Lecture 2 - Assessment and Diagnosis Flashcards
the First Session
- Therapist: “What brings you here today?”
- Patient: “I’m _____ … I have _____”
- Therapist: “Tell me more …”
- A story begins …
Objectives of the First Session
- Listen: Attentive, Therapeutic, Empathy
- Validate
- Observe
- Orient to the therapeutic process
- match? or referral?
how the Scientific Method is involved in the First Session
the Clinical Psychologist is a Scientist:
- theory
- hypothesis
- data collection
- evidence in support of or disproving the hypothesis
- reformulating the hypothesis
- empirically supported interventions
psychological assessment
- a procedure
- use of psychological tests, observation, and interviews
- develop a summary of the client’s symptoms and problems
psychological diagnosis
- a general “summary classification”
- use of a diagnostic manual, e.g. DSM-5
types of assessment
- Clinical Psychologists are the only professionals comprehensively trained in Psychological Assessment
- Some Clinical Psychologists are primarily assessors
- Psychological assessment includes Neuropsychological Assessment (a subspeciality of Clinical Psychology) and Psychodiagnostic Assessment
Step 1 of assessment
Identify and characterize the presenting problem:
- situational or pervasive?
- duration?
- prior attempts to help or treat?
- how does problem impact social roles?
- does problem match any DSM disorder criteria?
Step 2 of assessment
Comprehensive assessment may incorporate the following:
- a general physical examination
- a neurological examination
Neuropsychological assessment
Objective: assess cognitive domains
- attention, memory, executive function, language, visuospatial ability, intelligence
- as a clue to the extent and location of brain damage (e.g. Dementia)
- as a way of characterizing the level of cognitive functioning (e.g. Learning Disabilities)
Psychodiagnostic assessment
Objective: to assess an individual’s psychological presentation
- three procedures commonly used in psychodiagnostic assessments include: assessment interviews (structured or unstructured), clinical observation of behavior, and psychological tests
assessment interviews
clinician obtains information about the client’s situation, personality, and behavior
structured interviews
restrict freedom to explore but increase reliability
unstructured interviews
allow for more exploration but decrease reliability
clinical observation of behavior
- ideally in a natural environment, such as a child’s behavior in a classroom or at home
- often in a clinic or hospital where the client seeks help
- rating scales can augment clinical observations of behavior and can increase reliability and validity (e.g. w/ ADHD)
the two general categories of psychological tests for use in clinical practice are …
… intelligence tests and personality tests
most commonly used intelligence tests
- the WISC-IV and the Stanford-Binet (for children)
- the WAIS-IV (for 16 y.o and older)
personality tests include …
… projective and objective personality tests
in projective personality tests …
… unstructured stimuli are presented to a subject and the subject projects meaning or structure onto the stimuli
- these projections are believed to be unconscious processes
projective personality tests include:
- the Rorschach Inkblot Test
- the Thematic Apperception Test
- the Sentence Completion Test
Rorschach Inkblot Test
see many dif. inkblots, can code what you see
- not used alone to give comprehensive interpretation, part of more comprehensive assessment
Thematic Apperception Test
shown a picture, asked “What do you see? Can you tell a story w/ a beginning, middle, or end?”
