California Profesional Psychology School Class Flashcards
Crisis
a period of psychological disequilibrium, experienced as a result of a hazardous event or situation that constitutes a significant problem that cannot be remedied by using familiar coping strategies
defining feature of crisis is it is time-limited and ordinarily lasts for no more than 6-8 weeks…without appropriate resolution, crisis may produce lasting dysfunction
Components of Crisis (Golan)
- Hazardous event - specific stressor initiating reactions leading to crisis that may be anticipated (marriage/retirement) or unanticipated (death)
- Vulnerable State - person’s responses to hazardous event marked by increase in tension and sense of ineffectiveness the person attempted to relieve by using customary coping strategies…if attempts are unsuccessful, tension increases and ability to function decreases
- Precipitating Factor - final stressful event in series of events moving person from state of acute vulnerability to state of disequilibrium/disorganization.
- Active Crisis State - when coping skills have broken down and tension is at a maximum level leading to state of disequilibrium. Person usually recognizes that customary coping mechanisms are inadequate and thus, may be highly motivated to seek and accept help
3 stages:
a) physical and psychological agitation
b) preoccupation with the events that led to the crisis
c) gradual return to a state of equilibrium
- Reintegration - restoration of equilibrium after crisis involving ability to objectively evaluate crisis situation and develop and use adaptive coping strategies.
Crisis Origins (types)
crises categorized in terms of their origin as situational or maturational
Situational Crises (crises origin)
triggered by sudden, uncontrollable, and usually unanticipated event that threatens the person’s sense of psychological, biological, and/or social well-being. Ex, natural/man-made disaster, assault, rape, unexpected job loss, expected death, physical illness/injury
Maturational (Developmental) Crises [crises origin]
embedded in developmental processes; occurs when a person is struggling with the transition from one life stage to another
may be universal in that they reflect normal life-cycle transitions (ie. puberty, retirement transitions) or non-universal in that not all people experience them during the course of normal development (i.e. change in social status due to divorce or relocation to another country)
Phases (reactions to a crisis)
1) impact phase - occurs immediately after the event and lasts from a few minutes to a few hours… person exhibit shock, fear, agitation, confusing, or other overt signs of distress and may deny that the vent has occurred
2) recoil phase - occurs when individual begins to acknowledge the reality of situation and attempts to make sense of what has happened; characterized by an intensification of emotional and physical symptoms
3) posttraumatic recovery phase - may involve alternating periods of adjustment and relapse as the person becomes fully aware of the implications of what has occurred and attempts to re-establish a state of equilibrium; duration depends on severity of crisis, individual’s characteristics, and the effectiveness of treatment
Symptoms (reactions to a crisis)
combination of affective, cognitive, behavioral, and physical symptoms that may appear a few hours, days, or even months after precipitating event occurs
affective sxs: shock, disbelief, numbness, fear, anger, irritability, anxiety, sadness, guilt or shame, and helplessness
cognitive sxs: flashbacks, intrusive thoughts and images, nightmares, disorientation, confusion, and impaired memory, concentration and design-making
behavioral sxs: difficulties accomplishing activities of daily living, social withdrawal, change in sexual activity, an inability to perform work-related duties, behaviors that are inappropriate or inconsistent with thoughts and feelings (i.e. laughing while describing an unpleasant event), impulsive and dangerous actions, and substance abuse
physical sxs: sleep disturbances, appetite changes, muscle tension and aches, nausea and diarrhea or constipation, sweating, hyperventilation, agitation, palpitations, dizziness, and a heightened startle response
Risk Factors (reactions to a crisis)
pre-event factors: previous unresolved trauma or loss, previous psychiatric history or substance abuse, concurrent life stressors, socioeconomic disadvantage, and female gender
peri-event factors: sudden and unexpected event, man-made (vs natural) disaster, prolonged exposure to the vent, perceived or actual threat to life of self or others, exposure to horrific scenes or sensory experiences and substantial personal loss
post-event factors: survivor or performance guilt, adverse reactions by others, and a lack of social support
Anniversary Reaction (reactions to a crisis)
refers to physical, emotional, and behavioral symptoms that occur around the anniversary of the event that precipitated crisis.
sxs may include re-experiencing even in dreams or flashbacks; depression, anxiety, anger, and/or fear; feelings of guilt or helplessness; and physical symptoms.
for many people, recognizing sxs are due to anniversary reaction is alleviating but for others, may require treatment
Impact of Culture (reactions to a crisis)
requires recognition that culture may impact how one reacts to and recovers from a crisis; culture affects how people express their feelings, interpret their psychological symptoms, and respond to help
Characteristics of Crisis Assessment
1) clearly linked to crisis resolution (ex client learns during assessment that fear and sense of helplessness are normal responses, this awareness may help alleviate their reactions)
2) focuses primarily on immediate problems but also addresses historical information that is pertinent to understanding and resolving the current crisis (i.e. history of solving problems and coping with stressful events)
3) assessment is a collaborative effort with person and significant others of this person to identify treatment goals and a treatment plan and encourages the client to make decisions during the course of treatment
Communication Skills (crisis assessment)
establishing rapport is essential to crisis assessment and intervention; depends on provider’s ability to convey empathy, concern, and sincerity, which is affected by use of communication techniques that let the client know that they are understood.
effective communication techniques:
1) silence (allow time for the client to speak and facilitate catharsis by avoiding interruptions)
2) nonverbal attending (relay interest and concern through body language
3) restatement (confirm accuracy of understanding by repeating important information
4) paraphrasing (demonstrate understanding and empty by summarizing major points
5) reflection of emotion (acknowledge and mirror emotional reactions)
6) closed-ended questions (to get specific information
7) open-ended questions (ask what, why, how, etc to obtain more detailed info)
Assessment Domains (crisis assessment)
1) Risk to life…of self and others: when danger signs present, conduct structured inquiry to collect info to help identify and implement appropriate plan to protect life. Use direct questions
2) Origins, Severity, and Development of Crisis: involves identifying the hazardous event and precipitating factor(s) that led to the client’s current distress which helps determine if indiv’s distress is a manifestation of chronic stress or acute crisis state, identify the phase of clt’s crisis state, and help identify the appropriate intervention. Precipitating event can be difficult to identify so use of direct questions can help identify the precipitating factor(s).
3) Manifestations of the Crisis: goal of this aspect of assessment is to determine how the client interprets the events that led to the crisis (i.e. as a threat, loss, or challenge), emotional, cognitive, behavioral,a nd physical symptoms, and usually way of responding to stress. This info will help identify appropriate intervention strategies and establish a baseline for evaluating the client’s progress in treatment (ex “how do you feel about what just happened?” and “how do you usually cope with stressful events?”;;; interpret symptoms as a normal response to stressful event rather than as signs of pathology (assigning a diagnosis to a person’s reaction to crisis may result in viewing the reaction as an illness rather than opportunity for growth);;;; clt’s pre-crisis functioning within affective, cognitive, and behavioral domains should be assessed to determine the extent of change th client has experienced in these domains as a result of the crisis event which will hep determine the extent to which the client’s current functioning is atypical and whether impairments in functioning are related to the current crisis or are chronic;;; clt’s subjective interpretation of recent stressful events is a key determinant of their crisis response and may be assessed by considering questions such as, “is interpretation consistent with relating of situation? if not, does clt’s interpretation differ from reality to the extent that it constitutes a threat to the clt’s or someone else’s well-being? to what extent is clt open to changing irrational beliefs about crisis situation and reframing them in more rational terms?”;;; socialization processes and value systems affect how people interpret events
4) Family, community, and sociocultural factors: evaluate relevant family factors, community resources, and cultural influences to clarify the origins of the crisis and the client’s reaction to it and to identify what alternatives are available to help the client resolve the crisis and restore him/her to a pre crisis level of functioning
Types of Assessment (crisis) - 1) Triage assessment
occurs immediately following a community disaster or other traumatic event and is conducted by first responders. Involves obtaining crucial demographic data and information about clt’s perceptions of the event, coping skills and sources of support safety and lethality, mental status, current symptoms, preexisting psychiatric conditions, environmental stressors, and ability to benefit from treatment. Purpose of triage assessment is to determine if an intervention is necessary and, if so, to identify the appropriate intervention - i.e. emergency inpatient hospitalization, outpatient treatment, or referral to a support group or social service agency
Types of Assessment (crisis) -
1 Triage assessment 2 Crisis Assessment 2a Rapid assessment instruments (RAIs) 2b Semi-Strucured Interviews 3 Biopsychosocial Assessment
Types of Assessment (crisis) - 2) Crisis Assessment
goal of crisis assessment is to “provide a systematic method of organizing clt information related to personal characteristics, parameters of crisis episode, and the intensity and duration of the crisis and..then utilize these data to develop effective treatment plans…important to distinguish between normal reactions to crisis event and reactions that are excessive or that reflect a pre-existing condition/disorder
2a Rapid Assessment Intervals (RAIs) are brief standardized self-report measures that are easy to administer and score and can be included in the initial assessment and used to monitor the progress of treatment (BSI-Brief Symptom inventory, BDI, Impact of Events Scale, Lewis Roberts Crisis State Assessment Scale)
2b Semi-Structured Interviews: ex, Myer’s Triage Assessment Model [ 1) affective domain includes 3 types of reactions - anger/hostility, anxiety/fear, and sadness/melancholy. Optimal interventions for ppl whose strongest reactions are in affective domain are supportive strategies that validate the client’s feelings; catharsis strategies to help express; and awareness strategies that help clt become more conscious of emotions
2) cognitive domain represents clt’s perceptions of crisis event as a transgression, threat, or loss. Respective effective interventions are ordering strategies that promote rational thinking; clarifying strategies that help the clt consider alternative interpretations; and delimiting strategies that help clt stop catastrophizing the crisis situation
3) behavioral domain consists of 3 types of reaction - avoidance, approach and immobility. Respective interventions are guiding (helping clt identify and obtain resources); protecting (keeping clt and others safe); and mobilizing (mobilizing sources of support and assistance).
Types of Assessment (crisis) - 3) Biopsychosocial Assessment
to obtain information on person’s biological and psychological functioning and sociocultural experiences that will be helpful for formulating treatment goals and a treatment plan. Amount of info collected depends on severity of crisis and urgency and nature of services required (i.e. developmental crisis vs emergency situation)
Myer’s Triage Assessment Model
1) affective domain includes 3 types of reactions - anger/hostility, anxiety/fear, and sadness/melancholy. Optimal interventions for ppl whose strongest reactions are in affective domain are supportive strategies that validate the client’s feelings; catharsis strategies to help express; and awareness strategies that help clt become more conscious of emotions
2) cognitive domain represents clt’s perceptions of crisis event as a transgression, threat, or loss. Respective effective interventions are ordering strategies that promote rational thinking; clarifying strategies that help the clt consider alternative interpretations; and delimiting strategies that help clt stop catastrophizing the crisis situation
3) behavioral domain consists of 3 types of reaction - avoidance, approach and immobility. Respective interventions are guiding (helping clt identify and obtain resources); protecting (keeping clt and others safe); and mobilizing (mobilizing sources of support and assistance).
