THE CONCEPT OF PSYCHOLOGICAL ASSESSMENT IN CLINICAL PSYCHOLOGY

<< THE PROCESS OF DIAGNOSIS:ADVANTAGES OF DIAGNOSIS, DESCRIPTION

THE CLINICAL INTERVIEW:The intake / admission interview, Structured interview >>

Clinical Psychology (PSY401)

LESSON 15

THE CONCEPT OF PSYCHOLOGICAL ASSESSMENT IN CLINICAL PSYCHOLOGY

DEFINITION OF PSYCHOLOGICAL ASSESSMENT

Psychological assessment can be defined as "the process of systematically gathering information about a

person in relation to his or her environment so that decisions can be made, based on this information

that is in the best interests of the individual".

For a clinical psychologist a number of questions are important to consider like what are patient's

current problems and the possible resources he has for dealing with these problems? What information

about his past might be contributing to the problem? Are there any people in patients' life who might be

able to solve these problems? And what is his behavior likely to be in future? Clinical psychologist is

uniquely equipped, however, to examine these issues systematically through procedures that have been

carefully developed and evaluated by their field.

STEPS IN THE ASSESSMENT PROCESS

First a psychologist formulates an initial question or set of questions. These questions are typically

developed in response to a referral or request for help made by either an individual or by others on

behalf of an individual. (e.g., concerned family members, parent, and physician).

Second, a psychologist generates a set of goals for collection information----what the psychologist

hopes to accomplish during the assessment process.

The third step in the assessment process involves the identification of standards for interpreting the

information that is collected.

Fourth, a psychologist must collect the relevant data. This step includes collecting information about the

person and the environment and carefully describing and recording what is observed.

The fifth step in the assessment process involves making decisions and judgment on the basis of the data

that have been collected. Finally, a psychologist must communicate these judgments and decisions to

others typically in the form of a psychological report.

Psychological theory and research are the two primary factors that shape the clinical assessment process

and make it more systematic than the way people form impressions of others in everyday life. Theories

guide psychologists in forming certain types of questions and hypothesis and in looking for certain types

of information

THE PROCESS OF PYSCHOLOGICAL ASSESSMENT

STEP 1: DECIDING WHAT IS BEING ASSESSED

The assessment process begins with a series of questions. Is there a significant psychological problem?

What is the nature of this person's problem? Is the problem primarily one of the emotion, thought, or

behavior? What are possible causes of the problem? What is the course of the problem likely to be if it

goes untreated? What type of treatment is likely to be the most helpful? These questions come in part

from the client and are called the "referral questions"------questions that led the client to refer to the

psychologist.

115

Clinical Psychology (PSY401)

THE REFERAL

The assessment process begins with a referral. Someone--a patient, a teacher, a psychiatrist, a judge, or

perhaps a psychologist--poses a question about the patient. "Why is Johnny disobedient?" or "Why

can't Alice learn to read like other children?" clinicians thus begin with the referral question. It is

important that they take pains to understand precisely what the question is or what the referral source is

seeking. In some instances, the question may be impossible to answer; in others, the clinician may

decide that a direct answer is inappropriate or the question needs rephrasing.

Often Client's presenting concerns are tied to a recent event. The recent event, however, may represent

the final step in a more long-standing problem. The questions and concerns that a client poses at the

time of referral do not necessarily tell the whole story. A client is unlikely to be aware of all the

information that may be relevant to a psychologist in formulating and understanding of the problem.

Furthermore, the client may purposefully or unknowingly withhold information from the psychologist

for a variety of reasons. It is important to recognize that clinical psychologist cannot simply use

intuition and subjective judgment to identify the complex factors that lead to a referral or to a request for

help. Rather, a clinical psychologist will need to turn the theory and research in formulating a more

complete set of initial questions to guide a formal assessment.

What does a psychologist want to know about a person who is seeking help? Most current theories of

human behavior recognize multiple levels of functioning that are relevant to understanding any

behavior. For example, all emotions are associated with underlying biological processes, they exist

within the conscious

(but private) awareness of the individual, and they are linked to some type of observable antecedent

and/or consequent event, either externally in the environment or internally within the experience of the

individual. Further many theories consider these processes to be interdependent and reciprocally related.

