been injured but who are actually malingering and faking bad (i.e., accentuating deficits that don’t really exist, such as the child who pretends to have a stomach ache to get out of going to school). What is the problem with the Fake Bad Scale? Analyses indicate that it tends to misclassify an unacceptably high proportion of people as fakers who are not actually faking (see Butcher, Arbisi, Atlis, & McNulty, 2008; Nelson, Sweet, & Demakis, 2006). The situation reached its apex in 2007 when MMPI-2 test results were barred for use in court cases in Florida. These concerns have resulted in the recommendation that multiple assessments be used when trying to detect malingering (see McDermott, 2012).

33 Projective Personality Tests …a psychological assessment device in which a set of standard stimuli, ambiguous enough to allow variation in responses, is presented to the individual. The projective hypothesis As the stimulus materials are unstructured, the client’s responses will be determined primarily by unconscious processes and will reveal his or her true attitudes, motivations, and modes of behaviour.

34 Rorschach Inkblot Test Is the best-known projective technique. a person is shown 10 inkblots, one at a time, and asked to tell what figures or objects he or she sees in each of them. Half the inkblots are in black, white, and shades of grey, two also have red splotches, and three are in pastel colours.

35 Posting of the Rorschach Online This test has been a matter of controversy and public debate, including in 2009, when the test was posted on Wikipedia along with recommended answers when the copyright lapsed and the measure was deemed to be in the public domain (for a discussion, see Butcher, 2010).

36 Thematic Apperception Test (TAT) …a person is shown a series of black-and-white pictures one by one and asked to tell a story related to each.

37 The Origins of Projective Tests and Their Assumptions Projective techniques are derived from the psychoanalytic paradigm. The use of projective tests assumes that the respondent would be either unable or unwilling to express his or her true feelings if asked directly. The real purposes of a test are best left unclear so as to bypass the defence mechanism of repression and get to the basic causes of distress.

38 The Origins of Projective Tests and Their Assumptions The content of the person’s responses was viewed as symbolic of internal dynamics Other uses of projective tests concentrate more on the form of the person’s responses. The test is considered more as a perceptual- cognitive task, and the person ’s responses are viewed as a sample of how he or she perceptually and cognitively organizes real-life situations (Exner, 1986).

39 Reliability and Validity With Projective Measures Regarding its reliability and validity, this work has enthusiastic supporters, as well as harsh critics (e.g., Garb, Wood, Lilienfeld, & Nezworski, 2005). Attempting to make a blanket statement about the validity of the Exner system for scoring the Rorschach is not the right approach The Rorschach appears to have considerable validity in identifying people with schizophrenia or at risk of developing schizophrenia (Viglione, 1999).

40 The Roberts Apperception Test for Children A standardized, objectively scored assessment tool Pictures of children and families are presented to the child, who tells a story about each one. Roberts test provides objective criteria for scoring, along with normative data to determine whether the child ’s pattern of responses is abnormal. Unique to this test are the scales that provide information about a child ’s coping skills.

41 Critics of Projective Tests Critics of projective testing have been and remain particularly concerned about its use as part of assessment and testimony in the courtroom. these measures continue to be used because they “overpathologize” respondents, suggesting that they are psychologically sick or dangerous in a way that might fit the agendas of certain lawyers. Another common use is to establish post-traumatic stress dysfunction in personal injury cases.

42 Intelligence Tests Alfred Binet, a French psychologist, originally constructed mental tests to help the Parisian school board predict which children were in need of special schooling. An intelligence test, often referred as an IQ (intelligence quotient) test, is a standardized means of assessing a person ’s current mental ability.

43 How are intelligence tests used? To predict how well a child will perform in school. To diagnose learning disabilities and to identify areas of strengths and weaknesses for academic planning To help determine whether a person is mentally retarded To identify intellectually gifted children A part of neuropsychological evaluations The periodic testing of a person believed to be suffering from a degenerative dementia so that deterioration of mental ability can be followed over time.

44 Distribution of IQ Scores Scores on most IQ tests are standardized so that 100 is the mean and 15 or 16 is the standard deviation (a measure of how scores are dispersed above and below the average). Approximately 65% of the population receives scores between 85 and 115. IQ tests are highly reliable (e.g., Carnivez & Watkins, 1998) and have good criterion validity.