Goals of Crisis Intervention
usually include
1) relieve clt’s current symptoms
2) help clt identify and gain understanding of factors that led to crisis state
3) use remedial measures and available resources to restore the clt to pre-crisis level of functioning or, if possible, improve functioning above the pre-crisis level)
4) help clt develop adaptive coping strategies that can be used in current and future situations
5) help clt connect current stresses with past life experiences
Note: 1st 3 goals must be addressed in all crisis interventions while last two are feasible/necessary in only some situations
Crisis Intervention vs long-term therapy
Crisis Intervention vs Long-Term Therapy
Regarding diagnosis: focused crisis assessment vs comprehensive diagnostic evaluation
Regarding Treatment Focus: immediate traumatized aspects of person vs underlying causes and whole person
Regarding Treatment Plan: Problem-speific plan to alleviate crisis symptoms vs Personalized comprehensive plan that addresses long-term needs
Regarding Treatment Strategies: Time-limited techniques for immediate resolution of the crisis vs Various techniques that address short-term, intermediate, and long-term goals
Regarding Evaluation of Results: Behavioral evaluation of person’s return to pre-crisis state of equilibrium vs Behavioral evaluation of therapeutic outcome in terms of person’s overall functioning
Principles of Crisis Intervention
7 core principles
1) Proximity - crisis intervention are usually provided in surroundings that are close to the clt’s normal area of functioning or where the precipitating event occurred
2) Immediacy - to maximize their effectiveness, crisis interventions are provided as soon as feasible after precipitating event
3) Expectancy - refers to the need to instill hope as early as possible
4) Brevity - most crisis interventions involve 1-5 contacts with clt
5) Simplicity - interventions are usually simple rather than complex and address one issue at a time
6) Innovation - refers to the modification of routine interventions to fit the situation and clt’s needs
7) Practicality - for an intervention to be useful, must be able to be carried out by the clt
Crisis Intervention Tasks
4 Primary Tasks of Crisis Intervention
1) physical survival (maintaining physical health and preventing suicide/homicide)
2) expression of feelings (identifying and expressing feelings related to the crisis and understanding how feelings impact psychological and physical well being)
3) cognitive mastery (developing a reality-based understanding of the crisis event by addressing irrational beliefs and fears and unfinished business and modifying self-image in light of the crisis event
4) behavioral and interpersonal adjustments (adapting to changes in daily life activities, relationships, and goals and minimizing the long-term negative consequences of the crisis)
Evaluating Crisis Intervention Outcomes
before deciding to end intervention, consider:
1) has clt regained equilibrium in all basic ares of functioning (behavioral, affective, cognitive, somatic, interpersonal)?
2) has clt regained their coping capabilities?
3) has clt integrated crisis event into their life as a whole so that it no longer requires intense attention?
4) were previously unresolved personality issues triggered by crisis and if so, have they been successfully worked through or is additional treatment required?
Crisis Intervention Models - Stress-Crisis Continuum by Burgess and Roberts 2005
7 level stress-crisis continuum to help providers identify the type of crisis a clt is experiencing and choose an appropriate intervention
Level 1 - Somatic Distress - crisis due to somatic distress is precipitated by a biomedical disease (i.e. cancer, diabetes) or by depression, anxiety, or other minor psychiatric state. Respective intervention include patient education about illness and medical treatments focusing on sx reduction
Level 2 - Transitional Crisis - crisis due to stressful events that are usually anticipated but cannot be entirely controlled by the person (i.e. adolescent pregnancy, job transition). Respective interventions include education about life transitions, anticipatory guidance to help prepare for the transition, self-help groups and individual therapy
Level 3 - Traumatic Stress Crisis - precipitated by an external stressor that is ordinarily unpredictable and is sudden, life-threatening, and overwhelming (e.g., natural disaster, sexual assault, sudden death). Respective interventions include crisis-oriented cognitive-behavioral therapy, strategic solution-focused therapy, and pharmacotherapy
Level 4 - Family Crisis - precipitated by family or other primary interpersonal relationship and may be related to a developmental issue such as dependency or sexual intimacy (i.e. child abuse, DV, homelessness,) Respective interventions goals are to destabilize lives, strengthen interpersonal relationships and deter psychiatric symptomatology which may be achieved with comprehensive psychoeducation and indiv/couple/family interventions
Level 5 - Serious Mental Illness - occurs when dementia, psychosis, or other serious mental illness increases the likelihood that another problem will precipitate a crisis state. Immediate crisis intervention should focus on symptom reduction thru enhancing problem-solving skills, environmental manipulation, and/or pharmacotherapy. hospitalization and long term indiv and grp treatments are likely to be required
Level 6 - Psychiatric Emergencies - involves severe impairment in general functioning with a threat or actual harm to self and/or others (i.e. suicide attempt, homicide, OverDose. Respective Interventions focus on rapid assessment, mobilization of appropriate resources, and provision of emergency care.
Level 7 - Catastrophic Crises - combines 2 or more level 3 Crises with a level 4-6 crises. Requires comprehensive multimodal intervention
Seven Stage Crisis Intervention Model by Roberts
Most frequently cited models and applied to various situational and maturational crises.
1) Crisis assessment: evaluate lethality of SI/HI, immediate medical/psychosocial needs, and risk/protective factors
2) Establish Rapport - convey respect, genuineness and acceptance
3) Identify Major Problems - ID and prioritize problems including precipitating event, nature of clt’s reactions, and clt’s lethality and previous coping methods
4) Explore Feelings and Emotions - through this process, help clt ID maladaptive beliefs underlying emotions, consider behavior options and restore emotional balance
5) Generate and Explore Alternatives - stage where clt may sign no-suicide/-violece contract, consider hospitalization, etc.
6) Develop and Implement an Action Plan - implementation of interventions and promote cognitive master of crisis (i.e. understanding what led to crisis, meaning of crisis, and replacing maladaptive beliefs with adaptive ones). This stage ends with resolution of crisis.
7) Follow-up - Post crisis evaluation assessing clt’s overall functioning and satisfaction w/treatment and determine how clt is handling current stressors. Establish a follow-up plan (i.e. follow-up session once a month, annually, periodical “booster” sessions.
Intervention Approaches (Crisis Intervention Methods) by Gilliland and James
depends on clt’s level of mobility/immobility (ability to autonomously change/cope in response to different moods, feelings, emotions, needs, conditions and influences)
1) nondirective - usually when clt can do it themselves and crises are less severe. Provider supports clt to make their own decisions
2) collaborative approach - when non directive doesn’t work, but enough mobility to work with provider. Provider’s rol is catalyst, facilitator, consultant, and provider of support
3) directive - when clt is too immobile to cope effectively with crisis due to psychiatric symptoms and level of functioning. Provider assumes temporary responsibility and control, defines problems and alternative solutions, and facilitates the clt’s ability to take action by providing instruction and explicit guidance.
Intervention Alternatives
1) Psychological First Aid (PFA) - mental health services provided to an individual immediately following exposure to a disaster or other traumatic event with primary goal of bolstering sense of safety, well-being and empowerment. This is often 1st phase in intervention process and involves 6 steps (1-immediate intervention - provide immediate contact, address safety needs, and prevent legal bxs, 2-establish rapport, 3- assessment, 4-take action, 5-utilize referral sources, and 6-provide aftercare)
2) Group Interventions (ex. group cognitive processing therapy is effective for female survivors of sexual assault; cognitive behavioral group therapy shows reduction of trauma related sxs in children physically abused; bereavement support groups for couple whose baby died and for children who experienced suicide of parent or sibling) —-Critical Incident Stress Management (CISM) is multimodal approach for individuals who have been exposed to a disaster or other traumatic event and combines grp therapy with indiv counseling and support, family interventions, and follow up services and referrals Group defusing (structured small-group discussions occurring within a few hours after traumatic event allowing members to vent and reflect on feelings in safe, supportive environment) and debriefing (more formal meetings that are held at intervals during first several days to weeks after even are used to provide info to victims and their families, help victims deal with trauma related symptoms, and facilitate post-crisis psychological closure) are components of CISM
3) Individual Interventions (behavior, cognitive-behavior, and solution-focused therapy). Some evidence supporting Trauma-Focused CBT.
4) Family Interventions - Harris’s systematic model based on problem-solving approach involving 5 steps: 1)making psychological (therapeutic) contact with the family by building rapport and encouraging family members to express their feelings and tell their personal stories; 2)exploring dimension of emily problem by ID-ing immediate concerns, ID-ing family strengths and weaknesses, and mobilizing social support; 3) exploring possible solutions by helping family ID alternatives and create a “family healing theory”; 4) assisting family in taking concrete action by ID-ing ways to overcome obstacles and urging members to work toward resolving their probs; 5) providing follow-up by continuing to see family, make referrals, and/or check on their progress.
5) Referrals - refer to professionals, services, or agencies depending on clt’s need
Assessment Goals for (Suicide)
determine imminent and future risk for SI, get info needed to develop treatment plan, and once treatment beings, monitor its effectiveness
Timing of Assessment (for Suicide)
Suicide assessment is done at 1 initial evaluation, 2 during each session of several months following release from psychiatric hospitalization, 3 during each session of a suicide intervention, 4 at onset of new, painful, or disabling medical condition, 5 at onset of a new or intensification of a co-existing psychiatric disorder, 6 at onset of signs of relapse or recurrence of sxs, 7 at occurrence of a major stressor, and 8 on the emergence of other high-risk factors
Assessment Methods (suicide)
involves integrating info from a variety of sources including a clinical interview, a mental status exam, clt’s family members, clt’s physician and other health care providers, and psychological tests
1) risk factors: (for general risk factors = 1 suicidal thoughts/behaviors, gestures, plans, and history of suicide attempts; 2 psychiatric diagnosis; 3 psychiatric symptoms; 4 physical illness; 5 psychosocial factors (recent stressful life event or chronic stress, lack of social support, history of violence or trauma, and family history of suicide or mental illness; and 6 demographic characteristics) (for adolescents, risk factors are aggression and hostility especially when combined with depression, impulsivity, recent interpersonal conflict/loss, substance abuse, history of physical and/or sexual abuse)
(for Older adults, risk factors are physical illness, depression/bipolar do, multiple losses associated with aging, access to firearms or other lethal means
Gender, Age, and Race relationship to Risk Factors for Suicide
high risk is associated with male gender, older age, and White race
for males, rates are highest among those ages 75 an older but for women, rates are highest for ages 45-54.
Rates for completed suicide are higher for men, while rates for attempted suicide are higher for women
RE race/ethnicity, for most age groups, Whites have the highest rates of suicide with exception for American/Indian/Alaskan Native people aged 15-34 which is nearly double the national average for that age group
Protective Factors relationship to Risk Factors for Suicide
include good coping and problem-solving skills, intact reality testing, a sense of responsibility toward family, ability to garner social support, cultural or moral/religious values that discourage suicide, fear of suicide, motivation to seek help and access to mental health services, and a positive therapeutic appliance
Making Predictions relationship to Risk Factors for Suicide
can’t make predictions but in general, the greater the number of risk factors and the fewer the number of protective factors, the higher the level of risk
Suicide Screening Questions
ask clt direction questions about suicidal thoughts plans, behaviors, and intent. this is a critical aspect of suicide assessment
1) being with questions addressing feelings about living: do you ever feel that life isn’t worth living? do you sometimes feel as though you’d like to go to sleep and never wake up? how does the future look o you?
2) follow-up questions with questions that address specific thoughts about death, suicide, and self-harm: have you been thinking about harming yourself lately? have you been thinking about what it would be like to die?