The implication of these complex relationships for psychological assessment is clear---a psychologist

may assess the client and his or her problem at a number of different levels. The primary aspects of the

person that are possible targets for assessment are biological processes, cognitions, emotions and

behavior.

Biological and Psycho-physiological processes include heart rate reactivity, blood pressure galvanic

skin response, muscle tension, sexual arousal, startle response, and eye tracking movement.

Cognitive processes include intellectual functioning, perceptions of the self, perceptions of others,

beliefs about the causes of events, and perception of contingency and control.

Emotional processes that are the focus of assessment include mood states, trait levels of emotions, and

emotional reactivity, finally, measure of overt behavior include performance on standardized tasks,

observations of behavior in simulated situations, and behavior observed in the client's natural

environment.

In addition to these various aspects environment is also multifaceted, confronting psychologists with a

choice among several levels of focus. These levels of focus include distinctions, intermediate, and distal

environment as well as objective versus subjective or perceived features of the environment.

116

Clinical Psychology (PSY401)

The Proximal and, or Immediate features of the environment include the client's family environment

and the characteristics of the school or work setting.

Intermediate levels of the environment include the geographic region in which the individual resides.

Finally, the Distal, or Broader, environment includes the general geographic and socio-cultural

environment in which the client lives.

Despite the potential importance of the different aspects of the individual and the environment,

psychologists cannot assess all these factors for any single case. Both the time and the cost involved in

conducting such as extensive assessment would be prohibitive. A psychologist's theoretical orientation

plays a critical role in guiding the psychologist to obtain certain types of information and to disregard

other aspects of the person or the environment.

STEP 2: DETERMINING THE GOALS OF ASSESMENT

The second step in the process of clinical assessment is the formulation of the psychologist's goal in a

particular case. Once again, psychologists are confronted with a number of choices as they carry out the

assessment process. Goals may include diagnostic classification, determination of the severity of a

problem, risk screening for future problems and evaluation of the effects of treatment, and prediction

about the likelihood of certain types of future behavior.

DIAGNOSIS

Diagnosis is perhaps a most familiar term than assessment in the work of clinical psychologists.

Although generating a diagnosis is one of the tasks in which a psychologist may engage, it is actually a

subset of the broader process of assessment. Within the process of psychological assessment, the task of

diagnosing implies that certain procedures or tests are administered to an individual in order to classify

the person problem and, if possible, to identify causes and prescribe treatment, psychologists typically

make diagnosis based on the DSM-IV criteria.

Diagnostic decisions are often the first goal of the assessment process. Optimally, diagnosis should

provide information about the specific features, or symptoms that the person shares with other

individuals who have been identified as having the same pattern of symptoms. If the criteria for making

particular diagnosis are clear and have been carefully evaluated in this case, the psychologist will be

able to draw on research and information about these other individuals.

There is a close link between assessment procedures and the diagnostic system that a psychologists uses

for u understanding and classifying psychotherapy. Specifically, assessment involves the identification

of the features or characteristics that distinguish individual cases from one another, whereas a diagnostic

system involves the grouping together of individual cases according to their identifying features. Any

diagnostic system .such as DSM IV should specify a method of assessment to measure and quantify the

important symptoms of the various categories or disorders within the diagnostic system. A diagnostic

system represents one of the outcomes of assessment ---the classification of individuals using the

information that has been generated.

SEVERITY

It is not always sufficient to know that an individual meets the criteria for a particular problem or

disorder, because there can be substantial differences among individuals with a similar problem, a

concept referred t o as heterogeneity. Or it may also be compared with the term severity or variability in

the disease. For example breast cancer may vary from a small-localized tumor (stage 1) to carcinoma

that has spread throughout other parts and systems of the body (stage IV).

117

Clinical Psychology (PSY401)

Discrimination of the severity of problems or disorders requires assessment and methods that are

sensitive to variation in the f frequency, intensity, and duration of specific symptoms. If a patient meets

the criteria for major depression, the psychologist must gather additional information about the problem.