45 Considerations With IQ Given the widespread use of IQ tests and other measures of cognitive ability, it is important that test-takers are evaluated according to norms that are applicable to their geographical, cultural, and racial backgrounds.

46 Comparing Races In Terms of IQ Intelligence tests and other measures of cognitive ability have been the source of extensive controversy over the years as a result of apparent racial and cultural differences. Reynolds and Suzuki (2012) note that differences between Black and White populations have been assessed for over 50 years and it is typically the case that Blacks have scores that are lower by 15 points (or one standard deviation). There are some indications that this gap is narrowing with it now being about 10 points (see Nisbett et al., 2012).

47 Comparing Races In Terms of IQ This difference in the scores of Blacks and Whites has been highly controversial because authors such as Jensen and Rushton have attributed the difference to genetic factors, despite the fact that research has yielded no evidence of genetic polymorphisms (Nisbett et al., 2012).

48 IQ Scores and The Environment Environmental factors play a role in light of evidence that there is a substantial increase in IQ scores when children are adopted and move from working class homes to middle-class homes (Nisbett et al., 2012).

49 Stereotype Threat (Gasquoine, 2009) Also known as differential diagnostic threat Scores fluctuate out of concerns about how the information will be used according to stereotypical preconceptions about members of a particular group.

50 Cultural bias or racial bias in assessment This is not a simple issue it is not clear that such biases make the assessment instruments useless. Some studies of bias in testing conducted in the United States have demonstrated that mainstream procedures, such as the Wechsler Intelligence Scale for Children—Revised, have equivalent predictive validity for minority and non-minority children (Sattler, 1992) Racially Sensitive Norms

51 Emotional Intelligence Reflected in such abilities as delaying gratification and being sensitive to the needs of others (Goleman, 1995). Emotional intelligence may also be an important protective factor in terms of levels of adjustment. High levels of emotional intelligence are associated negatively with alexithymia (see Saklofske, Austin, & Minski, 2003), a condition of reduced emotional awareness that is a risk factor for a variety of adjustment problems. High levels of emotional intelligence are associated with greater levels of subjective well-being and reduced proneness to depression (Saklofske et al., 2003).

52 Behavioural And Cognitive Assessment And Case Formulation A case formulation is: “a provisional map of a person ’s presenting problems that describes the territory of the problems and explains the processes that caused and maintain the problem” (Bieling & Kuyken, 2003, p. 53). It includes a clinician’s inferences about underlying processes that can be tested as hypotheses. It is used as the basis for planning interventions and evolves over time as further information is discovered.

53 SORC …behaviourally oriented clinicians often use a system that involves the assessment of four sets of variables, sometimes referred to by the acronym SORC S - stimuli O – organismic R - overt responses C - consequent variables

54 Stimuli S stands for stimuli the environmental situations that precede the problem. For instance, the clinician will try to ascertain which situations tend to elicit anxiety.

55 Organismic Referring to both physiological and psychological factors assumed to be operating “under the skin.” Perhaps the client ’s fatigue is caused in part by excessive use of alcohol or by a cognitive tendency toward self deprecation manifested in such statements as “I never do anything right, so what ’s the point in trying?”

56 Overt Responses These probably receive the most attention from behavioural clinicians, who must determine what behaviour is problematic, as well as the behaviour’s frequency, intensity, and form. For example, a client might say that he or she is forgetful and procrastinates. Does the person mean that he or she does not return phone calls, arrives late for appointments, or both?

57 Consequent variables Events that appear to be reinforcing or punishing the behaviour in question. When the client avoids a feared situation, does his or her spouse offer sympathy and excuses, thereby unwittingly keeping the person from facing up to his or her fears?

58 Cognitive Behavioural Case Formulation …place considerable emphasis on cognitive events such as people’s distorted thinking patterns, negative self-instructions, irrational automatic thoughts and beliefs, and schemas.

59 Direct Observation Of Behaviour Formal behavioural observation The observer divides the uninterrupted sequence of behaviour into various parts and applies terms that make sense within a learning framework. It is difficult to observe most behaviour as it actually takes place and little control can be exercised over where and when it may occur. Many therapists contrive artificial situations in their consulting rooms or in a laboratory so that they can observe how a client or a family acts under certain conditions.

