Lecture 4 - Clinical Assessment

Question 1

Aims of clinical assessment

Answer 1

Aims to chart cognitive, emotional, personality,
and behavioural factors associated with
psychopathology

Assessment can be used to:
– Make a diagnosis
– Identify targets for therapeutic interventions
– Monitor effects of treatment over time
– Conduct research aimed at learning more about psychopathology

Question 2

Methods of Assessment

Answer 2

1) Clinical observation
2) Clinical interviews
3) Biologically based assessment
4) Psychological tests

Question 3

Clinical Interviews

Answer 3

• An interview is any interpersonal encounter in which language is used to gather information about a client
• Clinical interviewer
  – Pays attention to how a respondent answers questions
  – Will be sensitive to emotion associated with a particular topic
• Influence of paradigm
• Type of information sought
• How it is obtained
• How it is interpreted

Question 4

Theoretical stance of interviewer

Answer 4

Psychodynamic Interviewer
- Likely to remain sceptical of verbal reports, look at unconscious

CBT Interviewer
- Focus on circumstances, thoughts and emotions

Question 5

Regardless of theoretical stance…

Answer 5

important to:
– Develop rapport
– Obtain trust
– Empathise with client (facilitate discussion)
Interviews vary in structure
Generally clinicians tend to conduct using
‘vague’ outlines

Question 6

Clinical Interview Assessment Example

Answer 6

Client Appearance/Speech & Sensory
Perception
– Client’s appearance, body language and behaviour; Speech pitch/pace impediments?
– Disability?
Client Emotions
– Client’s predominant mood/emotions? Do these vary/alter?
– Suicide ideation?

Question 7

Assessment Example cont. History

Answer 7

Has there been counselling before? When, Where, Whom, Outcome?
– Support outside of counselling relationship?
– Is any medication being taken? Will this interfere with the client’s ability to engage in our work?
– Are there any boundary issues with other professionals?
(consider confidentiality, other contracts)
– Are there any obvious indications against counselling?
(Alcohol/drug dependency, suicide risk, hospitalisation)

Question 8

Assessment cont. Concerning Counselling

Answer 8

– Does the client have capacity for insight? Are
they motivated?
– Client’s ability to connect/empathise?
– Presenting Problem? (incl. any client goals)

Question 9

Assessment cont. Concerning the therapist

Answer 9

– Do I feel competent to work with the issues
that the client brings?
– What thoughts and feelings do I have when I am with this client?– Development of the problem. How will I work with this client?

Question 10

Limitations of the Clinical Interview

Answer 10

• Unstructured Nature
• Reliability: low test-retest
• Merit of info provided by clients - truthful
• Interviewer Bias: primacy effect, prioritising negative info (Meehl, 1996), influence of client demographics

Question 11

Structured Interviews

Answer 11

Gathering particular, structured
information
Generally demonstrate good inter-rater
reliability (Blanchard & Brown, 1998)
lowest -> OCD
highest -> alcohol, Narcissistic

Question 12

Psychological Tests

Answer 12

Structured ways about gathering info

Method of administration

Psychometric approach
– Stable underlying characteristics or traits exist at different levels in everyone
– Assessment of psychopathology symptoms,
intelligence and neurological or cognitive
deficits

Question 12

Sample Structured Interview

Answer 12

Structured Clinical Interview (SCID) for Axis I DSM-IV

Question 13

Advantages of Psychological Tests

Answer 13

+ Rigid response requirements
+ Assess client one or more specific characteristics/traits or individual pathology
+ Rigorously tested
+ Standardisation: Comparison to normal distribution, estimate meeting of diagnostic criteria

Question 14

Personality Inventories

Answer 14

Minnesota Multiphasic Personality Inventory
(MMPI)– Originally developed with 800 psychiatric and 800 non-psychiatric patients (Hathaway & McKinley, 1943)
– Included only Qs that differentiate the two grps

Updated by Butcher, Dahlstrom, Graham, Tellegen et al. (1989)– MMPI-2
* Consists of 567 self-statements re: mood, physical concerns, social attitudes etc. (true, false, cannot say)

Question 15

MMPI-2

Answer 15

10 Clinical Sub-scales
4 Validity Scales
–Allow estimation of whether client has
provided false information
Range of scores: 0-120
Above 70 indicative of psychopathology

Question 16

MMPI-2 Validity Sub-scales and Sample Items

Answer 16

Sub-scale: L (lie scale) -> Measurement: Tendency of respondent to respond in a socially acceptable way -> Example Item: ‘I approve of every person I meet’