An important factor in determining the severity of a disorder is t he degree of impairment that is present

in the person's daily life. For example a patient with an eating disorder may have suffered from Bulimia

Nervosa foe several years, yet is still able to be successful in her college courses, work at a part-time

job, and maintain her friendship. Another patient with bulimia, however, may find that her

preoccupation with eating and her concerns about being overweight have become the predominant

feature in her life. Thus psychologist must consider the individual`s overall life functioning and

competence in order to have a complete understanding of the scopes of the problem.

SCREENING

Not all psychological assessment takes place with individuals who have been referred for clinical

services. Often clinical psychologists are called on to screen large groups of individuals, either to

identify the presence of problems or to predict who is at greatest risk to develop a problem at some point

in the future. For example, several interesting examples of screening related to depression have been

developed. Depression is highly prevalent in the general population, but only a small portion of

depressed individuals seek treatment for the disorder. Efforts to screen for depression have been

undertaken on a large scale.

In depression screening individuals are encouraged to complete a brief depression questionnaire that

assesses their current level of depressive symptoms. Those who score above a certain cutoff level that

we associated with increased risk for depression are then contacted for a diagnostic interview to

determine if they are suffering from Major Depression.

Children whose parents suffer from Major Depression Disorders are much more likely to develop

serious psychological and behavioral problems than are children whose parents do not exhibit an

identifiable form of psychopathology. Psychologists may be called on to screen or identify early

evidence of problems among children in these families in order to facilitate early interventions that may

prevent the development of such problems.

Depression in adolescence is also a prevalent problem that typically goes unrecognized, specifically

depression in adolescent has been found to be associated with somatic problems like recurrent

headaches. Depression screening tools can also utilized in medical emergency rooms. Brief depression

questioners are administered to emergency room patients to identify those who may need treatment for

depression.

PREDICTIONS

In addition to generating detailed description of an individual's current functioning, psychologists are

often called on to make predictions about how a person may behave at some point in the future. These

predictions may span very short periods of time to long-term predictions about subsequent risk for

disorders.

One of the greatest challenges for psychologists is the prediction of violent behavior especially in

relation to the prediction of youth violence. The accurate prediction of violent behavior could then lead

to attempts to prevent violent acts before they occur. Despite the extraordinary significance of

predicting violent behavior, psychologists have been largely unsuccessful in this effort. This lack of

success is due, in part, to the fact that we do not sufficiently understand the complex factors that leads to

acts of violence.

Psychologists are actually effective in making predictions about certain problems, particularly if those

problems have reasonably high rate of occurrence in the population. For example patterns of aggressive

118

Clinical Psychology (PSY401)

and disruptive behavior disorders in adolescence can be predicted with some degree of accuracy from

information collected in early childhood. In the prediction of violence and other low base rate behaviors,

psychologists must carefully weigh the consequences of false positive and false negative predictions. if

the consequences of wrongly predicting an outcome (a false positive) are small and the costs of missing

an outcome that does occur(false negative) are great, then it will be acceptable to over-predict.

However, if there are negative consequences to wrongly predicting an outcome, then even one instance

of over prediction will be problematic.

EVALUATION OF INTERVENTION

Assessment is often thought of as an initial step in formulating a sense of a client's problem or a

diagnosis and in developing a plan for treatment. However, effective assessment does not end once

treatment begins. Rather, assessment methods should be re-administered at regular intervals to monitor

and evaluate the effects of treatment.

For example, by obtaining pretreatment or baseline information on the nature and severity of a client's

problems, follow-up assessment with the same instrument can be conducted to allow for evaluation of

changes that have resulted from treatment (this is called the ABA method).

Evaluating change requires a few essential steps. Obviously, the same instruments must be used at both

the pretreatment and follow-up assessments that exact comparisons can be made on these scales.

Further its is essential that the measures can be counted on to produce consistent or reliable information,

that is, the measures must be minimally affected by error so that meaningful changes cab be

distinguished from random fluctuations.

Finally, criteria (cut off points) must be developed to distinguish clinically meaningful change from

reliable but relatively trivial shifts in the target problems.

STEP 3: SELECTING STANDARDS FOR MAKING DECISIONS

Knowing what to measure is only part of the process of assessment. A psychologist must also know

what to do with the information once it is collected. Making decisions about the information is essential,

and decisions and judgments require points of reference for comparison.