60 Self-Observation Self-monitoring Self-monitoring has been used to collect a wide variety of data of interest to both clinicians and researchers, including moods, stressful experiences, coping behaviours, and thoughts (Stone et al., 1998). Self-monitoring is also known as ecological momentary assessment (EMA) (Stone & Shiffman, 1994) and experience sampling (see Trull & Ebner-Priemer, 2009).

61 Ecological Momentary Assessment (EMA) EMA involves the collection of data in real time retrospective recall of moods, thoughts, or experiences may be inaccurate. Memory researchers have shown not only that simple forgetting leads to inaccurate retrospective recall, but also that recalled information can be biased.

62 Reactivity The phenomenon of behaviour changing because it is being observed Considerable research indicates that behaviour may be altered by the very fact that it is being self-monitored; that is, the self- consciousness required for self-monitoring affects the behaviour (Haynes & Horn, 1982).

63 Self-Report Inventories …some of these questionnaires are similar to the personality tests. …others have a greater situational focus than traditional questionnaires. McFall and Lillesand (1971), for example, employed a Conflict Resolution Inventory 35 items that focused on the respondent’s ability to refuse unreasonable requests.

64 Cognitive Assessment The most widely employed cognitive assessment methods are self-report questionnaires that tap a wide range of cognitions, such as fear of negative evaluation a tendency to think irrationally a tendency to make negative inferences about life experiences.

65 Specialized Approaches To Cognitive Assessment Articulated Thoughts in Simulated Situations (ATSS) In this procedure, a person pretends that he or she is a participant in a situation, such as listening to a teaching assistant criticize a term paper. Presented on audio tape, the scene pauses every 10 or 15 seconds. During the ensuing 30 seconds of silence, the participant talks aloud about whatever is going through his or her mind in reaction to the words just heard.

66 Specialized Approaches To Cognitive Assessment Thought listing the person writes down his or her thoughts prior to or following an event of interest, such as entering a room to talk to a stranger, as a way to determine the cognitive components of social anxiety (Cacioppo, von Hippel, & Ernst, 1997).

67 Specialized Approaches To Cognitive Assessment Videotape reconstruction involves videotaping an individual while he or she is engaged in some task or an actual or roleplayed problematic situation. The person then watches the videotape while attempting to reconstruct his or her thoughts and feelings at the time as accurately as possible.

68 Specialized Approaches To Cognitive Assessment: A Problem Various cognitive assessment techniques often correlate poorly with one another This challenge can be especially difficult when it comes to cognitive assessment of children (e.g., Lodge, Tripp, & Harte, 2000). One has increased confidence when several different strategies are employed.

69 Family Assessment Considers the role of the family in the development of abnormal behaviour Central to classical psychoanalytic theories object-relations theories (e.g., Kernberg, 1985) that focus on an infant ’s attachment to the mother figure to social learning theory with its emphasis on the role of imitation of powerful parent figures (e.g., Bandura & Walters, 1963) interpersonal theories (e.g., Sullivan, 1953) that regard people as products of their social interactions. Family systems perspective (e.g., Minuchin et al., 1975) behaviours produced in the family environment reflect the various components that are present in the family setting, including the characteristics of each family member and the various interactions between family members.

70 Family Assessment equifinality the notion that the same goal or endpoint can result from many different starting points and different processes.

71 Family Assessment Clinicians and researchers often rely heavily on self- report measures of the family environment and family functioning these measures provide little insight into the family as an interacting system. Examples of measures used in Family Assessment Family Environment Scale (FES) Family Adaptation and Cohesion Evaluation Scale— Fourth Edition (FACES-IV; Olson, 2011) The Parental Bonding Inventory


73 Biological Assessment Types Of Brain Imaging Computerized axial tomography (CT scan) A moving beam of X-rays passes into a horizontal cross-section of the client ’s brain, scanning it through 360 degrees; the moving X-ray detector on the other side measures the amount of radioactivity that penetrates, thus detecting subtle differences in tissue density. the client’s head is moved, and the machine scans another cross-section of the brain.

74 Biological Assessment Types Of Brain Imaging Magnetic resonance imaging (MRI) MRI is superior to the CT scan because it produces pictures of higher quality and does not rely on even the small amount of radiation required by a CT scan. the person is placed inside a large, circular magnet, which causes the hydrogen atoms in the body to move. When the magnetic force is turned off, the atoms return to their original positions and thereby produce an electromagnetic signal. These signals are then read by the computer and translated into pictures of brain tissue.