Other sub-scales: ? (Evasive), F (fake), K (defensive)

Question 17

MMPI-2 Advantages and Disadvantages

Answer 17

Utility of validity scales

Internal reliability and clinical validity
–Corresponds accurately with clinical diagnoses and ratings of symptoms by clinicians and familial members (Ganellan, 1996; Graham, 1990; Vacha-Hasse, Kogan, Tani & Woodall, 2001)

Time consuming to administer

Short versions available (Dahlstrom & Archer,
2000)

Question 18

Specific Trait Inventories

Answer 18

State Trait Anxiety Inventory (STAI)
Spielberger, Gorsuch, & Lushene (1970)

Eating Disorders (Eating Disorder Inventory (EDI-3))
Garner et al. (2004)

Depression (Beck Depression Inventory (BDI-II)
Beck, et al. (1996)

Question 19

Specific Trait Inventories: Advantages and Disadvantages

Answer 19

+ Useful as research tools
- Some relatively underdeveloped
+ Potential diagnostic and theoretical value
- Majority fail to include ‘validity’ scales as MMPI
+ Some valuable with good psychometric properties

Question 20

Projective Tests

Answer 20

Paradigm– ‘A group of tests usually consisting of a standard fixed set of stimuli that are presented to clients, but which are ambiguous enough for clients to put their own interpretation on what the stimuli represent’ (Davey, 2008, p. 35)

Stimuli interpreted according to unconscious
processes revealing true attitudes, motivations
and modes of behaviour – projective hypothesis

Question 21

Projective Tests Examples

Answer 21

Rorschach Inkblot Test
Thematic Apperception Test
Sentence Completion Test

Question 22

Rorschach Inkblot test

Answer 22

A projective personality test using inkblots

Client asked to react to each inkblots, one at a time

Client is believed to ‘project’ his or her personality onto

Question 23

Rorschach Inkblot Test cont.

Answer 23

Responses systematically scored according
to:
* Vagueness/synthesis of multiple images
* Location
* Variety of determinants (shape, colour,
texture etc)
* Form quality (faithfulness to actual form)
* Content
* Degree of mental organising activity
* Illogical/incongruous or incoherent
aspects
(Exner & Weiner, 1995)

Question 24

Thematic Apperception Test (TAT)

Answer 24

A projective personality test consisting of black and white pictures of people in vague or ambiguous situations Client asked to tell the story behind each (Morgan & Murray, 1935)

Question 25

Sentence Completion Test

Answer 25

First developed in 1920s Provides clients with the first part of an uncompleted sentence: – ‘I like…' – ‘I think of myself as…’ – ‘I feel guilty when…’ Allows identification of – Topics that can be further explored with clients – Ways in which an individual’s psychopathology might bias his/her thinking – Ways in which he/she processes information

Question 26

Using Sentence Completion test to identify trauma-relevant thinking biases in combat veterans with PTSD (Kimble et al., 2002)

Answer 26

Ps given 33 sentences to complete Items generated so could be completed with military/non-military content – ‘He was almost hit by a…’ – ‘The night sky was full of…’ – ‘The air was heavy with the smell of…’ – ‘The silence was broken by the…’ Results: Veterans with PTSD completed sentences with more military endings, thinking biases in accessing, retrieving and encoding

Question 27

Problems with Projective Tests

Answer 27

- Use over the years - Relevance to psychodynamic approach - Reliability of such tests - Cultural bias of traditional TAT pictures - Clinician training Some projective tests can infer psychopathology in the absence of other convincing evidence – Hamel, Shaffer and Erdberg (2000) * Inkblot Test to 100 schoolchildren none of whom had any history of MHPs * Results of test were interpreted that in almost all cases there was evidence of faulty reasoning that might be indicative of SZ or mood disorder

Question 28

Intelligence Tests

Answer 28

Regularly used by clinicians in a variety of settings for a variety of reasons – In combination with other measures of ability * Intellectual and learning difficulties – Identify intellectually gifted children – Assessment of needs of individuals with learning, developmental or intellectual difficulties – As part of neuropsychological evaluation

Question 29

Wechsler Adult Intelligence Scale (WAIS)

Answer 29

Provides scores on a range of different abilities including: – Vocabulary – Arithmetic Abilities – Digit Span – Information Comprehension – Letter-Numbering Sequences – Picture Completion Ability – Reasoning Ability – Symbol Search – Object Assembly Ability

