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Chapter 4

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University of Toronto Scarborough
Health Studies

Chapter 4 – Clinical Assessment Procedures RELIABILITY AND VALIDITY IN ASSESSMENT  Types of reliability (repeatability): o Inter-rater reliability – the degree to which two independent observers or judges agree o Test-retest reliability – measures the extent to which people being observed twice or taking the same test twice, perhaps several weeks to months apart, score generally the same way o Alternate-form reliability – the extent to which scores of the two tests in test-retest validity are consistent o Internal consistency reliability – assess whether the items on a test are related to one another  Types of validity (accuracy): o Content validity – refers to whether a measure adequately samples the domain of interest o Criterion validity – evaluated by determining whether a measure is associated in an expected way with some other measure (criterion) o Construct validity – relevant when we want to interpret a test as a measure of some characteristic or construct that is not simply define, a construct is an inferred attribute PSYCHOLOGICAL ASSESSMENT  Clinical interview – a psychological assessment technique to determine cognitive, emotional, personality, and behavioural factors, similar to regular interviews; the paradigm within which an interviewer operates influences the type of information sought, how it is obtained, and how it is interpreted  Psychodynamic clinicians assume that people entering therapy usually are not even aware of what is truly bothering them  Clinicians often tend to overlook situational factors of the interviewer that may exert strong influences on what the client says (ex. would you tell a clinician who’s dressed young and informally that you’ve tried illegal drugs or would you tell the clinician wearing a business suit?)  Structured interview – one in which that questions are set out in prescribed fashion for the interviewer which assists researchers and clinicians in making diagnostic decisions  Structured Clinical Interview Diagnosis (SCID) – is a branching interview from the DSM-IV for Axis I, the client’s response to one question determines the next question that is asked, contains detailed instructions to the interviewer concerning when and how to probe in detail and when to go on to questions bearing on another diagnosis (see Figure 4.1)  Psychological tests – are standardized procedures designed to measure a person’s performance on a particular task or to assess his/her personality, thoughts, or feelings, and behaviour; the same test is administered to many people at different times, statistical norms for the test can thereby be established (standardization)  Personality inventory – self-report questionnaire indicating whether statements assessing habitual tendencies apply to him/her, the best known and most frequently used test in the USA is the Minnesota Multiphasic Personality Inventory (MMPI)  MMPI developed by Hathaway and McKinley in 194043 and revised as the MMPI-2 in 1989; it’s called multiphasic because it’s designed to detect a number of psychological problems (see Table 4.1)  To ensure the validity of the MMPI, the test designers have included several validity scales designed to detect deliberately faked responses (ex. one scale is the lie scale, a series of statements sets a trap for the person who is trying to look good)  Projective personality tests: derived from the psychoanalytic paradigm, a psychological assessment device in which a set of standard stimuli (inkblots/drawings) ambiguous enough to allow variation in responses is presented to the individual, since the stimulus responses are unstructured it is expected that the client’s responses will be determined primarily by unconscious processes that will reveal his/her true identities (this notion is the projective hypothesis) o Rorschach Inkblot Test – best-known projective technique, a person is shown 10 inkblots, one at a time, and asked to tell what figures or objects he/she sees in them o Thematic Apperception Test (TAT) – a person is shown a series of black-and-white pictures one by one and is asked to tell a story related to each  Projective tests used in a substantial amount of legal cases and one third by forensic psychologists  Critics of projective testing concerned about its use as part of assessment and testimony in courtroom (ex. Rorschach test or TAT used to “overpathologize” a respondent to suggest that they’re psychologically sick or dangerous to fit the agenda of certain lawyers  Intelligence tests: intelligence quotient test, standardized means of assessing a person’s current mental ability; designed by French psychologist, Alfred Binet (two types: Wechsler Intelligence Scale, WAIS, and the Stanford-Binet test)  Intelligence tests used in conjunction with achievement tests, diagnosing learning disabilities, identifying strengths and weakness for academic planning, determining whether a person is mentally handicapped, identifying intellectually