Standards are used to determine if a problem exists, how severe a problem is, and whether the individual

has evidenced improvement over a specified period of time.

Comparisons can be made to standards that involve other people (normative standards) or to the self at

other points in time (self-referent standards)

Psychological assessment reflects the meeting point of two important functions of psychology--interest

in the nature of people in general (the normative, or nomothetic tradition) and concerns about a specific

person (the individual, idiographic tradition).

When working with an individual, a psychologist is drawing on the idiographic traditions. This process

involves the discovery of what is unique about this person given his or her history, current personality

structure, and present environment conditions.

In arriving at an impression of this individual, however, the psychologist is frequently required to make

judgments about this person in comparison to most other people. In doing so, the psychologist draws on

the nomothetic tradition of laws and rules that apply to the behavior of people in general.

119

Clinical Psychology (PSY401)

The application of normative information to individual decisions is a complex process. No single

individual is ever represented perfectly by data collected on large samples of people. Therefore

predictions made on the basis on data collected on large samples will not necessarily hold true for any

particular individual, which means that psychologists are often involved in making educated guesses

about an individual based on the knowledge base accumulated about people in general.

In making normative comparisons, the psychologist must determine the degree to which a particular

individual is similar to the normative sample on demographic characteristics such as age, sex, ethnicity,

education, and economic status. For example, it would be inaccurate (and inappropriate) to make

predictions about an inner city African American adolescent's performance on a test if the normative

sample that is used in deriving scores was composed only of middle and upper socioeconomic status

Caucasian youth.

VARIABILITY OF A NORMATIVE SAMPLE

It can be represented in several ways, but the most common is based on the mean as a measure of

central tendency and the standard deviation as a measure of variability. The mean score for a population

on a measure is determined by summing all the scores from a sample that is representative of the

population and dividing by the number of individuals in the sample. For use in psychological

assessment, the mean and standard deviation are often converted to standard scores that allow for easy

comparison across very different measures.

SELF-REFERENT STANDARDS

Some of the judgments that are made as part of the clinical assessment process do not involve

comparisons to others. Rather, it is important to consider how much or how little this person has

changed over time or across different situations. In such instances, the appropriate criterion is the person

himself or herself.

Self-referent standards can also be useful in determining the initial goals of a client and the degree to

which he or she is satisfied with gains made in treatment. A client seeking help for a sleep disorder may

report substantial satisfaction with being able to obtain a period of four to five hours of uninterrupted

sleep on a nightly basis if the client who initiated treatment were unable to sleep for even a few minutes

each night. Self-referent standards in this case would not be a replacement for normative standards,

however, as it may still be important for health reasons to strive for greater gains in treatment until the

client is able to achieve the expected seven to eight hours of sleep per night.

STEP 4: COLLECTING ASSESSMENT DATA

Methods to Be Used

As psychologists make decisions about which aspects of the person-environment system are most

relevant to measure; they must also decide which of many methods will be used to assess the targets that

have been selected. These choices include the use of structured or unstructured clinical interviews,

reviews of the individual's history from school or medical records, measurements of physiological

functioning, a wide array of psychological tests self-reports from the individual, reports from significant

others in the individual's life, and methods for the direct observation of behavior in the natural

environment or in simulated conditions in the psychologist's office.

120

Clinical Psychology (PSY401)

Interviews can be relatively open-ended, following the preferences or style of the individual

psychologist, or highly structured in which a series of questions are asked in a prescribed manner and

order regardless of who administers the interview.

Physiological measures can include a device to monitor heart rate, blood pressure, skin temperature, or

muscle tension in a particular area of the body (e.g., the muscles of the jaw). Literally hundreds of

psychological tests have been developed, most of which are administered by a psychologist to a client

on an individual basis; a smaller number are administered in a group format. Psychological tests include

measures of intelligence assessments of neuro-psychological functioning, objective tests of personality,

and projective methods of assessing personality. Self-report measures have been designed to assess

symptoms of specific problems such as depression, stressful life events, current concerns and problems,

or perceptions of relationships with others. Direct observation methods are used to assess specific

behaviors as they occur either in the natural environment or under simulated conditions in the therapist's

office.