75 Biological Assessment Types Of Brain Imaging Functional Magnetic Resonance Imaging (fMRI) allows researchers to take MRI pictures so quickly that metabolic changes can be measured, providing a picture of the brain at work rather than of its structure alone. It enables investigators to map cognitive, affective, and experiential processes onto brain substrates. Using this technique, one study found that there was less activation in the frontal lobes of clients with schizophrenia than in the frontal lobes of people with normal-functioning brains as they performed a cognitive task (Yurgelun-Todd et al., 1996).

76 Biological Assessment Types Of Brain Imaging Positron emission tomography (PET scan) a more expensive and invasive procedure that allows for measurement of brain function. A substance used by the brain is labelled with a short-lived radioactive isotope and injected into the bloodstream. The radioactive molecules of the substance emit a particle called a positron, which quickly collides with an electron. A pair of high-energy light particles shoot out from the skull in opposite directions and are detected by the scanner. A computer analyzes millions of such recordings and converts them into a picture of the functioning brain. The images are in colour; fuzzy spots of lighter and warmer colours are areas in which metabolic rates for the substance are higher.

77 Neuropsychological Assessment Neurologist a physician who specializes in medical diseases that affect the nervous system. Neuropsychologist a psychologist who studies how dysfunctions of the brain affect the way we think, feel, and behave. Both kinds of specialists contribute much to each other as they work in different ways, often collaboratively, to learn how the nervous system functions and how to ameliorate problems caused by disease or injury to the brain.

78 The Goals of Neuropsychological Testing to measure as reliably, validly, and completely as possible the behavioural correlates of brain functions to identify the characteristic profile associated with a neurobehavioural syndrome (differential diagnosis) to establish possible localization, lateralization, and etiology of a brain lesion to determine whether neuropsychological deficits are present (i.e., cognitive, perceptual, or motor) regardless of diagnosis to describe neuropsychological strengths, weaknesses, and strategy of problem solving to assess the patient ’s feelings about his or her syndrome to provide treatment recommendations (i.e., to client, family, school)

79 Neuropsychological Assessment Neuropsychological Tests tests developed to assess behavioural disturbances caused by brain dysfunctions. based on the idea that different psychological functions (e.g., motor speed, memory, language) are localized in different areas of the brain. Thus, finding a deficit on a particular test can provide clues about where in the brain some damage may exist.

80 Psychophysiological Assessment Psychophysiology is concerned with the bodily changes that accompany psychological events or that are associated with a person ’s psychological characteristics. measures such as heart rate, tension in the muscles, blood flow in various parts of the body, and brain waves to study the physiological changes that occur when people are afraid, depressed, asleep, imagining, solving problems, and so on. The assessments described here are not sensitive enough to be used for diagnosis; they can, however, provide important information.

81 Psychophysiological Assessment Electrocardiogram Measures heart rate Each heartbeat generates spreading changes in electrical potential, which can be recorded by an electrocardiograph, or on a suitably tuned polygraph, and graphically depicted in an. Electrodes are usually placed on the chest and lead to an instrument for measuring electric currents.

82 Psychophysiological Assessment Electrodermal responding A measure of autonomic nervous system activity or skin conductance. Anxiety, fear, anger, and other emotions increase activity in the sympathetic nervous system, which then boosts sweat-gland activity. Conductance is typically measured by determining the current that flows through the skin when a known small voltage derived from an external source is passed between two electrodes on the hand. This current shows a pronounced increase after activation of the sweat glands.

83 Psychophysiological Assessment Electroencephalogram (EEG). A measure of brain activity Electrodes placed on the scalp record electrical activity in the underlying brain area. Abnormal patterns of electrical activity can indicate epilepsy or can help in locating brain lesions or tumours.

84 Copyright Copyright © 2014 John Wiley & Sons Canada, Ltd. All rights reserved. Reproduction or translation of this work beyond that permitted by Access Copyright (The Canadian Copyright Licensing Agency) is unlawful. Requests for further information should be addressed to the Permissions Department, John Wiley & Sons Canada, Ltd. The purchaser may make back-up copies for his or her own use only and not for distribution or resale. The author and the publisher assume no responsibility for errors, omissions, or damages caused by the use of these programs or from the use of the information contained herein.

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