Question 30

Problems with IQ Tests

Answer 30

- Intelligence as a construct - Current concepts of intelligence may be too narrow -> musical ability/physical skill? - Cultural biases of IQ tests -> based on limited views of what is adaptive - Measurement of capacity to learn

Question 31

Neurological Impairment Tests

Answer 31

Assessment as a result of structural and functional damage of brain Can cause changes in personality, deficits in cognitive functioning Different psychological functions (e.g., motor skills, memory, language, planning, executive functioning) localised in different areas of brain

Question 32

Assessment in Clinical Neuropsychology

Answer 32

– Determining the nature and location of any deficits – Providing information about onset, severity and progression of symptoms – Helping to discriminate between neurological and psychiatric symptoms – Helping to identify the focus for rehabilitation programmes

Question 33

Types of Neurological Test

Answer 33

Adult Memory and Information Processing Battery (AMIPB) (Coughlan & Hollows, 1985) – Comprises two tests of speed of information processing, verbal memory tests (list learning and story recall) and visual memory tests (design learning and figure recall) Halstead-Reitan Neuropsychological Test Battery (Broshek & Barth, 2000) – Compiled to evaluate brain and nervous system functioning across a fixed set of eight tests Mental State Examination (MMSE) (Folstein et al., 1975) – Overall levels of cognitive and mental functioning

Question 34

The Trail-Making Task

Answer 34

* Information processing speed * Visual scanning ability * Integration of visual and motor functions * Letter and number recognition and sequencing * Ability to maintain two different trains of thought

Question 35

Biologically Based Assessment

Answer 35

Psychophysiological Tests e.g: – Electrodermal responding (GSR) * Monitoring skin conductance response Stimuli that elicit anxiety – Cuthbert et al. (2003) Particular psychopathology – APD Ability of clients to cope following treatment intervention – Bobadilla & Taylor (2007); Grillion et al. (2004) Neuroimaging Techniques - Anatomical and structural info - Info re: brain activity and functioning - e.g. MRI, fMRI, PET

Question 36

Neuroimaging Techniques

Answer 36

CAT (computerized axial tomography) -> 3D structural image Magnetic resonance imaging -> structural better resolution than CAT Functional magnetic resonance imaging -> provides a picture of the brain as it functions Positron emission tomography -> Uses radioactive isotopes in the blood stream, both structural and functional

Question 37

Clinical Observation

Answer 37

Can supplement other assessment – Analogue Observations * Carried out in a controlled environment – Direct observation of a client’s behaviour – Self-observation/monitoring * Client observes and records own behaviour/thoughts * Ecological Momentary Assessment (EMA) (Stone & Shiffman, 1994)

Question 38

ABC Charts

Answer 38

A: The antecedents of behaviour B: The behaviour itself (what ind. did) C: The consequences of behaviour

Question 39

Clinical Observation Pros and Cons

Answer 39

+ Allows assessment of contextual factors (preceding and consequential (reinforcing) events) + Ecological validity + Can provide workable solutions + Provision of useful supplementary information - Time consuming - Observer effect - Problems with inter-observer reliability - Impact of observer expectation

Question 40

Cultural Biases in Assessment

Answer 40

Most assessments have been developed on Caucasian populations – Therefore, many tests may be culturally biased Clinicians need to be aware of these biases in their judgments and diagnoses

Question 41

Examples of Cultural Anomalies

Answer 41

1. Some ethnic groups score differently on assessment tests than others E.g., MMPI, Asian Americans score highly on most MMPI scales 2. Alcoholism and Schizophrenia (Garb, 1998) black Americans more likely diagnosed with alcoholism and sz 3. SES background ─ (Bentacourt & Lopez, 1993; Robins & Regier, 1991), low ses backgrounds more disturbed

Question 42

Causes of Cultural Anomalies

Answer 42

Mental health symptoms may manifest differently in different cultures Language differences between clinician and client can affect diagnosis Cultural stereotypes can affect the perception of what is 'normal' behaviour in ethnic groups Cultural differences in religious and spiritual beliefs can affect the expression of psychopathology Cultural differences can affect client-clinician relationships

Question 43

Addressing Cultural Anomalies

Answer 43

Clinicians need proper education and training when assessing and diagnosing minority persons (Hall, 1997) DSM-IV-TR made some attempt to identify potential cultural anomalies in diagnosis DSM-5 Cultural Formation Interview (CFI)