gifted children, or as part of neuropsychological evaluations (ex. period testing of a person believed to be suffering from degenerative dementia)  Approximately 65% of the population scores between 85-115  Scores on most IQ tests have 100 as the mean and 15-16 standard deviation (thus an IQ of 70 is two standard deviations below the mean, considered to have significantly below general intellectual functioning) BEHAVIOURAL AND COGNITIVE ASSESSMENT AND CASE FORMULATION:  Four variable system used by behaviourally-oriented clinicians: o S – (stimuli), the environmental situations that precede the problem o O – (organismic), referring to both psychological and physiological factors assumed to be operating “under the skin” o R – refers to overt responses o C – consequent variables, events that appear to be reinforcing or punishing the behaviour in question  Skinnerians have less focus on O variables since they focus more on observable stimuli and responses  C variables receive less attention from cognitively oriented clinicians  Cognitive-behavioural case formulation – emphasis of study on people’s distorted thinking patterns, negative self-instructions, irrational automatic thoughts and beliefs, and schemas; complex psychological problems present challenge to clinicians  McCabe and Antony (2004) – complex-case of 60 year old with wide range of anxiety symptoms, different cognitive-behavioural perspectives on conceptualization and treatment provided by experts in the area  Boschen and Oei (2008) – presented cognitive-behavioural case formulation framework for anxiety disorders; strong general consensus among practicing clinicians from all therapeutic schools that case formation is an essential step to providing effective, purposive treatment  Moscovitch (2009) – formulated new model to facilitate individualized case conceptualization of social phobia  Haynes, Mumma, and Pinson (2009) – reviewed the conceptual and psychometric foundations of individualized behaviour assessment and provided a step-by-step guide for the development and evaluation of an idiographic assessment instrument  Causal Analysis of Synthesis and Events (CASE) – is a comprehensive, systematic, but flexible, and “theoretically neutral” system method when dealing with both intrapersonal and interpersonal clinical problems, expected to help train therapists facilitate dialogue between therapists of different theoretical orientations  Behavioural observation – the observer divides the uninterrupted sequence of behaviour into various parts and applies terms that make sense within a learning framework (ex. Kevin speaks to his mother in a normal tone but the mother says nothing, the ordinary behaviour is ignored, therefore not reinforced by mother’s attention since she does not reply; Kevin then repeats his question by yelling which meets disapproval from the mother, punishment is reinforced by father by telling Kevin not to yell at the mom)  Cognitive assessment – focuses on a person’s perception of a situation, since the same event can be perceived differently or by different people, or at different times  DiBartolo and Grills (2006) – examined the validity of child, parent, and teacher reports of social anxiety in children, found that there was no general consensus in predicting child’s responses to a social evaluative task, children were better at predicting their own anxious feelings than parents and teachers  Self-monitoring – individuals observe their own behaviour, also referred to as ecological momentary assessment (EMA), involves the collection of data in real time as opposed to reflecting back over some time period and report on recently experienced thoughts, moods, or stressors; range from having to complete a diary at specific times of the day, or having a handheld computer that lets individuals record responses directly to the computer  EMA seen as more dependable since reflecting back on memories might not always be accurate or biased, the EMA is also useful in clinical settings to reveal information that traditional assessment features might miss (ex. man who has severe anxiety attacks describes himself to be a happy person and that his life is going very well, thus no reason could be found for anxiety attacks, but with EMA it is revealed that a third of his thoughts concerned annoyance with his children: “he left the record player on again.”)  