Typically a psychologist will draw on several of these methods in conducting a clinical assessment of a

single case. The assessment process often begins with an interview as a means of obtaining general

information about the individual and establishing rapport with the client. This initial interview may be

followed by psychological testing, observations of behavior, and/or psychological assessment.

The choice of methods is influenced by a number of factors. For example, the age of the client is an

important consideration. Adult assessment typically involves tests and interviews administered to the

individual, whereas child assessment often involves information obtained from other informants (e.g.,

parents, teachers) on the child's behavior. The referral question also plays a significant role in the

assessment methods that are used. The procedures used with an adult referred for a sexual dysfunction

will be quite different than those used in response to a' referral for an anxiety disorder. The selection of

methods is also strongly influenced by the psychologist's theoretical orientation and taxonomy of

psychopathology.

RELIABILITY AND VALIDITY

The most fundamental concern that a clinical psychologist must face when conducting a clinical

assessment centers on the accuracy of the data she or he collects. Accuracy may be reflected in the

consistency of the measure (reliability) and in the degree to which it reflects the construct of interest

(Validity).

RELIABILITY

The first way is determine accuracy is to consider the reliability of the information that is obtained.

Reliability refers to the consistency of the observation or measurements that are made and provides a

first step towards ensuring trustworthy information.

First, there is test-retest reliability - the extent to which an individual makes similar responses to the

same test stimuli on repeated occasions. If each time we test a person we get different responses, the test

data may not be very useful. In some instances, clients may remember on the second occasion their

responses from the first time. Or they may develop a kind of "test-wise ness" from the first test that

influences their scores the second time around. In still other cases, clients may rehearse between testing

occasions or show practice effects.

For all these reasons, another gauge of reliability is sometimes used - equivalent-forms reliability.

Here, equivalent or parallel forms of a test are developed to avoid the preceding problems. Sometimes it

is too expensive (in time or money) to develop an equivalent form or it is difficult or impossible to be

sure the forms are really equivalent.

121

Clinical Psychology (PSY401)

Under such circumstances, or when retesting is not practical, assessing split-half reliability is a

possibility. This means that a test is divided into halves (usually odd-numbered items versus even-

numbered items), and participants' scores on the two halves are compared. Split-half reliability also

serves as one possible index of a test's internal consistency: Do the items on the test appear to be

measuring the same thing? That is, are the items highly correlated with each other? The preferred

method of assessing internal consistency reliability involves computing the average of all possible split-

half correlations for a given test.

Another aspect of reliability is inter-rater or inter-judge reliability i.e. index of the degree of

agreement between two or more raters or judgers as to the level of a trait that is present or the

presence/absence of a features or diagnosis.

VALIDITY

An assessment method's validity is as important as determining its reliability. Validity reflects the

degree to which an assessment technique measures what it is designed or intended to measure. Validity

is determined by using maximally different methods to measure the same construct. Several different

types of validity exist.

Content Validity indicates the degree to which a group of test items actually covers the various aspects

of the variable under study.

Predictive Validity is demonstrated when test scores accurately predict some behavior or event in the

future.

Concurrent Validity involves relating today's test scores to a concurrent criterion.

Finally, Construct Validity is shown when test scores relate to other measures or behaviors in a logical,

theoretically expected fashion.

STEP 5: MAKING DECISIONS

The information obtained in the psychological assessment process is valuable only to the extent that it

can be used in making important decisions about the person or persons who are the focus of assessment.

The goals of assessment--diagnosis, screening, prediction, and evaluation of intervention--determine

the types of decisions that are made. The decisions that are made on the basis of psychological

assessments can have profound effects on people's lives. The process of making decisions is complex

and the stakes are high. Therefore, it is important to understand the factors that influence the decisions

and judgments made by clinical psychologists and ways to optimize the quality of these decisions.

CLINICAL VERSUS STATISTICAL PREDICTION

Because people, including clinical psychologists, are faced with a number of obstacles in the process of

making judgments about the behavior of other people, how can the judgment process be improved? The

issue is relatively straightforward. When clinicians use psychological assessment data, what is the best

way for them to make judgments and predictions about individuals? Should the data be combined using

statistical methods to make estimates of probability, or should the information he combined more

subjectively by the individual clinician based on his or her experience? Statistical or actuarial judgments

or predictions are made or the basis of data on large numbers of individual; that can be used to

determine the rates at which certain events or relationships take place (base rates) and the probability

that an event will happen in the future in light of current information.

