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Chapter 4

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Konstantine Zakzanis

Chapter 4: Clinical Assessment Procedures - All clinical assessment procedures are more or less formal ways of finding out what is wrong with a person, what may have caused a problem or problem, and what steps may be taken to improve the individual’s conditions - Procedures also used to evaluate the effects of therapeutic interventions [Reliability and Validity in Assessment] - Psychometrics: study of reliability and validity - Reliability o Consistency of measurement o Inter-ratter reliability  Degree to which two independent observers or judges agree o Test-retest reliability  Measures extent to which people being observed twice or taking the same test twice, perhaps several weeks or months apart, score in generally the same way.  Makes sense only when theory assumes that people will not chance appreciably b/w testing on the variable being measured  i.e. intelligence tests o alternate-form reliability  two forms of tests used rather than giving same test twice, perhaps when there is concern that people will remember their answers from the first test and aim merely to be consistent  extent to which scores on the two forms of test are consistent o internal consistency reliability  assesses whether the items on the test are related to one another - correlation: measure of how closely two variables are related - correlation calculated b/w raters or sets of items; higher the correlation, better the reliability - Validity o Related to whether a measure fulfills its intended purpose o Unreliable measure will not have good validity because unreliable measure does not yield consistent results, it will not relate very strongly to other measures 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 (the criterion)  Concurrent validity: both variables are measured at the same point in time  Predictive validity: evaluating the measure’s ability to predict some other variable that is measured in the future o Construct Validity:  Relevant when we want to interpret a test as a measure of some characteristic or construct that is not simply defined  Inferred attribute, such as anxiousness or distorted cognition, that a test is trying to measure  People’s responses to a questionnaire are determined by more variables than simply the construct being measured  It is evaluated by looking at a wide variety of data from multiple sources  Self report measure would achieve some construct validity of the people with anxiety disorders scored higher than a control group  Self report measure could be related to other measure thought to suggest anxiety, such as observations of fidgeting, trembling or excessive sweating  When related to observational one then its construct validity increases  Studies may also examine change on self-report measure  If the measure has construct validity, we would expect scores of patients with anxiety disorders to become lower after a course of therapy that is effective in reducing anxiety [PSYCHOLOGICAL ASSESSMENT] - Designed to determine cognitive, emotional, personality and behavioural factors in psychopathological functioning - Concentrates on measuring underlying personality structures and traits : obsessiveness, paranoia, coldness, aggressiveness  Clinical Interviews o Interview: any interpersonal encounter, conversational in style, in which one person, the interviewer, uses language as the principal means of finding out about another, the interviewee  Characteristics of Clinical Interviews:  Interviewer pays attention to how the respondent answers-or does not answer- questions; attentive to any emotion accompanying the comments  The paradigm within which an interviewer operates influences the type of information sought, how it is obtained and how it is interpreted  Psychoanalyst: Person’s childhood history; likely to remain sceptical of verbal reports because the paradigm holds that the most significant aspects of disturbed or normal Peron’s developmental history are repressed into the unconscious  Behaviourally oriented clinician: focus on current environmental conditions that can be related to changes in the person’s behaviour  Clinical interview does not follow one prescribed course but varies with the paradigm adopted by the interviewer  Find only the information for which they are looking  Conducted with people who are under considerable stress  Recognize importance of establishing rapport with the client  Interviewer must obtain the trust of the person; it is naive to assume that a client will easily reveal information to another, even to an authority figure with the title “doctor”  Psychodynamic clinicians assume that people entering therapy usually are not even aware of what is truly bothering them  Behavioural clinicians: concentrate more on what can be observed, also appreciate the difficulties people have in sorting out the factors responsible for their distress  Most clinicians emphasize with their clients in an effort to draw them out, to encourage them to elaborate on their concerns, and to examine different facets of a problem  Humanistic therapists employ specific empathy techniques to accomplish these goals  A simple summary statement of what the client has been saying can help sustain the momentum of talk about painful and possibly embarrassing events and feelings, and an accepting attitude toward personal disclosures dispels the fear that revealing “secret of the heart” to another human being will have disastrous consequences  Clinicians tend to overlook situational factors of the interview that may exert strong influences on what the patient says or does  Interviews vary in the degree to which they are structured  Exactly how info is collected is left largely up to the particular interview and depends, too , on the responsiveness and responses of the interviewee  Because overwhelming majority of clinical interviews are conducted within confidential relationships, it has been possible to establish either their reliability or their validity through systematic research  The reliability for initial clinical interviews is low  Both reliability and validity may be low for a single clinical interview that is conducted in an unstructured fashion; but they do more than one interview with a given patient, hence a self-corrective process is probably at work  Structured Interviews: is one in which the questions are set out in a prescribed fashion for the interviewer  Structured Clinical Interview Diagnosis (SCID) for Axis I of DSM IV: assists researchers and clinicians in making diagnostic decisions o Branching interview; client’s response to one question determines the next question that is asked o 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 o Most symptoms are rated on a 3-point scale of severity, with instructions in the interview schedule for directly translating the symptoms rating into diagnoses  Use of SI is a major factor in the improvement of diagnostic reliability  SI developed for diagnosing personality disorders and more specific disorders such as anxiety disorders  With adequate training of clinicians, inter-ratter reliability for SI is good  Rogers argued tat SI essential to