3) for clients who have thoughts about death, suicide, or self-harm, follow-up with more specific questions about those thoughts and about a suicide plan, intent, and lethality: what led up to your thoughts of suicide? do you have a specific plan for how you will kill yourself?
4) for clients who have attempted suicide or engaged in self-harm, follow-up with more specific questions about those incidents: what was happening in your life right before the attempt?
5) As appropriate, follow-up with questions that address the clt’s risk for harm to others: are there other people who you would want to die with you?
Psychological Tests (assessment methods for suicide)
these instruments are not likely to be useful when clt is in acute crisis state and in need of immediate intervention, they can be helpful for detecting SI in clts who are not overtly suicidal
Beck Scale for Suicide Ideation (BSS) - 21 item self-report measure that quantifies the intensity of individual’s suicidal ideation over previous week and addresses clt’s suicidal wishes, attitudes, and plans. Scores range from 0 to 38 with hither scores indicating greater severity of suicidal ideation.
Beck Depression Inventory - 2nd Ed (BDI-II) - 21 items that address cognitive, affective, behavioral, and physical aspects of depression and correspond to the DSM’s diagnostic criteria for depressive dos. Each item has four choose that are rated according to severity from 0 to 3. Severe depression = 29-63.
Beck hopelessness Scale (BHS) - 20 true/false items that evaluate negative attitudes about the future. Total score ranges 0-20, with higher scores indicating a greater degree of hopelessness
Reasons for Living Inventory - 48 item rating scale assessing beliefs and expectations that reduce the likelihood that an individual will act on suicidal ideas. Proivdes total score and 6 sub scales (survival and coping beliefs, responsibility to family, child-related concerns, fear of suicide, fear of social disapproval, and moral objections to suicide. Scores range from 1 to 6, with higher scores indicating more reasons for living
Minnesota Multiphasic Personality Inventory (MMPI-2/MMPI-A) - No MMPI “suicide profile” has been found to be an accurate predictor of suicide risk. Elevated score on Scale 2 (depression) raises possibility of suicide, especially when elevation is high to very high on Scales 4 (psychopathic deviant), 7 (Psychasthenia), 8 (Schizophrenia), and/or 9 (Hypomania).
10 Scales of the MMPI
The MMPI has 10 clinical scales that are used to indicate different psychological conditions. Despite the names given to each scale, they are not a pure measure since many conditions have overlapping symptoms. Because of this, most psychologists simply refer to each scale by number.
Scale 1 – Hypochondriasis: This scale was designed to asses a neurotic concern over bodily functioning. The 32-items on this scale concern somatic symptoms and physical well being. The scale was originally developed to identify patients displaying the symptoms of hypochondria.
Scale 2 – Depression: This scale was originally designed to identify depression, characterized by poor morale, lack of hope in the future, and a general dissatisfaction with one’s own life situation. Very high scores may indicate depression, while moderate scores tend to reveal a general dissatisfaction with one’s life.
Scale 3 – Hysteria: The third scale was originally designed to identify those who display hysteria in stressful situations. Those who are well educated and of a high social class tend to score higher on this scale. Women also tend to score higher than men on this scale.
Scale 4 - Psychopathic Deviate: Originally developed to identify psychopathic patients, this scale measures social deviation, lack of acceptance of authority, and amorality. This scale can be thought of as a measure of disobedience. High scorers tend to be more rebellious, while low scorers are more accepting of authority. Despite the name of this scale, high scorers are usually diagnosed with a personality disorder rather than a psychotic disorder.
Scale 5 – Masculinity/Femininity: This scale was designed by the original author’s to identify homosexual tendencies, but was found to be largely ineffective. High scores on this scale are related to factors such as intelligence, socioeconomic status, and education. Women tend to score low on this scale.
Scale 6 – Paranoia: This scale was originally developed to identify patients with paranoid symptoms such as suspiciousness, feelings of persecution, grandiose self-concepts, excessive sensitivity, and rigid attitudes. Those who score high on this scale tend to have paranoid symptoms.
Scale 7 – Psychasthenia: This diagnostic label is no longer used today and the symptoms described on this scale are more reflective of obsessive-compulsive disorder. This scale was originally used to measure excessive doubts, compulsions, obsessions, and unreasonable fears.
Scale 8 – Schizophrenia: This scale was originally developed to identify schizophrenic patients and reflects a wide variety of areas including bizarre thought processes and peculiar perceptions, social alienation, poor familial relationships, difficulties in concentration and impulse control, lack of deep interests, disturbing questions of self-worth and self-identity, and sexual difficulties. This scale is considered difficult to interpret.
Scale 9 – Hypomania: This scale was developed to identify characteristics of hypomania such as elevated mood, accelerated speech and motor activity, irritability, flight of ideas, and brief periods of depression.
Scale 0 – Social Introversion: This scale was developed later than the other nine scales as is designed to assess a person’s tendency to withdraw from social contacts and responsibilities.
Rorschach Inkblot Test
revised Rorschach Suicide Constellation (S-CON) consists of 12 variables intended to ID clts at risk for suicide. S-CON score of 8 or more indicates a very high potential for suicide, while a score of 6 or 7 suggests the need for additional evaluation for suicide potential
Treatment Goals (for Suicide)
Primary and Secondary Goals
Primary goals are to: 1 ensure the clt’s safety by eliminating or reducing access to common methods of suicide (firearms, meds); 2 establish a therapeutic alliance with trust and rapport; 3 alleviate acute risk symptoms that are amenable to treatment (panic sxs, agitation,insomnia, substance abuse)
Secondary goals are to reduce future suicide risk by addressing mania, depression, and other conditions and risk factors
Treatment Alternatives (for Suicide)
3 types: hospitalization, outpatient crisis intervention, and outpatient psychotherapy.
Consider clt’s preferences and the potential risks and benefits of each approach
No suicide contracts do not guarantee person’s safety and should be used only as a component of a comprehensive intervention
Hospitalization (for Suicide)
appropriate for clt who just attempted suicide or is at imminent risk for suicide as indicated by presence of a specific suicide plan with access to lethal means in conjunction with other risk factors such as impaired judgment, current impulsive behavior, severe mental illness or chemical dependency, and/or a lack of social support. Initial alternative should be to encourage voluntary hospitalization but involuntary hold should be initiate if clt refuses voluntary hosp.
Outpatient Crisis Intervention (for Suicide)
when clt is at moderate risk for suicide as evidenced by suicidal intent with lack of access to lethal means, fair or good judgment, presence of social support, and a willingness to comply with treatment. Crisis intervention for suicide risk could involve 7 stage crisis intervention model by Roberts and Ottens or other crisis intervention model
intervention should address: reducing social isolation, removing lethal means of suicide, encouraging clt to express anger in alternative ways, relieving anxiety and sleep loss, and persuading clt to postpone a decision about suicide until after crisis has ended.
Outpatient Psychotherapy (for Suicide)
appropriate as follow-up to hospitalization and crisis intervention and the treatment for clots who are at low risk for suicide as evidenced by suicidal intent with an absence of a specific suicide plan, the present of social support, and willingness to talk about problems and comply with treatment. Beneficial therapies for suicidal clots include CBT, interpersonal therapy, DBT, and problem-solving therapy
Danger (risk) to others
refers to a number of harmful acts including emotions, sexual and physical violence, intimidation and threats, neglect or abuse of dependents, stalking and harassment, property damage, and reckless bx.
Legal and Ethical Issues (Danger to others)
issues of concern regarding legal and ethics: maintaining clt’s confidentiality vs due to warn/protect clt’s intended victim(s) and the need to involuntarily hospitalize clt.
Confidentiality vs Duty to Warn/Protect
Exception to confidentiality in law and ethical standards is when clt is a serious risk of danger to otters.
Tarasoff decision established therapist’s duty to protect a readily identifiable victim by warning them, notifying police, and/or taking other reasonably necessary steps.
California adopted Civil Code Setion 43.92 as an immunity statute designed to establish “warning as one way, but no the exclusive way, to get immunity and discharge the tidy to warn or protect.”… in addition, Standard 4.05 of APA Ethics Code states that psychologists may disclose confidential info without clt’s consent as mandated by law or where permitted by law for a valid purpose to protect clt, psychologist, or others from harm”
Involuntary Hospitalization
voluntary hospitalization is usually an option before initiating an involuntary hold; involuntary hold should be considered only when the danger the clt poses is imminent and due to mental disorder or chronic alcoholism, and the clt has refused or unable to comply with recommendation to enter a psychiatric hospital voluntarily
Protection from Violent Clts
When faced with a violent clt, important to remain calm, encourage communication by asking open-ended questions, and attempt to determine intensity of clt’s feelings and lethality of their intent
Methods: less intrusive (speaking softly, moving slowly, adequate physical distance from clt, leaving door open, expressing sympathetic concern for clt’s well-being, setting limits on bx and suggesting alternatives to violence) vs more intrusive (when less intrusive methods fail and include leaving the room, calling for help, picking up a potential “weapon” and if necessary, fitting back. Calling for help is acceptable only if clt’s condition permits violation of confidentiality or clt gives permission for doing so
Assessment Goals (for Clt with Danger to Others)
to determine probably that clt will commit a violent act in the near future, ID factors contributing to clt’s dangerous bxs and intent, and obtain additional info that is needed to identify treatment goals and develop a treatment plan
Timing of Assessment (for Clt with Danger to Others)
assessment is an ongoing process that should be conducted during the first contact with the client and when there is a change in clt’s mental state or legal status, clt experiences major change in life circumstances (job, divorce), or there is a modification in clt’s care (discharge from psychiatric hospital, referral to new provider)
Assessment Methods (for Clt with Danger to Others)
assessment of clt with danger to others requires comprehensive approach involving obtaining info on multiple factors (i.e. history of violent bx, access to weapons and potential victims, and other risk factors; mental status and overall level o functioning; current stressors and coping skills; and the clt’s willingness and ability to collaborate with treatment.) from multiple sources (family members, friends, informants familiar with clt, medical and mental health records; and police and court records
Note: any threat of harm against others should always be taken seriously
Risk Factors (for Clt with Danger to Others)
Demographic, personality, and situational factors associated with high risk for danger to others:
1 Demographic Characteristics (past violent behavior, male gender, younger age (late teens to early twenties), lower SES, low intelligence, history of child abuse or witnessing spouse abuse, father who has a criminal arrest history
2 Psychiatric Diagnosis
3 Psychiatric Symptoms
4 Situational factors: lack of social support, access to weapons, high level of perceived stress, victim specificity and availability, non-compliance with treatment and poor therapeutic alliance
Screening Questions (for Clt with Danger to Others)
Borum, Swartz, and Swanson recommend a 2-stage approach for asking clt questions related to potential for violent bx
initial screening questions are general and less sensitive and are asked of all clients - i.e. what mass you mad? what do ou do when mad? own weapons?
second screening questions are more detailed questions asked to obtain information about past incidents of violence and current intent when an elevated risk for violence is suggested by clt’s answers to the initial screening questions or by a history of violent behavior, a stated intent to harm someone, or other factor(s)
Psychological Tests and Other Assessment Tools (for Clt with Danger to Others)
tests are not likely to be necessary when clt express intent to harm someone or useful when clt is in acute crisis state and in need of immediate intervention. Test are helpful for detecting potential for violence
Psychopathy Check List-Revised (PCL-R): measure of psychopathy and often used to predict violent recidivism. 20 items measure traits associated with psychopathy (i.e. pathological lying, poor behavioral controls, grandiose sense of self-worth). Scored on 3 point scale. Score range 0-40, with scores over 30 suggesting presents of psychopathy
MMPI-2 and MMIP-A: several MMPI scales are useful for detecting anger and aggression. Very high Scale 4 = clt may be aggressive or assaultive. Elevated scores on 4 and 9 associated with underlying sense of anger, alienation, impulsiveness, and antisocial tendencies with the energy to act on these feelings. Elevated Scores on 6, 4 and 9 = clt is likely to be very dangerous and to have poor judgment and their acting out is likely to be violent and seem justified to them because strong feelings of resentment toward others. High scores on 4 and 2 are associated with personality disorders, especially passive-aggressive and antisocial personality traits, and with hostility that may be expressed either directly or indirectly.