122

Clinical Psychology (PSY401)

Over 100 studies have compared the use of the clinical and statistical methods in making judgments in

psychological assessment, including diagnostic decisions, evaluations of brain dysfunction, and

predictions of future violent behavior, predictions of work or school performance and predictions of

positive response to various forms of psychological and pharmacological treatment. The evidence

clearly shows the superiority of statistical methods in making judgments. One of the reasons for the

relative superiority of statistically based judgments is that they are perfectly reliable--they always

combine the available information in exactly the same way. Human information processing, as we have

already explained, is not perfectly reliable but is prone to a certain inherent level of inconsistency and

error.

Findings from research comparing clinical and statistical methods do not mean that the clinical decision-

making process should be cold and inhuman, carried out solely by computers. The role of the clinician

is crucial for certain types of tasks that cannot be conducted adequately by purely empirical methods,

including the generation of hypotheses and the use of theory in formulating questions. The important

point is that statistical methods are superior for certain aspects of the process of psychological

assessment, freeing psychologists to carry out other tasks for which they are uniquely suited.

STEP 6: COMMUNICATING THE INFORMATION

After collecting information that is pertinent to the evaluation of an individual and the environments in

which she or he functions, scoring the measures that were used, and interpreting the scores, the

psychologist is faced with the final task of clinical assessment: communicating this information and

interpretations to the interested parties. This communication typically takes the form of a written

psychological report that is shared with the client, other professionals (physicians, teachers, and other

mental health professionals), a court of law, or family members who are responsible for the client.

The challenges for psychologists in conveying assessment information are many, including the need to

be accurate, to provide an explanation of the basis for their judgments, and to communicate free of

technical jargon.

Just as the assessment process shares many features with the process of research, a good psychological

report shares many features with a good research article. It should begin with an introduction to the

case, including a description of the referral questions that were asked or the hypotheses that were tested.

The methods or assessment procedures that were used should be described in sufficient detail so that the

reader can understand and evaluate their quality. The results are reported next--a clear and succinct

summary of the data. Finally, a discussion and interpretation of the results is provided, including

recommendations for future assessment or intervention.

ETHICAL ISSUES IN ASSESSMENT

Psychologists are guided by a general set of rules or a code of conduct that includes rules for ethical

conduct in the psychological assessment process. These guidelines have been developed to protect the

best interests of the clients that are served by professional psychologists. Foremost among these

guidelines are concerns for protecting clients from abuse by actions of psychologists, ensuring the

confidentiality of information that is obtained, protecting clients' rights to privacy, ensuring the use of

procedures that have well-established reliability and validity, and using the results of psychological

assessment data in the best interests of clients.

Psychologists often obtain information about clients that reflects the most personal and intimate aspects

of their lives. This information is shared with a psychologist in the strictest of confidence and with the

expectation that no one has a right to access that information without the full informed consent of the

client. Therefore, clients have the right lo be aware of and to understand any and all information that has

been obtained as part of the assessment process, to know where and how that information is stored, and

to regulate who has access to that information.

123

Clinical Psychology (PSY401)

The clearest example of the need to protect confidentiality centers on the disposition of the results of

psychological tests and written psychological reports. How are the data and reports stored? How long

are they retained? Who has access to test results and reports? Information from clinical assessments of

individuals is always considered confidential, regardless of the length of time since the data were

collected. Data that were collected from a person's past must be considered cautiously, because the

characteristics that were measured may have changed significantly over time.

Although the concepts of reliability and validity may appear to be dry statistical abstractions, they are

essential in the fair and ethical treatment of individuals. The use of a measure that has either poor or

unknown reliability may produce information about a client that is not trustworthy. A lack of reliability

in a measure indicates that if that test or procedure were used again it would not be expected to produce

the same results. Therefore, an erroneous judgment could be made regarding a client's welfare on the

basis of this unreliable information. If a test or procedure is not reliable it cannot be valid. Lack of

validity indicates that the results are not an accurate representation of the psychological functioning of

the individual.

124

Table of Contents: