Lecture 4 - Clinical Assessment Flashcards
Aims of clinical assessment
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
Methods of Assessment
1) Clinical observation
2) Clinical interviews
3) Biologically based assessment
4) Psychological tests
Clinical Interviews
- 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
Theoretical stance of interviewer
Psychodynamic Interviewer
- Likely to remain sceptical of verbal reports, look at unconscious
CBT Interviewer
- Focus on circumstances, thoughts and emotions
Regardless of theoretical stance…
important to:
– Develop rapport
– Obtain trust
– Empathise with client (facilitate discussion)
Interviews vary in structure
Generally clinicians tend to conduct using
‘vague’ outlines
Clinical Interview Assessment Example
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?
Assessment Example cont. History
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)
Assessment cont. Concerning Counselling
– Does the client have capacity for insight? Are
they motivated?
– Client’s ability to connect/empathise?
– Presenting Problem? (incl. any client goals)
Assessment cont. Concerning the therapist
– 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?
Limitations of the Clinical Interview
- 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
Structured Interviews
Gathering particular, structured
information
Generally demonstrate good inter-rater
reliability (Blanchard & Brown, 1998)
lowest -> OCD
highest -> alcohol, Narcissistic
Psychological Tests
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
Sample Structured Interview
Structured Clinical Interview (SCID) for Axis I DSM-IV
Advantages of Psychological Tests
+ 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
Personality Inventories
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)
MMPI-2
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
MMPI-2 Validity Sub-scales and Sample Items
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)
MMPI-2 Advantages and Disadvantages
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)
Specific Trait Inventories
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)
Specific Trait Inventories: Advantages and Disadvantages
+ 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
Projective Tests
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
Projective Tests Examples
Rorschach Inkblot Test
Thematic Apperception Test
Sentence Completion Test
Rorschach Inkblot test
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
Rorschach Inkblot Test cont.
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)
Thematic Apperception Test (TAT)
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)
Sentence Completion Test
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
Using Sentence Completion test to identify trauma-relevant thinking biases in combat veterans with PTSD (Kimble et al., 2002)
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
Problems with Projective Tests
- 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
Intelligence Tests
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
Wechsler Adult Intelligence Scale (WAIS)
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
Problems with IQ Tests
- 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
Neurological Impairment Tests
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
Assessment in Clinical Neuropsychology
– 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
Types of Neurological Test
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
The Trail-Making Task
- 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
Biologically Based Assessment
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
Neuroimaging Techniques
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
Clinical Observation
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)
ABC Charts
A: The antecedents of behaviour
B: The behaviour itself (what ind. did)
C: The consequences of behaviour
Clinical Observation Pros and Cons
+ 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
Cultural Biases in Assessment
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
Examples of Cultural Anomalies
- Some ethnic groups score differently on assessment tests than others
E.g., MMPI, Asian Americans score highly on most MMPI scales - Alcoholism and Schizophrenia
(Garb, 1998) black Americans more likely diagnosed with alcoholism and sz - SES background
─ (Bentacourt & Lopez, 1993; Robins & Regier, 1991), low ses backgrounds more disturbed
Causes of Cultural Anomalies
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
Addressing Cultural Anomalies
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)
