Ch. 3 Clinical Assessment, Diagnosis, and Treatment

Question 1

Clinical Assessment

Answer 1

ASSESSMENT – collecting of relevant information in an effort to reach a conclusion.

IDIOGRAPHIC INFORMATION – Individual information about the client.

• Collecting this is the first step for a therapist to put them in a position to assess and diagnose, putting them in a position to offer treatment.

TOOLS AND TECHNIQUES – 3 Categories:

1. Clinical Interviews
2. Tests
3. Observations

• And to be useful, these tools must be:
  
  • Standardized – set up common steps to be followed along with standardizing the way they are interpreted.
  • Reliable – refers to the consistency of the assessment measure.
    
    • An assessment tool must have high TEST-RETEST RELIABILITY, one kind of reliability, if it yields similar results every time it is given to the same people.
    • An assessment tool must have high INTERRATER (or interjudge) RELIABILITY, another kind of reliability, if different judges independently agree on how to score and interpret it.
  • Valid – it must accurately measure what it is supposed to measure.
    
    • Ex: Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those readings are not valid, or accurate.
  • FACE VALIDITY – appears to be valid simply because it makes sense. This type of validity is NEVER sufficient. Thus, an assessment tool must also have high Predictive Validity and Concurrent Validity.
    
    • PREDICTIVE VALIDITY – a tool’s ability to predict future characteristics or behavior. Without predictive ability, it’s useless.
    • CONCURRENT VALIDITY – the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques.

CLINICAL INTERVIEWS – collect detailed information about the person’s problems, feelings, lifestyle, relationships, and history. The interviews can take a different slant depending on the interviewer’s preferred approach:

• Psychodynamic interviewers try to learn about the person’s needs and memories of past events and relationships.
• Cognitive-Behavioral interviewers try to identify information about the stimuli that trigger responses, consequences of the responses, and/or assumptions and interpretations that influence the person.
• Humanistic clinicians ask about the person’s self-evaluation, selfconcept, and values.
• Biological clinicians look for signs of biochemical or brain dysfunction.
• Sociocultural interviewers ask about the family, social, and cultural environments.

INTERVIEW STRUCTURE – can be:

• UNSTRUCTURED – clinician asks mostly open-ended questions – “Tell me about yourself?”
  
  • appeal to psychodynamic and humanistic clinicians.
• STRUCTURED – clinicians ask prepared, specific questions, often using a standard set of questions designed for all interviews.
  
  • Many structured interviews include a MENTAL STATUS EXAM, a set of questions and observations that systematically evaluate the client’s awareness, orientation, attention span, memory, judgment, etc.
    
    • Designed to reveal the degree and nature of a client’s abnormal functioning.
    • Used by cognitive-behavioral clinicians.
  • Structure allows comparisons among individuals.
• LIMITATIONS:
  
  • Can lack validity, or accuracy.
    
    • Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discussing embarrassing topics.
    • Or people may be unable to give an accurate report due to such things as incorrect thinking or warped world views.
    • Those being interviewed might also be influenced by the demeanor and bias of the interviewer as well as their own biases toward the interviewer’s gender or race.
  • Interviewers may make mistakes in judgments and be influenced by biases. Essentially, their interpretation is subjective.

CLINICAL TESTS – tests for gathering information about a few aspects of a person’s psychological functioning from which broader information about the person can be inferred. There are six kinds most often used:

• PROJECTIVE TESTS – clients must interpret vague stimuli, such as inkblots or ambiguous pictures. Theoretically, when instructions are so general, people will “project” aspects of their personality into the task. revealing unconscious drives and conflicts.
  
  • RORSCHACH TEST – Symmetrical Inkblots are interpreted by the client – images a viewer saw seemed to correspond in important ways with his or her psychological condition.
    
    • 10 inkblots are standard in the RORSCHACH PSYCHODYNAMIC INKBLOT TEST – among the most widely used int he 20th century.
  • THEMATIC APPERCEPTION TEST (TAT) – people are shown 30 cards with black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each card, usually identifying with one of the characters on each card.
  • SENTANCE-COMPLETION TEST – test-takers complete a series of unfinished sentences, such as “I wish …” or “My father. …” The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore.
  • DRAWING – clients draw human figures and talk about them. Evaluations of these drawings are based on the details and shape of the drawing.
    
    • Draw-a-Person (DAP) test, the most popular of the drawing tests.
  • NOT consistently shown much reliability or validity.
• PERSONALITY INVENTORIES – A test, designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either characteristic or uncharacteristic of themselves.
  
