Topic 4

• Clinical assessment


  The collection and synthesis of information to reach a clinical judgment about people and their problems
• Clinical assessment is a special version of the kind of assessment that most of us engage in almost every day
• Referral question


  The trigger that shapes the clinician's choice of assessment instruments and the interpretation and communication of results
• Examples of referral questions from various sources

  • Therapist
  • Physician or treatment team
  • Client
  • School
  • Parent
  • Court
  • Employer, government agency, or other third party
• Planning data collection procedures

  • Clinicians must consider the referral question, the quality of assessment instruments, the client's characteristics, and the need to communicate results clearly
• Collecting assessment data


  • Clinical psychologists can collect data from interviews, observations, tests, and historical records
  • They use multiple assessment sources to cross-validate information
• Processing data and forming conclusions

  • Clinicians must integrate and synthesize the collected data to reach a clinical judgment
• Without clinical assessment, high-quality research on the causes, correlates, and treatment of mental disorders would be essentially impossible
• DSM-5 did not substantially change the number of possible diagnoses; rather, it modified the diagnostic criteria for certain disorders and reorganized disorders into 17 broad categories
• Concerns about lowered diagnostic standards, the introduction of too many new disorders, and the lack of empirical grounding for some disorders

  Led to increased "medicalization" of psychological disorders and a de-emphasis on understanding of the sociocultural factors associated with disorders
• Clinicians and researchers concerned about the shortcomings of DSM-5 and ICD-11 have proposed alternative diagnostic systems
• Dimensional approaches to diagnosis


  • Avoid the DSM's dichotomies, which may fail to capture potentially useful information about clients
  • Base diagnoses on measurement of client characteristics on a selected set of dimensions that are relevant for each disorder
• Dimensional approaches to diagnosis

  • Borderline personality disorder diagnosis in DSM-5
  • Hierarchical Taxonomy of Psychopathology (HiTOP)
• Psychodynamic Diagnostic Manual (PDM)

  Promotes more in-depth assessment and encourages clinicians to look beyond overt disorder features during the diagnostic process
• Positive psychology approach


  Systematic assessment of clients' strengths, not just problematic symptoms
• Research Domain Criteria (RDoC)

  Conceptualizes mental disorders as disorders of brain circuitry, emphasizing continuous transdiagnostic vulnerability markers
• No diagnostic system is likely to ever accomplish all the goals of differentiating among a wide variety of complex disorders
• Diagnostic classification and descriptive assessment can go hand in hand
• Descriptive assessment


  Focuses on identifying factors such as antecedent conditions, environmental incentives and disincentives, alternative sources of reward, thinking style, ego strengths and weaknesses, cognitive functioning and defense mechanisms, quality of relationships, and characteristics of sense of self
• Broader description of clients is unlikely to dominate clinical assessment due to time and cost constraints
• Arriving at a diagnosis


  Leads to a preferred treatment
• Diagnostic classification remains somewhat unreliable, making it challenging to argue that specific treatments work for specific diagnoses
• Assessment for treatment planning


  Addresses the question: What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?
• Clinicians are increasingly asked to provide evidence of their effectiveness, requiring assessment of treatment outcomes
• Ways to assess treatment results


  • Questionnaires, client self-reports, psychological tests, reports by relatives and friends
• Monitoring outcomes throughout the course of treatment allows clinicians to revise their approach as the client is not making the expected progress
• Assessments can also be used as an explicit component of treatment

  Discussing clients' treatment results with them can have therapeutic value
• Discussing assessment results


  • Encourages clients to be more objective and accurate in tracking their own behaviors over time (self-monitoring)
  • Increases clients' trust in the therapist and in the treatment
  • Provides an additional avenue of therapeutic interaction
  • Gives clients greater insight into their strengths and weaknesses
• Prognosis


  A prediction about the outcome of treatment, or more generally about changes in symptoms without treatment or under certain circumstances
• Many DSM diagnoses contain information relevant to prognosis, including results of long-term studies of the course of a disorder as well as other data related to the time of its typical onset, chronicity, people who are most at risk, and the like
• Prognosis can be influenced by assessment of client factors

  Impulsivity, coping style, and repeated resistance to therapist suggestions
• Predicting performance

  Clinicians collect and/or examine descriptive assessment results to provide data on which to base predictions and selections for jobs or situations
• Examples of clinical assessment programs aimed at predicting performance appeared during World War II, when psychiatrist Henry Murray used specialized tests, interviews, and observations to select soldiers who would be the most successful spies, saboteurs, and other behind-enemy-lines operatives
• Researchers who seek to improve the prediction of dangerousness are now focusing on combining assessment evidence from four domains: personality traits, clinical factors, historical factors, and contextual factors
• The American Psychiatric Association has stated that psychiatrists have no special knowledge or ability that allows them to accurately predict dangerous behavior, and the same is no doubt true for clinical psychologists
• Clinicians usually prefer to make predictions about the probability of danger or the level of risk (e.g., high, moderate, low) rather than about whether a particular individual will or won't commit a particular act
• Clinicians try whenever possible to base their predictions on one of several assessment instruments that are designed to predict dangerousness, although none of these instruments has shown better than modest predictive accuracy
• Psychometric properties


  The "credentials" of assessment instruments, including reliability, validity, standardization, and utility
• Factors that determine sound clinical judgments

  • The soundness of the tests and other assessment instruments clinicians use
  • The clinician's level of experience and theoretical orientation
  • The situation in which assessment occurs
  • A variety of cultural factors
• Sound clinical judgments depend on the soundness of the tests and other assessment instruments clinicians use to help make those judgments