- story you tell says something specific about your own story
advantages of projective tests
- comprehensive
- potential advancement of psychodynamic, psychoanalytic conceptualization
disadvantages of projective tests
- length of time to administer and interpret
- subjectivity
- advanced skill/training necessary to interpret/score
- debates over reliability and validity
objective personality tests
- typically structured questionnaires, self-report or rating scales
- include the MMPI and MMPI-2 (Minnesota Multiphasic Personality Inventory)
MMPI and MMPI-2 (Minnesota Multiphasic Personality Inventory)
- the most widely used personality test for clinical and forensic assessment
- subject’s response is compared to norms and clinical samples
- the MMPI includes ten clinical scales measuring psychopathology and a few validity scales measuring honesty, straightforwardness
advantages of objective tests
- cost-effective, reliable, objective
- computer scoring
disadvantages of objective tests
- too mechanistic, reduces complexity
- self-report biases, distortions
Integration of Assessment Data
- assessment data from various sources must be integrated into a coherent working model
- a definitive picture may emerge or sometimes, there are discrepancies that necessitate further assessment
Components of an assessment report
- Referral Question
- Background Information (including family history, psychosocial history, medical history, and psychological history)
- Behavioral Observations
- Tests Administered
- Test Results
- Summary and Diagnostic Impressions
- Recommendations
ethical issues in assessment include:
- Potential cultural bias
- Theoretical orientation of the clinician
- Underemphasis on the external situation
- Insufficient validation
- Inaccurate data or premature evaluation
classifying abnormal behavior
classification involves the attempt to delineate meaningful sub varieties of maladaptive behavior
benefits of classification
- Introduction of order
- Enables communication
- Enables statistical research
- Insurance reimbursement
three basic approaches to classification models are:
- the categorical approach
- the dimensional approach
- the diagnostic approach
categorical approach
a patient is healthy or disordered, but there is no overlap
dimensional approach
the patient may fall along a range from superior functioning to absolutely impaired functioning
formal diagnositic classifcaiton of mental disorders
- the Diagnostic and Statistical Manual of Mental Disorders (DSM)
- the International Classification of Disease (ICD)
example: DSM-IV TR Diagnosis
Axis I: Major Depressive Disorder; Alcohol Dependence Disorder; Generalized Anxiety Disorder
Axis II: Borderline Personality Disorder
Axis III: Anemia
Axis IV: Recent Arrest, falling grades, conflicts w/ parents
Axis V: GAF = 70
DSM (pre-DSM-5) had 5 axes:
Axis I: Clinical syndromes or other conditions that may be the focus of clinical attention
Axis II: Personality disorders, mental retardation
- Axis III: General medical conditions
- Axis IV: Psychosocial and environmental problems
- Axis V: Global assessment of functioning
DSM criticisms
- The Pathology Assumption
- Reduces Complexity
- Presentations that do not fit (e.g. Complex/Developmental Trauma)
- May promote selective bias in evidence in
patient and therapist
Non-pathological models
- healing
- learned
- survival
(e.g. Internal Family Systems, IFS)
Conviction of Psychotherapy
the belief that people w/ psychological problems can change-can learn more adaptive ways of perceiving, evaluating, and behaving is the conviction underlying all psychotherapy
- an effective psychotherapist assists clients w/ changing dysfunctional emotion, cognitive and behavior patterns and replacing them w/ new, functional ones
Why seek therapy?
- current stressors
- historical issues/problems
- referrals by others - reluctant clients
- personal growth
professional therapists
- Religious Counselors
- Psychologists - PhD
- Clinical or Counseling, PsyD
- Psychiatrists - MD
- Clinical Social Workers - LICSW
- Psychiatric Nurse Practitioners - NP
the therapeutic relationship is a …
… working alliance
- Collaborative relationship
- Agreement on goals and takes
- Affective bond
- Clear communication
- Pt./Client’s motivation, expectation of receiving
help
Success of therapy based in …
… therapeutic alliance, not in how advanced degree is/years of training
Estimating therapy gains
- Therapist impression
- Client report
- Family/friend report (as people grow in therapy, some of their old friend may not be friends w/ them anymore, b/c they became friends with the old them)
- Pre-treatment vs. post-treatment scores
- Measures of change in overt behaviors
- Insight does not automatically guarantee change!
Objectifying and quantifying change: Would change occur anyway?
- Most researchers agree that psychotherapy is more effective than no treatment even though some psychological states may resolve w/o treatment
- Often times, time itself heals a lot of things (e.g., therapy can’t heal bereavement)
Can therapy be harmful?
- People may deteriorate in treatment
- Boundary violations often play a role (all info given is in pt.’s interest, it is all therapy)
What approaches should be used?
- current emphasis on evidence based or empirically supported approaches
- however, it is a challenge to control all variables in therapy
treatment approaches
psychosocial approaches
- behavior - exposure, aversion, modeling, token economics
- cognitive and cognitive behavioral therapy (Rational Emotive-Ellis and Beck’s Cognitive Therapy)
- Humanistic - experimential (client-centered therapy by Carl Rogers, motivational interviewing, Gestalt)
- psychodynamic/psychoanalytic
couple and family therapy
eclecticism and integration
biological approaches
- psychopharmacology
- electroconvulsive therapy (ECT)
- neurosurgery
- deep brain stimulation