Millon Clinical Multiaxial Inventory - III (MCMI-III): used to assess DSM-IV personality disorders and clinical syndromes, and scores on several scales are useful for assessing risk for violent behavior. (Ex. high score on Antisocial scale (6a) is associated with impulsive acting out of antisocial feelings; high score on Aggressive scale (6b) indicates a propensity for aggressive outbursts, often with an absence of shame or guilt; and elevated scores on both scales are associated with expressions of antisocial feelings that are likely to be direct and abusive…High scores on Aggressive and Paranoid (P) scales suggest that person’s paranoia may be expressed in a controlling, intimidating, and belligerent way and that they may brood about perceived injustices and develop plans of revenge.
Determining Risk (for Clt with Danger to Others)
determining risk is always subjective, thus subject to error
Low Risk - when clt has few risk factors, does not have a history of impulsive behaviors, and does not have a specific plan or the means to carry out a plan
Moderate Risk - when clt has multiple risk factors, expresses low to moderate intent to carry out a plan or does not have the means to carry out a plan, exhibits only minimal cognitive or emotional impairment, and has protective factors (i.e. social support, safety plan)
High Risk - when has concrete plan and access to lethal means to carry out that plan, has multiple risk factors (i.e. impulsivity and low frustration tolerance, significant mental health problems, limited social support), and is unwilling or unable to form a therapeutic relationship
Treatment Goals (for Clt with Danger to Others)
initial goals are to build rapport with clt and reduce risk for future violence by bringing violent, aggressive behavior under control. Treatment goals depend on factors such as setting (inpatient vs outpatient), clt’s characteristics, and the underlying cause(s) of and contributor(s) to clt’s threatening, aggressive, or violent behavior
Treatment Methods (for Clt with Danger to Others)
methods for reducing risk depend on nature, lethality, and immediacy of violence throated by clt but may include having clt agree to adhere to a medication regimen, a safety plan, and/or a no-violence contract
Treatment Alternatives (for Clt with Danger to Others)
appropriate treatment depends on level of risk and causes of violent behavior. when choosing a treatment, primary guiding principle is to try and keep the clt in the least restrictive environment
Hospitalization - if clt poses imminent danger to others as a result of mental disorder, voluntary psychiatric hospitalization is usually the preferred intervention; but if clt refuses voluntary, then involuntary hospitalization may be necessary. follow up with a hospitalized clt until crisis is stabilized and then proceed with treatment if possible. (if clt’s imminent danger is not due to mental disorder, it may be necessary to consider alternatives such as referral to substance abuse treatment program or involvement with criminal justice system)
Outpatient Management - when clt is sincere in desire to change and risk for future violence is low. Treatment includes teaching communication, problem-solving, stress management, and anger management skills; fostering development of empathy in the clt for potential victims and increasing their understanding of consequences of violence; and working with clt to develop a safety plan that includes reducing environmental triggers for violent behavior and removing access to weapons. (CBT-thought patterns that can be controlled and replaced with pro-social thinking. Strategies incl training in cognitive self-control, anger management, social perspective-taking, social problem-solving, and relapse prevention) (Couple and Family therapy - often useful since most violence occurs within families. Intervention include educating family members about family dynamics leading to violence and early warning signs of violent bx, training in interventions for high-risk situations (i.e using time outs and impulse delay tactics), training in communication and problem-solving skills, and referral to support groups) (Group therapy - often less threatening to clts than individual therapy and provides opportunities to that others struggle similarly, see how others have successfully dealt with situations that normally trigger violence, and learnt to resolve conflicts with other group members in a supportive environment.)
Consultation - important adjust when choosing appropriate management strategy for potentially dangerous clt. consultation increases predictive accuracy and facilitates ID of appropriate interventions and can reduce legal liability
Bereavement (definition)
the state or condition that is caused by a loss and includes both grief and mourning
Grief
Psychological, behavioral, and physical experience of loss
Mourning
external expression of grief and is affected by a number of factors including gender, culture, relgion/spirituality, and the cause of the loss
(Grief/Bereavement)
loss of family member or friend is probably most common precipitant of grief but may also be triggered by other factors (serious health problem, death of pet, substantial financial loss, change in a familiar social role)
Types of Grief
1) Anticipatory Grief - refers to a grief reaction that occurs prior to an expected loss. Similar to normal grief in terms of symptoms but has some unique characteristics (i.e. rehearse actual seat in their mind, spend time thinking about what life will be like when person dies, and vacillate between acceptance and denial). Beneficial effects because provides individual with time to accept the reality of the loss, to prepare for life without the deceased, and to resolve unfinished business by expressing feelings and addressing unresolved issues
2) Normal (Uncomplicated) Grief - a process involving stages or tasks (5 stages: denial, anger, bargaining, depression, and acceptance). Responses often include shock and disbelief, sadness and depression, anxiety, anger, guilt, a sense of emptiness, disturbances in sleep and appetite, dreams about the deceased, and/or sensing the presence of the deceased. Duration varies but most severe symptoms subside within 6-12 months
3) Complicated Grief (also referred to as unresolved or pathological grief and may occur when progression through the stages or tasks of normal grieving is disturbed or blocked.) - may include reactions associated with normal grief that are more intense or prolonged as well as social isolation, impairments in cognitive/motor skills, hostile/violent behavior, severe depression, symptoms of PTSD, phobias and irrational fears, avoiding reminder of the deceased, and/or imitating the deceased. High risk for complicated grief linked to very close, dependent, or conflicted relationship with the deceased, sudden or unanticipated death, multiple losses, lack of social support, past history of mental illness or substance abuse, concurrent circumstances that interfere with grieving such as physical illness or present of other stress, and a lack of cultural traditions or spiritual beliefs. No standard diagnosis for pathological grief reactions. DSM includes Bereavement with “Conditions that may be a Focus of Clinical Attention” when “the focus of clinical attention is a reaction to the death of a loved one. Person with pathological grief may have symptoms that meet other disorders.
4 types of complicated grief
Masked Grief - when a person experiences troublesome symptoms but does not recognize them as being related to the loss
Delayed Grief - when an intense grief reaction emerges at a later time, often in response to a minor event
Distorted or Exaggerated Grief - involves atypical or very intense symptoms (i.e. development of irrational fears, physical or psychiatric symptoms, SI)
Chronic Grief - characterized by symptoms that have a prolonged duration and do not subside in severity
Assessment Goals an Methods (Grief/Bereavement)
Primary goals of assessment are to determine how clt is coping with loss and to distinguish between grief and other conditions or disorders so that an appropriate intervention can be identified.
main source of info is from clinical interview to address nature of loss, clt’s current symptoms, mental status and level of functioning (including risk for self-destructive bx), psychiatric history, coping style, concurrent stresssors, and support network)
BSI-II, BDI-II, Acute Stress Disorder Scale, Impact of Events Scale-Rtevised and DSM’s GAF
Treatment Goals (Grief/Bereavement)
depends on type of loss, nature and severity of clt’s grief, and presence of co-existing problems. Primary goal is to help clt successfully complete the grieving process
Treatment Alternatives (Grief/Bereavement)
variety of interventions aimed at particular types of loss
brief interventions based on crisis theory are often beneficial for addressing acute grief reaction.
normal grief may require an intervention or not; or may need grief/supportive counseling, referral to a support or self-help group, and/or referral to a physician for short-term medication for insomnia or anxiety may be appropriate.
complicated grief may require more intensive, grief-focused therapy
Grief therapy (grief treatment alternatives)
time-limited therapy appropriate for ppl with complicated grief reaction that is prolonged, delayed, exaggerated, or manifested as somatic o behavioral symptoms. Primary goal is to help clt resolve conflicts related to separating from the deceased person that are interfering with completion of the 4 tasks of mourning - 1) accepting the reality of loss, 2) working through the pain and emotional aspects of the loss, 3) adapting to an environment without presence of deceased, and 4) establishing a new rx with deceased person and reengaging in life. Therapy determines which of the four tasks have not been completed and then using interventions that address those tasks. There is a diff between grief therapy and counseling. Counseling is appropriate for normal grief.
Interpersonal Psychotherapy (IPT) (grief treatment alternatives)
for ppl whose depression is related to abnormal (complicated) grief. Primary goal = to facilitate the clt’s grieving process and help clt reestablish interests and interpersonal relationships. Strategies include linking onset of depressive symptoms to the loss, reconstructing clt’s relationship with deceased person, exploring feeling associated with loss, and identifying ways to connect with others
IPT was designed as treatment for depression and explicitly targets abnormal (complicated) grief. IPT targets 3 other areas such as interpersonal role disputes, role transitions and interpersonal deficits.
Cognitive-Behavioral Interventions (grief treatment alternatives)
Shear et al 2005 used a targeted complicated grief treatment combining education about grief, imaginal exposure through listening to a recorded retelling of the each, in vivo exposure to avoided situations, reducing distress through guided “conversations” with the deceased and recalling positive memories involving the deceased, and identifying personal life goals and ways to achieve those goals to be an effective approach for resolving the symptoms of complicated grief.
Group Counseling (grief treatment alternatives)
benefits = reducing social isolation and providing opportunities for chars is and acquiring coping skills. Most common are psychodynamic, interpersonal, and cognitive-behavioral
Family Focused Grief Therapy (FFGT) (grief treatment alternatives)
time-limited approach that emphasizes prevention by providing treatment to families that include a terminally-ill member and are at risk for complicated grief and other negative outcomes following death of that person.
Focuses on improving family functioning by enhancing family cohesion, conflict resolution, and communication of thoughts and feelings
Kubler-Ross Stages of Grief
denial, anger, bargaining, depression and acceptance (DABDA)
Research found that stages do not always occur in this order and stages may be repeated
Legal Definition (for Grave Disability)
defined in California’s Welfare and Institutions Code (WIC)
WIC Sections 5008(h)(1) and (3) define it “as a result of a mental disorder or chronic alcoholism, he/she “is unable to provide for his or her basic personal needs for food, clothing, or shelter”
Sections 5008(h)(2) states a person who is mentally retarded cannot be determined to be gravely disabled by reason of being mentally retarded alone (includes epilepsy, other developmental disabilities, alcoholism, other drug abuse, or repeated antisocial bxs, by themselves constitute a mental disorder”
Section 5585.25 - minor is gravely disabled when, as a result of a mental disorder, he/sh is unable to use the elements of life which are essential to health, safety, and development, including food, clothing, and shelter, even though provide to the minor by others.
Assessment (for Grave Disability)
Consider whether the person’s inability to care for basic personal needs is due to mental disorder and if so, whether that inability threatens the person’s survival.
primary goal = to determine the extent to which a clt’s mental disorder or chronic alcoholism interferes with ability to effectively deal with everyday functioning. Signs of GD is malnutrition/dehydration, inability to maintain a level of personal hygiene needed to prevent infection and illness, and/or be unable to formulate a reasonable plan for obtaining shelter. Info is primarily collected from clinical interview with clt, interviews with family members and others familiar with clt, and a review of clt’s medical and legal records.
determination of GD by assessment cannot include poverty or other factors that are not a mental disorder or chronic alcoholism. Mental disorder is what’s in DSM
1) Mental Status Exam - systematic method for obtaining info on individual’s appearance and behavior, communication processes, thought content and processes, cognition (memory, attention, general knowledge), emotional functioning, and orientation. Mini-MSE is a brief version of MSE assessing cognitive functioning
2) Global Assessment of Functioning (GAF) Scale - to record T’s judgment of clt’s overall level of psychological, social, and occupational functioning at time of evaluation (note: know 0-30 range)
3) MMPI-2/MMPI-A - generally elevated scales on MMPI may indicate functional impairment, especially elevations on 6 (Paranoia), 8 (schizophrenia), and 9 (Hypomania)
4) MCMI-III - generally elevated scores indicate a high level of functional impairment, especially on Severe Personality Pathology Scales (Schizotypal, Borderline, Paranoid) or Severe Syndrome scales (Thought Disorder, Major Depression, Delusional Disorder)
Global Assessment of Functioning (GAF) Scale
0 to 10 Persistent range of severely hurting self or others (i.e reorient violence) OR persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death
11 to 20 Some danger of hurting self or others (i.e. suicide attempts without clear expectations of death, frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (i.e. smears feces) OR gross impairment in communication (i.e largely incoherent or mute)
21 to 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (i.e. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (i.e. stays in bed all day, no job, home, or friends)
Hospitalization (for Grave Disability)
appropriate for GD and disability cannot be managed safely in a less restrictive environment. Voluntary hospitalization is considered first before involuntary hold. Involuntary commitment should be used only when disability is result of a mental disorder or chronic alcoholism and the individual has refused or is unable to comply with a recommendation to enter a psychiatric hospital voluntarily
1) Lanterman-Petris-Short Act (WIC Sections 5000) - regulations for involuntary commitment. Commitment beings with a 72 hour hold (5150) which may be followed by a 14 day hold (5250) and then additional post certification holds.
2) necessary to consider whether there are reliable people who can care for clt when determining GD person for involuntarily hospitalization
Psychologist on staff at hospital that accepts involuntary holds may admit for involuntary confinement
Psychologist NOT on staff can activate a hold by calling police, mobile crisis tea, or psychiatric emergency response team. Psychologist should also notify hospital that a clt will be arriving for intake and attempt to speak with admitting psychiatrist/psychologist to discuss admitting diagnosis. Psychologist can assist in determining what clinical action is needed too
Clinical Assessment (for Clinical Assessment and Evaluation)
involves collecting and evaluating information for purpose of determining a diagnosis, identifying an appropriate treatment plan, or evaluating the progress and outcomes of treatment.
Info is obtained directly from clt, but because clts are not always able or willing to provide complete or accurate info, it may be necessary to obtain info from other sources (family, physicians, educational/employment records).
Thorough assessment might require referral to other professionals for specialized evaluations i.e. pcp
adopt a BIOPSYCHOSOCIAL ORIENTATION TO ASSESSMENT - chosing assessment techniques that provide info on biological, psychological, and social factors that are contributing to clt’s probs and sxs
Malingering
requires evidence that symptoms have been intentionally produced for the purpose of obtaining external incentives (ie. financial compensation, avoiding criminal prosecution, gaining access to drugs). Collecting collateral info helps to determine this
Informed Consent for Assessment (Legal and Ethical issues in Assessment)
Standard 9.03 APA Code - must obtain informed consent for assessments, evaluations, or diagnostic services except when a) testing is mandated by law/governmental regulations, b)informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity; or c) one purpose of the testing is to evaluate clt’s decisional capacity.” Also requires to provide individuals who have “questionable capacity to consent” with info about the nature and purpose of the assessment in reasonably understandable language.
Privilege (Legal and Ethical issues in Assessment)
Legal EXCEPTIONS TO PRIVILEGE:
when appointed by court to examine a defendant to help court make a decision about clt - i.e. competent to stand trial or ascertain defendant’s state of mind at time of crime. MUST inform defendant before perming evaluation that his/her communications will not be confidential. Failure to do so leads to evaluation cannot be submitted to court. does NOT apply when court orders evaluation at request of defendant’s lawyer in order to provide lawyer with info needed to advise defendant whether to enter or withdraw a plea based on insanity or to present a defense based on his/her emotional condition…since purpose of evaluation is to help lawyer to develop legal strategy
Specialty Guidelines for Forensic Psychologists state that forensic psychologists must inform person being evaluated of limits of confidentiality prior to conducting the evaluation but must also “make every effort to maintain confidentiality with regard to any info that does not bear directly upon the legal purpose of the evaluations
When eval is NOT court-ordered, person being evaluated is ordinarily the “client,” meaning cannot reveal any info in court or other legal proceeding unless clt waives the privilege or court determines that an exception to privilege applies and orders the psychologist to do so.
no privilege when psychologist is appointed by Board of Prison Terms to evaluate an inmate to determine need for mental health treatment. no privilege in proceeding brought by or on behalf of an individual to establish his/her competence
Release of Information (Legal and Ethical issues in Assessment)
RE: release of test data:
(according to ethics code) Test data defined as “raw and scaled scores, clt responses to test questions or stimuli, and psychologists’ notes and recordings concerning clt statements and behavior during an examination.”
(According to ethics code) Pursuant to clt release, psychologists provide test data to clt or other persons ID-ed in release. Psychoogists may refrain from releasing test data to protect clt or others from substantial harm or misue/misprepresentation of the dat or the test.
Law/HIPAA can take precedence over ethics code.HIPAA says, may deny clt’s request for test data if I belief releasing data “is reasonably likely to endanger the life or physical safety” of clt or other person. Moreover, clt has right to request a review of the denial
Guidelines for explaining assessments to clients and others: take reasonable steps to ensure that explanations of results are given to individual or designated representative unless nature of rx precludes provision of an explanation of results (i.e. organizational consulting, pre-employent or security screenings, and forensic evaluations), and this fact has been clearly explained to person being assessed in advance
in Standards for Educational and Psychological Testing, interpretations of test results “should describe in simple language what the test covers, what scores mean, the precision of scores, common misinterpretations of test scores, and how scores will be used.” Includes providing minors with info in language appropriate to their developmental level.
In ethics code, “include in written and oral reports and consultations, only info germane to the purpose for which the communication is made, which is consistent with HIPAA’s “minimum necessary” requirement (except in certain circumstances, must limit disclosure of PHI (Protected Health Info) to the minimum necessary to accomplish the disclosure’s purpose.
Electronic Storage and Transmission of Information (Legal and Ethical issues in Assessment)
HIPAA’s Security Rule : related to creation, storage, and transmission of test data and other PHI in any electronic form; lists administrative, physical, and technical safeguards for protecting electronic PHI (ePHI) from unauthorized use.
Safeguards categorized as “required implementation specifications” (A covered entity’s policies and procedures for ePHI MUST be consistent with required specifications (ex., under technical safeguards, unique user ID is a required specification, which means a covered entity must assign a unique and sufficiently complex password to each employee, which the employee uses to access systems containing ePHI) OR “addressable implementation specifications” (allow a covered entity some leeway when a) it is determined that the specification is not reasonable or appropriate for the covered entity’s environment and b) the covered entity documents why the specification is not reasonable or appropriate and implements an equivalent alternative measure as appropriate, i.e., encryption is an addressable specification). {Note: while encryption is included in Security Rule as addressable specification, Centers for Medicare and Medicaid Services recommended that encryption of ePHI be treated as mandatory.
California’s data breach notification law requires state agencies and private sector businesses that own or licence computerized data to notify any CA resident of unauthorized access to unencrypted personal info, which applies to electronic medical and health insurance info (this law covers only unencrypted personal info so most effective way to avoid liability is to encrypt all ePHI)
Use of Assessments and Assessment Results (Legal and Ethical issues in Assessment)
RE: USE OF ASSESSMENTS AND ASSESSMENT RESULTS
should ordinarily base conclusions on in-person evaluation that provides data that adequately supports those conclusions. when in-person is not feasible, must limit nature of conclusions and as appropriate, inform relevant parties about limitations of evaluation results
administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques
use assessment instruments whose validity and reliability have been established for use with members of pupation tested. if no validity and reliability have been established, must describe strengths and limitations of test results and interpretation
use assessment methods appropriate to an individual’s language preference and competence, unless use of alternative language is relevant to assessment issues
deviation from standard admin of attest may be acceptable when doing so is supported by research or other evidence. (ex, providing rest breaks or assistance with marking answer to person with physical disability as long as purpose of test is not to evaluate the nature or severity of examinee’s disability)
acceptability of modifying standardized test by TRANSLATING TEST ITEMS into another language addressed in Standards for Educational and Psychological Testing…methods used in establishing adequacy of the translation should be described, and empirical and logical evidence should be provided for score reliability and the validity of the translated test scores (i.e., reliability and validity of translated version for members of target population should be established before used with these individuals). Back translation (Two independent translators are involved in this preferred method. Translator one translates the original version into the target language then the second translator translates it back into the original language. The researcher can consult with the translators to determine discrepancies.) is not recommended as a stand-alone procedure.
take into account purpose of assessment as well as various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences that might affect our judgment or reduce accuracy of interpretations. If these exist, include in test report
avoid basing assessment and intervention decisions based on obsolete tests or results of currently used tests when those results are outdated which can be due to amount of time passed or to changes in examinee’s health or educational status since testing
when using automated and other scoring and interpretation services, must select these services based on evidence of validity of info they provide and psychologists retain responsibility for appropriate application, interpretation and use of assessment instruments whether they score anne interpret such tests themselves or use automated or other services.
Test Integrity and Security (Legal and Ethical issues in Assessment)
make reasonable efforts to maintain integrity and security of test materials and other assessment techniques consistent with law and contractual obligations and in a manner that permits adherence to this Ethics Code. Test material refers to manuals, instruments, protocols, and test questions or stimuli but does NOT apply to test data
“Test Integrity” aka “psychometric integrity” and refers to test’s reliability and validity
“Test security” refers to limiting unauthorized access to test items and other test materials.i.e. showing clt test items before admin
Assessment of Ethnic, Linguistic, and Culturally Diverse Populations.
Guidelines for Providers of Services to Ethnic, Linguistic, and Culturally Diverse Populations presents aspirational principles
be aware of how own cultural background, attitudes, and value may impact their work with clts and make efforts to correct prejudices and biases. cognizant of limits of our training and experience and seek consultation and make referrals as needed
consider impact of ethnicity and culture when working with members of various ethnic and cultural groups.consider how cultural values, attitudes, and beliefs of clts may impact diagnosis and intervention.
be aware of research and practice issues relevant to populations they serve
interact with clts in language requested by client or, if not feasible, make appropriate referral.If these options are not possible, can hire translator with cultural knowledge and appropriate professional background. if professional translator is unavailable, obtain services of a trained paraprofessional from clt’s culture. To avoid limiting validity of assessment or effectiveness of intervention, translator must not have a dual role with clt
Suggestions for improving cultural sensitivity of assessments: 1) conduct a self-assessment of your own biases and prejudices and familiarity with clt’s culture
2) determine clt’s preferred language and, if ou do not speak that language, refer the clt to a clinician who does or, if a referral is not possible, obtain the services of an interpreter
3) Establish a good therapeutic relationship with the client prior to assessment
4) use a multi-method assessment approach that, when possible, includes culturally sensitive instruments (i.e. instruments that have low cultural loadings and low linguistic demands
5) when interpreting result of an assessment, consider impact that clt’s culture may have had on those results.
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Should take into account a clt’s stage of racial/ethnic identity development (person’s sense of collective identity based on perception that he/she share common racial or ethnic heritage with a particular group) and level of acculturation when making assessment and intervention decisions. (most referred to are Atkinson, Morten, and Sue’s (1998) Racial/Cultural Identity Development Model
Racial/Cultural Identity Development Model (Atkinson, Morten, and Sue’s (1998)
1) Conformity
2) Dissonance and appreciating
3) Resistance and immersion
4) Introspection
5) Integrative awareness
Level of Acculturation (Legal and Ethical issues in Assessment)
influences psychological help-seeking behavior, compliance with treatments, and treatment outcomes…an important factor to consider when working with Native Americans and immigrants/refugees
Berry Acculturation - degree to which a member of culturally diverse (minority) group accepts and adheres to the values, behaviors, customs, etc. of his/her own group and those of the dominant (majority) group…. four groups: assimilation, integration, separation, and marginalization
Factors Affecting Accuracy of Clinical Judgment and Decision Making - CLIENT RESPONSES (Legal and Ethical issues in Assessment)
responses to interview and test questions/items can be impacted by many factors (i.e. current emotional or physical state, response to characteristics of clinician (gender, age, race, skill level), and willingness to talk about sensitive topics
Malingering (aka “Faking bad”)… concerned about not getting the help they would like. This is suspected when a) inconsistency between behavioral observation of clt and test results; b) results of tests or subtests produce inconsistent results; c) inconsistencies between data obtained directly from clt and info obtained from collateral sources; d) when scores on validity scales of some tests and scores on measure designed to deltic this type of responding (i.e. Structured Interview of Reported Symptoms.
Defensiveness (aka “Faking good”)…conscious effort to present better than actual. Motivations include seeking release from hospital, obtaining custody, making a favorable impression on therapist. Suspected when: a) provides minimal responsive answer to interview questions and guarded responses to test items that are inconsistent with a documented history of problems; b)overly interested in convincing psychologist of their numerous strengths, capabilities, and accomplishments and these assertions far exceed what is reasonably likely to be true. Can be datected by scores on validity scales and tests designed for this purpose
Factors Affecting Accuracy of Clinical Judgment and Decision Making - CLINICIAN BIASES (Legal and Ethical issues in Assessment)
may operate consciously or unconsciously
Preconceived Notions: perceptions and judgments may be influenced by beliefs about people based on demographic data, physical appearance as well as context in which assessment occurs
Confirmation Bias: commonly form opinions about a clt early based on info from referral source, data gathered early in assessment, and their preconceived notions which could also affect what additional info they decide to collect and how they interpret that info
Factors Affecting Accuracy of Clinical Judgment and Decision Making - STRATEGIES FOR IMPROVING CLINICAL JUDGMENT AND DECISION MAKING (Legal and Ethical issues in Assessment)
To improve validity of clinical judgments and decisions:
1 establish an optimal level of rapport and trust while patting attention to nonverbal bx
2 consider all sources of information and don’t overlook inconsistent data. consider strengths/assets and pathology/dysfunction to get balanced view of clt while considering clt’s circumstances and environment
3 supplement clt self-report data with info from other sources including family, friends, other professionals, medical evaluations, life records, and behavioral observations
4 be familiar with theories and research relevant to clt which includes empirically validated assessments and interventions and information on impact of racial, ethnic, and cultural factors on diagnosis and treatment
5 use base rate info to estimate utility of assessment procedures, especially for predicting rare phenomena.base rate refers to expected frequency of a characteristic, behavior, or diagnosis in a particular population. even when valid instrument may not improve ability to predict a bx when bx is rare
6 be aware of own expectations and biases and take steps to reduce impact on clinical decisions.
Clinical Interview ( (Clinical Assessment and Evaluation)
core of most assessments allowing to obtain info directly thru clt’s answers to questions and indirectly by observation of non-verbals
Types
Intake Interview - ID nature of clt’s problem; determine whether provider has resources/competencies to help clt; provide info about nature of available services, treatment options, and office policies; and obtain informed consent; opportunity to establish working relationship
Case (Psychological) History Interview - purpose is to obtain additional info about clt’s background to help formulate a diagnosis and determine how the clt’s presenting problem fits into the wider context of their life (i.e. obtain info on developmental history, family-of-origin, education, employment, recreation/leisure, dating and marital hx, sexual hx, physical health, and alcohol and drug use
Diagnostic Interview - goal is to obtain info needed to classify clt’s symptoms according to DSM or other diagnostic system. Can be structured (explicit directions, standard questions asked in specific oder, and a system for rating clt’s responses; ex = Structured Clinical interview for DSM-IV Axis I Disorders - SCID-I, Structured Interview for DSM-IV Axis II Personality Disorders - SCID-II, Diagnostic Interview for Children and Adolescents - DICA, and Diagnostic Interview Schedule for DSM-IV - DIS-IV), unstructured (use clinical judgment to decide what to ask, explore and investigate; formulate hypotheses about clt and sxs & tests these hypotheses by looking for info consistent with them)) and semi-structured (standardized questions designed to elicit specific info in a consistent way but include open-ended questions allowing to follow up on important issues raised by clt’s responses; ex = Semistructured Clinical Interview for Children and Adolescents - SCICA; Personality Disorder Interveiew-IV (PDI-IV), and Schedule for Affective Disorders and Schizophrenia (SADS)), and Crisis Interview (goal is to identify nature of clt’s crisis, provide immediate support to clt, and identify methods for resolving the crisis as quickly as possible.
Mental Status Examination (Clinical Assessment and Evaluation)
Provides info on clt’s current level of mental functioning and can be used in conjunction with other data to formulate appropriate psychiatric diagnoses and plans for further assessment and intervention (referral to specialist, admission to hospital, evaluation for med problems affecting psychological functioning
includes evaluation of domains of functioning (appearance; activity and behavior; attitude toward examiner; mood and affect; speech and language; thought content; thought process; insight and judgment; and sensorium/cognition
Mini Mental Status Exam (Clinical Assessment and Evaluation)
shortened version of MSE for assessing cognitive functioning; useful initial screening device for cognitive impairment and to follow course of illness and monitor response to treatment. Often used as diagnostic tool for dementia but this is not what it was designed for nor suffice on its own
Contains 11 questions assessing 6 aspects of cognitive functioning: 1) Orientation to time and place - ask for date, season, name of location; 2) Registration - measure of immediate verbal recall and is evaluated by determining how many trials it takes for person to accurately repeat three words named by examiner; 3) Attention and calculation - assessed by asking person to count backwards from 100 by a specific number of digits; 4) Recall - measure of delayed recall and involves asking person to recall the three words that were previously named by examiner; 5) Language - evaluated with questions including asking person to name familiar objects and to follow a simple three-stage command; 6) Visual Construction - ask person to copy a simple geometric figure.
Max score is 30…23 or 24 is the cutoff with scores below indicating cognitive impairment….scores on MMSE are affected by premorbid intelligence, educational experience, and race/ethnicity
Behavioral Assessment (Clinical Assessment and Evaluation)
Helby and Haynes definition: scientific approach to psychological assessment that emphasizes use of minimally inferential measures, use of measures that have been validated in ways appropriate for assessment context, assessment of functional relations, and derivation of judgments based on measurement in multiple situations, from multiple methods and sources, and across multiple times
they assist in deriving diagnoses, determine appropriate interventions for problematic bxs, and assessing progress and outcomes of interventions
focus on directly measurable behaviors and view of behavior as situationally specific. usually focuses on overt behavior but may also focus on physiological phenomena (ie. muscle tension, heart rate, blood pressure), cognitions, and social interactions
involves obtaining info on environmental events that elicit, maintain, or otherwise affect that bx. Environmental events preceding target bx (verbal instructions, presence of a person, participation in particular activity) are ANTECEDENTS. Events following behavior (desirable events that increase behavior such as praise and tokens) are CONSEQUENCES
includes identifying antecedents and consequences which is referee to as a FUNCTIONAL BEHAVIORAL ASSESSMENT because antecedents and consequences help explain the function (purpose or cause) of bx. Results of FBAsessment provide info needed to develop functional behavior plan identifying an alternative bx that serves same function as target bx as well as antecedents and consequences that support the alternative behavior…often used in schools for students and mental health settings for behavioral probs
FUNCTIONAL BEHAVIORAL ASSESSMENT is sometimes used interchangeably with FUNCTIONAL ANALYSIS/FUNCTIONAL BEHAVIORAL ANALYSIS but the latter was used to describe process of generating and testing hypotheses about antecedents and consequences of behavior
incorporates variety of assessment methods (i.e. interviews (with indiv and peers/loved ones) followed by behavioral observations in natural or analogue [controlled settings providing some elements of natural settings; recordings done by narrative recording-verbal descriptions of bx, event recording - recording frequency, duration, or intensity of bx, interval recording-recording whether or not bx occurred during predefined time intervals, self monitoring-i.e. Beck’s cognitive therapy’s Daily Record of Dysfunctional Thoughts- record disturbing automatic thoughts, events that preceded the, and their emotional reactions] settings, behavior rating scales, self-report inventories, and measure of physiological events.
Psychological Tests
tests scores alone are not sufficient for making diagnostic and treatment decisions. must integrated with other sources suh as clinical interview, clinical impressions and observations, and info from collateral sources
choice of psych test depends on purpose of testing, certain characteristics of clt (i.e demographics, reading ability, physical limitations), examiner’s training and experience, and psychometric properties of test
Tests should have appropriate norms and adequate levels of reliability and validity
Norms (Psychological Tests)
norm-referenced tests compare examinee’s performance to performance of a norm group. meaningful info about examine depends on extent to which examinee’s characteristics match those people included in norm (standardization sample).
To evaluate test norms, ask: a) is norm sample sample representative of population it is intended to represent - samples ar emore likely representative when sample size is large and was randomly selected from population;;; b) do characteristics of norm group include individuals of same age, race/ethnicity, and SES as examinee?;;; and c) how recent are test norms? Test norms (and content) should be periodically updated to ensure they are not outdated.
Reliability (Psychological Tests)
refers to consistency, and ability of a test to provide dependable, consistent scores is affected by the degree to which scores are susceptible to measurement error (i.e. to factors that are irrelevant to what is being measured by the test and that have an unpredictable effect on examinees’ scores).
usually reported in terms of a reliability (correlation) coefficient that ranges in value from 0 to 1.0 with larger values indicating higher levels of reliability. A coefficient of .90 or higher is preferred when test results are used to make important decisions about an examinee
To evaluate reliability:
1) test-retest reliability - used to determine reliability of tests designed to measure attributes that are relatively stable over time and are not affected by repeated measurement (i.e. practice effects); appropriate for test of aptitude which is a stable characteristic but not for a test of mood since mood fluctuates over time
2) alternate forms - indicates consistency of responding to different item samples (i.e. different forms of a test) and, when forms are administered at different times, the consistency of responding over time; NOT appropriate when attribute measured is likely to fluctuate over time and the forms will be administered at different times or when scores are likely to be affected by repeated measurement
3) internal consistency reliability - used to evaluate reliability when a test is designed to measure a single characteristic, when the characteristic measured by the test fluctuates over time, or when scores are likely to be affected by repeated explosure to the test; Split-half reliability and coefficient alpha are two methods for evaluating internal consistency reliability
4) Inter-Rater (interscorer) reliability - of interest whenever scores depend on a rater’s judgment (ie, behavioral observation scales and projective personality tests should have evidence of adequate inter-rater reliability
test are never perfectly reliable so interpret with caution which can be done by constructing a confidence interval around that score, which indicates the range within the examinee’s actual (true) score is likely to fall given obtained score. Confidence interval is calculated by using standard error of measurement (SEM), which is a type of standard deviation and is interpreted in terms of areas under the normal curve
Validity (Psychological Tests)
refers to accuracy or degree that it accurately measures what it is intended to measure.
1) Content validity - important for tests designed to measure a specific content or behavior domain (i.e. achievement tests, work sample tests); established primarily through judgment of subject matter experts who determine if test items are an adequate and representative sample of the domain assessed by the test
2) Construct validity - critical for test designed to measure a hypothetical trait or construct (i.e. self-esteem, intelligence, neuroticism); established through systematic accumulation of evidence that test is actually measuring the construct it was designed to measure (i.e. through the use of multitrait-multimethod matrix or factor analysis)
3) Criterion-related Validity - important for tests that will be used to predict or estimate an examinee’s status or performance on an external criterion (ie. when a measure of job knowledge will be used as a selection test to predict future job performance);
2 types of criterion-related validity (both assessed by correlating scores on the test (predictor) with scores on the criterion obtained by a sample of examinees: Concurrent validity (when test will be used to estimate current status on the criterion) and Predictive validity (when purpose of testing is to predict future performance on the criterion)
Objective Personality Tests
highly structured and present examinees with multiple-choice questions or other unambiguous stimuli
MMPI-2: self-report measure assessing social and personal maladjustment and is used to assis in diagnosis of mental disorders and treatment planning
567 true/false items and provides scores on 10 clinical scales and 8 validity scales as well as numerous sub scales and supplementary scales including Harris-Lingoes sub scales (e.g., subjective depression, psychomotor retardation, familial discord), social introversion sub scales, and content scales (.e. anxiety depression, health concerns)
Age range is for >18 years of age
at least 5th grade (Lexile average) or 4.6th grade (Flesch-Kincaid) reading level; other sources cite 6th or 8th grade level
MMPI-A is for 14-18 years of age
Scoring and Interpretation: raw scores on each scale converted to T-scores that have a mean of 50 and standard deviation of 10. A T-Score of 65 or higher is considered clinically significant; Interpretation begins by determining validity of profile
When LFK assume a V-shaped pattern, interpret with caution as it suggest an attempt to present oneself in a favorable light (to fake good) and has been found common for child custody litigants especially those exhibiting “parental alienation syndrome”
Extremely elevated F scale score and a high value on the F-K index (F minus K is greater than +9) suggest symptom exaggeration (an attempt to “fake bad”_ and have been linked to malingering
If profile is valid, focus on individual clinical scale scores and code-type(s) which consist of 2 or 3 most elevated scores.
Three point code of 1-2-3 with scales 1 and 3 having substantially higher scores than Scale 2 is known as the “neurotic triad” or “conversion valley” and is associated with somatization of psychological problems
Code of 6-7-8 (with scales 6 and 8 substantially higher scores than 7) is known as the “psychotic valley” and is associated with delusions, hallucinations, disordered thought, and a diagnosis of schizophrenia, especially the paranoid type
MMPI-2 Validity Scales
MMPI-2 Validity Scales - Validity Scales
? (Cannot Say/Omitted items) - High score = defensiveness, indecisiveness, reading difficulties
L (Lie) - High Score = attempt to “fake good,” defensiveness, denial; Low Score = frankness, exaggeration of negative characteristics
F (infrequency) - High Score = exaggeration of probs, deliberate malingering; Low Score - absence of unusual behavior, social conformity
K (correction) - High Score = attempt to “fake good,” defensiveness, lack of insight; Low Score = attempt to “fake bad,” excessive self-criticism
Fb (Back-F) - High Score = deviant responding to items at the end of test
Fp (Psychopathology Infrequency) - High score = endorses extremely bizarre content
VRIN (Variable Response) - High score = inconsistent responding to similar items
TRIN (True Response Inconsistency) - High score = gives “true” or “false” responses indiscriminantly
MMPI-2-RF (Restructured Form)
most recent version of MMPI; an alternative (but not a replacement) for MMPI-2 and designed to be consistent with current models of personality and psychopathology
338 items derived from MMPI-2 item pool and it utilizes the MMPI-2 standardization sample
9 restructured clinical (RC) scales (ie antisocial ehavior, dysfunctional negative emotions, hypomanic activation), 8 validity scales, and several additional scales.
RC scales can be used to clarify scores on MMPI-2’s clinical scales; ex, when someone gets elevated scores on Scales 6, 8 and 9 of MMPI-2, scores on Scales RC6, RC8, and RC9 of MMPI-2-RF can be used to determine if these elevations are due to psychotic symptoms or to demoralization and general distress
appropriate for >18 years or older
at least 5th grade (Lexile average) or 4.6th grade (Flesch-Kincaid) reading level
MCMI-III
175-item true/false self-report test used to assist in diagnosing DSM Axis I and Axis II disorders.
Scores on 14 personality disorder scales, 10 clinical syndrom scales (which represent the more prevalent Axis 1 disorders), and 4 correction scales that are used to detect distortions in examinee’s responses
appropriate for >18 years of age with at least 8th grade reading level
Millon Adolescent Clinical Inventory (MACI) is available for ages 13-19 whose reading ability is at 6th grade or above
Projective Pesonality Tests
differ in terms of content, format, and interpretation but are all based on assumption that examinee’s responses to ambiguous stimuli or tasks can elicit meaningful information about personality and underlying motivation and conflicts.
Rorschach - 10 inkblot cards (5 achromatic, 5 with color) each containing a bilaterally symmetrical inkblot; primary use is to obtain info about personality structure to assist in diagnosis and treatment planning; administered in 2 phases; During free association phase, present 10 cards in a prescribed order, asks examinee to describe what he/she sees, and keeps a verbatim record of examinee’s responses,,,,During subsequent inquiry phase, examiner actively questions the examinee about the features of the inkblot that determined his/her responses to facilitate scoring.; age range is >2 years of age; number of scoring and interpretation systems available; assesses for location, determinants (what in the inkblot determined response), form quality (how similar the perception is to the actual shape of inkblot), content (category the perception falls into- human, animal, or nature), and frequency of occurrence (extent to which perception is original or popular); interpretation inovles considering number and type of resonse in each category - color responses suggests emotionality and impulsivity; use of white spaces suggests oppositional tendencies; and confabulation (overanalyzing a part of the inkblot to the whole) may indicate brain damage, emotional disturbance, or mental retardation
Thematic Apperception Test (TAT) - based on Murray’s theory of needs; 19 cards containing vague black and white pictures that include one or more human figures and one blank card; make up a store about each picture including info about what is happening in picture, what led to that situation, how the people feel, ad how the story ends; several scoring systems (Murray’s system involved ID-ing story’s hero and evaluating the intensity, frequency, and duration of needs, environmental press, them, and outcomes expressed in each story; little utility for assigning specific diagnoses but may be useful for gross diagnostic distinctions such as distinguishing between Schizophrenia and neurosis
Projective Drawing Tests - House Tree Person, Draw a Person and Kinetic Family Drawings; assumes that in drawing peering persons or object, examinee projects an inner view of self, environment, and things he/she regards as important; used to assess personality and asset in diagnosis of psychopathology but validity for these purposes is questionable.
Measures of Intelligence
assesses scholastic aptitude, educational, and occupational counseling, and diagnosing Mental Retardation, Learning Disorders, and other disorders.
Most intelligence test yield one or more IQ scores which are deviation scores that indicate an examinee’s performance in relation to the performance of people in the norm (standardization) sample
Wechsler Adulte Intelligence Scale - Fourth Edition (WAIS-IV)
based on view that intelligence is a global ability comprised of numerous interrelated functions that allow the individual “to act purposefully, to think rationally, and to deal effectively with his (or her) environment.
Major difference between WAIS-IV and WAIS-III is that Verbal IQ and Performance IQ are no longer reported. Instead, WAIS-IV provides a Full-Scale IQ (FSIQ), four Index Scores, and scores on 10 core and five supplemental subtests.
Working Memory Index (WMI): simultaneous and sequential processing, attention, concentration, learning ability (Core vs supplemental subtests: Digit Span and Arithmetic vs Letter-Number Sequencing)
Processing Speed Index (PSI): speed of processing, cognitive flexibility, learning ability, short-term visual memory (Core vs supplemental subtests: Symbol Search and Coding vs Cancellation)
Perceptual Reasoning Index (PRI): nonverbal reasoning, visual problem-solving (Core vs supplemental subtests: Block Dsign, Matrix Reasoning, Visual Puzzles vs Figure Weights and Picture Completion
Verbal Comprehension Index (VCI): verbal reasoning, learning ability, practical and social judgment, general knowledge (Core vs supplemental subtests: Vocabulary, Similarities, and Information vs Comprehension)
Appropriate for aged 16 years through 90 years, 11 months; Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) for 6 - 16 years, 11 months, while the Wechsler Preschool and Primary Scale of Intelligence-Third Edition (WPPSI-III) is for 2 years, 6 months through 6 years, 3 months
Scoring and Interpretation: raw scores converted to standard scores using a conversion tables…FSIQ and Index Standard Scores have a mean of 100 and standard deviation of 15, and the subtest scores have a mean of 10 and standard deviation of 3; Interpretation involves multi-level approach that entails first considering FSIQ followed by consideration of index scores and subtest scores.
WAIS-IV Technical Manual says if there is a 1.5 standard deviation or more discrepancy between any 2 index scores, the FSIQ should be interpreted with caution and, if there is 1.5 standard deviation or more discrepancy between any two subtests that contribute to an index score, the index score must be interpreted with caution
Subtest scores are used to ID relative strengths and weaknesses
General Ability Index (GAI) can be derived from VCI and PRI scores and useful when examiner wants a summary score that minimizes the impact of working memory and processing speed
to increase clinical utility of WAIS-IV, Technical Manual provides score patterns characteristic of several clinical groups such as Borderline Intellectual functioning, Mild Cognitive Impairment, Alzheimer’s dementia, depression, and ADHS
Stanford-Binet Intelligence Scale, Fifth Edition (SB5)
a measure of general cognitive ability and to assist in psychoeducational evaluation, the diagnosis of developmental disabilities and exceptionalities, and forensic, career, neuropsychological, and early childhood assessment; development of SB5 was based on a hierarchical g (general mental ability) model that incorporates 5 cognitive factors that are each measured by subtests and activities that represent verbal and nonverbal domains.