  • Minnesota Multiphasic Personality Inventory (MMPI) – most widely used personality inventory. It measures 10 scales to create a personality profile:
    
    • Hypochondriasis – abnormal concern with bodily functions (“I have chest pains several times a week.”)
    • Depression – extreme pessimism and hopelessness (“I often feel hopeless about the future.”)
    • Hysteria – the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities (“My heart frequently pounds so hard I can feel it.”)
    • Psychopathic – showing a repeated and gross disregard for social customs and an emotional shallowness (“My activities and interests are often criticized by others.”)
    • Masculinity-femininity – Items that are thought to separate male and female respondents (“I like to arrange flowers.”)
    • Paranoia – show abnormal suspiciousness and delusions of grandeur or persecution (“There are evil people trying to influence my mind.”)
    • Psychasthenia – Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness (“I save nearly everything I buy, even after I have no use for it.”)
    • Schizophrenia – Items that show bizarre or unusual thoughts or behavior (“Things around me do not seem real.”)
    • Hypomania – Items that show emotional excitement, overactivity, and flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent reason.”)
    • Social introversion – Items that show shyness, little interest in people, and insecurity (“I am easily embarrassed.”)
  • Benefits over projective test:
    
    • Quick to administer
    • Objectively scored
    • Standardized, so one person’s scores can be compared with those of many others.
    • Display greater TEST-RETEST reliability
    • Only somewhat more validity, and accuracy
  • Detriment is that the personality traits that the tests seek to measure cannot be examined directly.
    
    • ​Also has cultural limitations
• RESPONSE INVENTORIES – Tests designed to measure a person’s responses in one specific area of functioning, such as affect, social skills, or cognitive processes.
  
  • Attempts to determine what role these specific factors play in the eperson’s disorder.
  • Most widely used inventories include:
    
    • BECK DEPRESSION INVENTORY – people rate their level of sadness and its effect on their functioning.
    • Social Skills Inventories – respondents indicate how they would react in a variety of social situations. Used particularly by behavioral and family-social clinicians
    • Cognitive inventories – reveal a person’s typical thoughts and assumptions and can help uncover counterproductive patterns of thinking.
    • Except for the Beck Depression Inventory, many of the test have not been fully vetted.
• PSYCHOPHYSIOLOGICAL TESTS – A test that measures physical responses (such as heart rate and muscle tension) as possible indicators of psychological problems. (Ex: Polygraph)
  
  • States of anxiety are regularly accompanied by physiological changes.
  • Problems with this approach include:
    
    • measurement is inaccurate and unreliable
    • expensive, massive equipment
    • intimidating to test-taker – can affect the outcome.
  • NOTE: Despite the polygraph having many detractors, studies have shown that the accuracy of lie detection rose to 100% in cases in which the MRI and polygraph agreed on the response, suggesting a cross-check between these techniques could be useful.
• NEUROLOGICAL and NEUROPHYSIOLOGICAL TESTS – A test that directly measures brain structure or activity.
  
  • Electroencephalogram (EEG) – records brain waves
  • NEUROIMAGING (BRAIN SCANNING) – actually takes “pictures” of the brain.
    
    • computerized axial tomography (CT scan or CAT scan), in which X rays of the brain’s structure are taken at different angles and combined
    • Positron Emission Tomography (PET scan) – a computer-produced motion picture of chemical activity in the brain
    • Magnetic Resonance Imaging (MRI) – uses the magnetic property of certain hydrogen atoms in the brain to create a detailed picture of the brain’s structure.
    • Functional Magnetic Resonance Imaging (fMRI) – converts MRI pictures into detailed pictures of neuron activity, producing images much clearer than PET scan images.
  • NEUROPSYCHOLOGICAL TESTS – A test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.
    
    • These techniques compensate for the inability of the brain imaging to detect subtle brain abnormalities.
• INTELLIGENCE TESTS – A test designed to measure a person’s intellectual ability.
  
  • Intelligence is an INFERRED QUALITY and so it can only be measured indirectly.
  • Even so, such tests tend to have high reliability.
  • Problems with IQ tests is that there are many powerful confounding factors, including low motivation and high anxiety, both of which can greatly confound the expression of intelligence.

CLINICAL OBSERVATIONS – Systematic observation in two forms:

• NATURALISTIC OBSERVATION –
• ANALOG OBSERVATION –