Arguments against EMA that the very fact that when one self-monitors it affects the self-conscious to alter one’s behaviour; desirable behaviour often increases in frequency while non-desirable behaviour will decrease  Reactivity – the phenomenon of behaviour changing because it is being observed  Cognitive Style Questionnaire (CSQ) – a measure of the cognitive vulnerability factor in the Hopelessness Theory of Depression (chapter 8), created by Abramson and Metalsky in 1982  Dysfunctional Attitude Scale (DAS) – assessment device used to identify pessimistic attitudes, schemas, or bias in the way individuals interpret events (ex. “People will probably think less of me if…”), correlated with the Cognitive Bias Questionnaire which measures the ways which depressed clients distort information  Articulated Thoughts In Simulated Situations (ATSS) – developed by Davidson et al. in 1983, method to assess immediate thoughts in specific situations, a person pretends that he or she is a participant in a situation, such as listening to a teaching assistant criticize a term paper, presented on audio tape, the scene pauses every 10-15 seconds and the participant talks aloud of whatever went through their mind in reaction to scene they had just witnessed  Thought-listening – where the individual writes down his/her thoughts prior to or following an event of interesting such as entering a room to talk to a stranger to analyze the cognitive components of social anxiety  Open-ended techniques such as thought-listening and ATSS are preferable when investigators know relatively little about the participant and want to familiarize themselves about their general cognitive terrain  Videotape reconstruction – a strategy for assessing people’s thoughts and feelings by videotaping an individual while they are engaged in some task or in an actual or role-played problematic situation, the individual then watches the videotape while attempting to reconstruct their thoughts or feelings at the time (often difficult to tell if people are reconstructing or constructing)  Equifinality – the notion that the same goal or endpoint can result from many different starting points and different processes (ex. Two people having the same symptoms of depression but each reach that point through very different background factors)  Family Environment Scale – developed by Moos (1986) designed to measure the actual family environment, and perceptions of ideal family environment, assesses three main themes: 1) the family relationship, 2) personal growth, and 3) system maintenance; used in Canada to observe link between perceived childhood family environment and levels of alcohol misuse and personality disorder  Family Adaption and Cohesion Evaluation Scale, third edition (FACE-III) – a circumplex model designed by Olson et al. 1985 assessing two dimensions: the family’s degree of cohesion (closeness) and degree of adaptability (ability to adjust by appropriate changes to roles and rules in a family); both dimensions have four levels (enmeshment, connected, separated, and disengaged)  A parent who is smothering and over controlling would contribute to enmeshment, a parent who is neglectful would contribute to disengagement  Parental Bond Inventory – assesses the level of care or warmth, and the level of controlling parental behaviours  Affectionless control – an over controlling parent who lacks warmth and caring  Enga Minnen Betraffande Uppfostran (Memories of My Childhood) – a widely used self-report measure developed to assess memories of parental reading styles, assesses several dimensions which includes emotional warmth, rejection, and overprotection. It is argued that parents may possibly receive negative ratings due to mood bias, dysmorphic individuals will perceive their parents in a more negative way than non-depressed individuals  Behavioural assessment is regarded as an objective approach that can provided richer sources of data that are less subjective to cognitive biases, however there is concern about the problem of reactivity (extent to which family members alter their behaviour when they know they’re being observed)  One of the earliest models of family functioning developed in Canada by Nathan Epstein and Jack Santa- Barbera called The McMaster Family Assessment Device (MFAD), a 60-item self-report measure that assesses family functioning in terms of problem solving, communication, roles, affective, responsiveness, affective involvement, and behaviour control  MFAD useful for general measure of perceived family adjustment, anxiety control and anxiety to determine whether control acts as a moderator/mediator between perceived family environment and anxiety in young adults  FAM-III (Family Assessment Measure-III) – an improvement of the MFAD, has seven main subscales that assess task accomplishment, role performance, communication, affective expression, involvement, control, and values/norm; two important advantages: 1) the FAM-II can be administered to tap three different levels of functioning (entire family, certain dyadic relationships, or the individual’s sense of his/her own level), 2) includes social desirability and defensiveness subscales to determine validity of self- reports Interviews Clinical Interviews Conversational techniques in which the clinician attempts to learn about the client’s problems; content of the interview varies depending on the paradigm of the interviewer Structured Interviews Questions to be asked are spelled out in detail in a booklet; most often used for gathering information to make a diagnosis Psychological Tests Personality Tests Self-report questionnaires, used to assess either a broad range of characteristics, as in the MMPI, or a single characteristic, such as dysfun
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