Age range is 2 to 85+
Fluid Reasoning (FR) ability to solve novel problems; (Nonverbal domain subtests/activities vs Verbal: Object Series-Matrices vs Early Reasoning, verbal Absurdities, Verbal Analogies)
Knowledge (KN): general information, vocabulary, language use; (Nonverbal domain subtests/activities vs Verbal: Procedural Knowledge, Picture Absurdities vs. Vocabulary)
Quantitative Reasoning (QR): logical reasoning, mathematical knowledge and conceptualization; (Nonverbal domain subtests/activities vs Verbal: Quantitative Reasoning vs Quantitative Reasoning)
Visual-Spatial Processing (VS): visualization, spatial reasoning, understanding of verbal spatial concepts; (Nonverbal domain subtests/activities vs Verbal: Form Board, Form Patterns vs Position and Direction)
Working Memory (WM): storing and manipulating information in short-term memory; (Nonverbal domain subtests/activities vs Verbal: Delayed Response, Block Span vs Memory for Sentences, Last Word)
Scoring and Interpretation: Subtest scores (M = 10, SD = 3) are combined to obtain the following composite scores (M = 100, SD = 15): five factor index scores, two domain scores (verbal and nonverbal), Abbreviated Battery IQ, and Full Scale IQ.
Change Sensitive Scores (CSS) may be calculated as these scores allow criterion-referenced interpretation of an examinee’s performance interns of developmental level (age) and complexity of the tasks and are useful for evaluating individuals in extreme levels of ability and for tracking changes in performance over time (i.e., changes that occur following TBI)
Culture-Fair (Culturally Sensitive) Tests
reduced cultural content and make use of nonverbal format to overcome cultural loading associated with language; these tests must be used with caution as they may be as culturally loaded as traditional tests and less valid on predictors of academic achievement and job performance
Leiter International Performance Scale - Revised (Leiter-R): measure of cognitive abilities for aged 2-21 years; can be administered without verbal instructions and useful for individuals with language problems or hearing impairment…match a set of response cards to corresponding illustrations on an easel; test items emphasize fluid intelligence and evaluation 4 domains of cognitive functioning - visualization, reasoning, memory, and attention
Raven’s Progressive Matrices: nonverbal measure of general intelligence (g) and is considered a culture-fair test because it is relatively independent of the effects of special education and cultural learning…solve problems involving abstract figures and designs by inciting which of several alternatives compete a given matrix; most commonly used vernon is Standard Progressive Matrices which is appropriate for aged 6-80; Colored Progressive Matrices (CPM) is an easier and shorter version for individuals 5-11 years and older adults; Advanced Progressive Matrices is for individuals 11 years and older who are of above average intelligence (instructions for this test are simple and can be pantomimed thus ok to use with hearing-imparied and non-English speaking individuals and individuals with aphasia or a physical disability
Columbia Mental Maturity Scale (CMMS): test of general reasoning ability for children aged 3-10. 92 cards each containing 3, 4, or 5 drawings and for each card, indicate the drawing that does not belong with others. Does not require verbal responses or fine motor skills. originally developed for children with cerebral palsy, it’s useful for children with brain damage, mental retardation, speech impairments, hearing loss, or limited English proficient.
Neurological Tests
used to screen for brain dysfunction and diagnose neurological disorders…evaluate mental processes ranging from simple motor performance to reasoning, problem-solving, and other complex cognitive abilities.
Halstead-Reitan Neuropsychological Battery: tests used in this battery were one to accurately differentiate between “normals” and individuals with brain damage; can select types and number of tests to use but administration includes a standard set of subtests designed to assess sensorimotor, perpetual, and language functioning; yields an average Impairment Index ranging from 0.0 to 1.0 which higher scores indicating more severe impairment. Original battery is for adults but downward extension is available for children 5-14 years.
Luria-Nebraska Neuropsychological Battery: consists of 11 subtests that each assess a different skill that is likely to be affected by brain damage. Each item is scored as 0 (normal performance),, 1 (borderline performance), or 2 (clearly abnormal performance,) and the battery provides scores on 14 scales (i.e. motor, tactile, visual, reading, arithmetic, memory); high score on three or more scale suggests neuropsych impairment; forms are available for adults and adolescents and one for children.
Bender Visual-Motor Gestalt Test - Second Edition (Bender-Gestalt-II): brief measure of visual-motor integration for aged 3 years and older; 16 stimulus cards containing geometric figures and requires the examinee to first copy the figures and then draw them from memory; valid screening device for neuropsychological impairment and is useful for tracking developmental changes in visual-motor skills but does not appear to be accurate for making psychiatric diagnoses; used as a screening test for organic brain dysfunction
Wechsler Memory Scale-Fourth Edition (WMS-IV) - comprehensive measure of memory providing scores on 5 Primary Indexes: auditory memory, visual memory, immediate memory, delayed memory, and visual working memory; co-normed with WAIS-IV so permits comparison on examinee’s intellect and memory
Measures of Specific Symptoms, Behaviors, and Abilities
assist in the detection and diagnosis of a wide range of problems including fears and anxiety, depression, eating disorders, attention deficit disorders, substance abuse, mental retardation, social skills, and marital relationships…useful for treatment planning, monitoring, and outcome assessment.
Beck Depression Inventory-II (BDI-II): 21 item self-report measure of depression for ppl aged 13 years and older with at least an 8th grade reading level; assess severity of complaints symptoms, and concerns related to current level of depression and target specific sxs of depression (incl severe depression and depression necessitating hospitalization); item scores range from 0-3 and are summed up for a total score ranging from 0-63; cutoff scores are: minimal depression 0-13, mild depression 14-19, moderate depression 20-28, and severe depression 29-63…. Beck Hopelessness Scale and Beck Scale for Suicidal Ideation are used to assess suicide risk and similar to BDI-II
Symptom Checklist-90-Revised (SCL-90-R): useful for evaluating type and severity of symptoms and tracking treatment outcomes for pp aged 13 through adult; 90 items that provide scores on 9 symptom dimensions (somaticization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and on 3 global indices (Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total)…Brief Symptom Inventory (BSI) is shortened version of SCL-90-R and consists of 53 items
Child Behavior Checklist for Ages 6-18
Behavior Assessment System for Children, Second Edition (BASC-2)
Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
Activities of Daily Living (ADLS)
Beck Depression Inventory-II (BDI-II):
21 item self-report measure of depression for ppl aged 13 years and older with at least an 8th grade reading level; assess severity of complaints symptoms, and concerns related to current level of depression and target specific sxs of depression (incl severe depression and depression necessitating hospitalization); item scores range from 0-3 and are summed up for a total score ranging from 0-63; cutoff scores are: minimal depression 0-13, mild depression 14-19, moderate depression 20-28, and severe depression 29-63…. Beck Hopelessness Scale and Beck Scale for Suicidal Ideation are used to assess suicide risk and similar to BDI-II
Symptom Checklist-90-Revised (SCL-90-R):
useful for evaluating type and severity of symptoms and tracking treatment outcomes for pp aged 13 through adult; 90 items that provide scores on 9 symptom dimensions (somaticization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and on 3 global indices (Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total)…Brief Symptom Inventory (BSI) is shortened version of SCL-90-R and consists of 53 items
Child Behavior Checklist for Ages 6-16 (CBCL/6-18)
obtains info about behavioral and emotional problems and competencies of a child or adolescent from parent or guardian. 118 items describing specific areas of behavioral or emotional functioning (child’s activities, chores, friends, and grades) plus 2 open-ended items for describing other concerns. Separate Scores are provided for externalizing symptoms (Delinquent behavior, aggressive behavior) and internalizing symptoms (anxious/depressed, social problems, attention problems)
Teacher’s Report Form for Ages 6-18, Youth Self-Report for Ages 11-18, Adult Self-Report, and Semistructured Clinical Interview for Children and Adolescents. These are all part of Achenbach System of Empirically based Assessment (ASEBA)
Behavior Assessment System for Children, Second Edition (BASC-2)
uses multidimensional approach to assess the emotions and behaviors of individuals 2 years to 21 years, 11 months…includes Teacher Rating Scales, Parent Rating Scales, Self-Report of Personality, Student Observation System, Parenting Relationship Questionnaire, and Structured Developmental History;;; useful for identifying behavior problems under Individuals with Disabilities and Education Act and for assisting in the determination of an appropriate DSM diagnosis.
Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
measure of adaptive functioning, and deficits in adaptive functioning are one of the diagnostic criteria for Mental Retardation;
consists of a Survey Interview Form and Parent/Caregiver and Teacher Rating Forms and is used to evaluate the personal and social skills of individuals from birth to age 90; useful for assisting in diagnosis of several disorders including Mental Retardation, Autism Spectrum Disorders, ADHD, Dementia, and brain injury and for developing educational and treatment plans;;; provides an Adaptive Behavior Composite score, 4 domain scores (Communication, Daily Living Skills, Socialization, and Motor Skills), and an optional Maladaptive Behavior Index Score.
Activities of Daily Living
routine activities and tasks of everyday life that are necessary for personal self-care and independent living
Basic ADLS (BADLS): related to personal care and mobility (eating, dressing, toileting, ambulation)
Instrumental ADLS (IADLS): necessary for independent living (shopping, meal preparation, financial management, and treatment compliance)
assessment of ADLs is an essential component of the evaluation of a person’s legal competence and is also useful for ID-ing appropriate interventions for individuals with Dementia and other disorders and monitoring and evaluating intervention outcomes.
Measures of ADL include Nottingham Extended Activities of Daily Living Scale, Laughton Instrumental Activities of Daily Living Scale, and Functional Independence Measure.
Diagnosis
See EPPP (Flash) Cards
Categorical classification system…polythetic criteria set
Multixial assessment system
Uncertainty = deferred, provisional, unspecified, NOS
Unspecified mental disorder (nonpsychotic) is coded when there is sufficient info to rule out a psychotic disorder but insufficient info to further specify disorder
Disorders usually 1st evident in Infancy, Childhood, and Adolescence
Mental Retardation, Learning DIsorders, Autistic Disorder, ADHD, Conduct Disorde,r Oppositional Defiant Disorder, Tourette’s Disorder, Stuttering, Feeding and Eating Disorders of Infancy and Early Childhood, Separation Anxiety Disorder, and Reactive Attachment Disorder
Learning Disorder
when a person’s achievement on a standardized achievement test is “substantially below” (which is 2 or more standard deviations between achievement and IQ test scores) that expected for their age, schooling, and level of intelligence, AND cannot be fully explained by a sensory deficit
Associated features: usually an IQ in average to above-average range but higher than normal rates of other problems and behaviors, incl delays in language development and/or motor coordination, attention and memory deficits, low self-esteem, and poor social skills
Most common comorbid disorder is ADHD; others incl Conduct DO, Oppositional Defiant DO, Major Depressive DO, and Dysthymic DO
Differential Diagnosis: must be distinguished from academic difficulties caused by a lack of opportunity, substandard teaching, and//or cultural factors (english is not primary language). If there’s a visual, auditory, or other sensory deficit, learning probs must exceed those normally associated with that deficit