improve validity of diagnoses o Rogers recommended SCID for clinician who is pressed for time and wishes to evaluate the possible existence of selected axis I disorders o DIS better for clients that have limited ability to speak English because its the most likely to maximize likelihood of a reliable diagnosis o Structured clinical interviews are available and should have high clinical utility across assessment situations  Psychological Tests o Standardized procedures designed to measure a person’s performance on a particular task or to assess his or her personality, or thoughts, feelings and behaviour o If results of diagnostic interview are inconclusive, psychological tests can provide information that can be used in a supplementary way to arrive at a diagnosis o Tests also yield info such as personality characteristics or situational determinants of a person’s problems o Same test administered to many people at different times and the responses are analyzed to indicate how certain kinds of people tend to respond o Standardization: process of constructing an assessment procedure that has norms that meets the various psychometric criteria for reliability and validity o Three Basic Types of Psychological tests  Self-report Personality Inventories: o Person is asked to complete a self-report questionnaire indicating whether statements assessing habitual tendencies apply to them o Minnesota Multiphasic Personality Inventory (MMPI): intended to serve as an inexpensive means of detecting psychopathology; called multiphasic because it was designed to detect a number of psychological problems; used to screen large groups of people o In developing test, investigators relied on factual information o 1) clinicians provided statements that they considered indicative of various mental problems; 2) items were rated as self-descriptive or not by patients already diagnosed as having particular disorders and by a large group of individuals considered normal; items are selected if patients in one clinical group responded to them more often in a certain way than did those in other groups; 3) sets of items were established as scales for determining whether a respondent should be diagnosed in a particular way (i.e. if individual answered a large # of times in a scale in the same way as had a certain diagnostic group, their behaviour was expected to resemble that of the particular diagnostic group ) o New version of MMPI: items containing allusions to sexual adjustment, bowel and bladder functions and excessive religiosity were removed because intrusive and objectable. Sexist words were also eliminated along wit outmoded idioms; new scale deal with substance abuse, Type A behaviour and martial problems o MMPI has validity scale designed to detect deliberately faked responses o Is reliable and has adequate criterion validity when it is related to ratings made by spouses or clinicians o Profiles can be used in conjunction with a therapist’s evaluation to help diagnose a client, assess personality functioning and coping style, and identify likely obstacles to treatment  Projective personality Tests o Psychological assessment device in which a set of standard stimuli-inkblots or drawings-ambiguous enough to allow variation in responses is presented to the individual o Assumption is that because the stimulus materials are unstructured, the patient’s responses will be determined primarily by unconscious processes and will reveal his or her true attitudes, motivations and modes of behaviour projective hypothesis o Rorschach inkblot Test: person is shown 10 inkblots, one at a time and asked to tell what figures or objects he or she sees in each of them; half inkblots are black , white and shades of grey, two also have red splotches and three are in pastel colours o Therapeutic Apperception Test (TAT): person is shown a series of black-and-white pictures one by one and asked to tell a story related to each o Projective techniques are derived from psychoanalytic paradigm; respondent would be either unable or unwilling to express his or her true feelings if asked directly o Tendency consistent with psychoanalytic assumption that people protect themselves from unpleasant thoughts and feelings by repressing them into the unconscious o Projective tests were used as a stimulus to fantasy that was assumed to bypass ego defences; content of person’s responses was viewed as symbolic of internal dynamics o Other uses of Rorschach test: concentrate more on the form of the person’s responses: perceptual-cognitive task, and persons responses are viewed as a sample of how he or she perceptually and cognitively organizes real- life situations o Robert’s Apperception Test for Children: illustrates how the use of projective tests has evolved to provide more standardized, objectively scored assessment tools. Pictures of child and families are presented to the child, who tells a story about each one; Robert’s test provides objective criteria for scoring, along with normative data to determine whether the child’s pattern of responses is abnormal o 1% on assessment on projective measures; 20% objective measures; 69% structured interviews o Projective techniques used across grades for various educational purposes, including determining eligibility for certain programs and indicating intervention needs  Intelligence tests  Often referred to as IQ (intelligent Quotient) test,  Standardized means of assessing a person’s current mental ability  Individually administered tests, WAIS, WISC and Standorf-Binet, are all based on the assumption that a detailed sample of an individual’s current intellectual functioning can predict how well he or she will perform in school  Used in conjunction with achievement tests, to diagnose learning disabilities and to identify areas of strengths and weaknesses for academic planning; to help determine whether a person is mentally retarded; to identify intellectually gifted children so that appropriate instruction can be provided them in school; as part of neuropsychological evaluations  Tap several functions asserted to constitute intelligence, including language skills, abstract thinking, non-verbal reasoning, visual-spatial skills, attention and concentration and speed of processing  Approximately 65% of population scores b/w 85 and 115  Those with a score below 70 are two SD below the mean of the population and considered to have “significant subaverage general intellectual functioning”  Scores above 130 (2 SD above the mean) are considered “intellectually gifted”  2.5% population falls at each of these extremes  IQ tests are highly reliable and have good criterion validity  Predict later educational entertainment and occupational success  IQ tests measure only what psychologists consider intelligence; factors other than what we think of pure intelligence play an important role in how people will do in school, such as family and personal circumstances, motivation to do well, and difficulty of the curriculum  Much more explained by IQ test scores than is explained  “emotional intelligence” : reflected in abilities as delaying gratification and being sensitive to needs of others; important to future success as the strictly intellectual achievements measured by traditional IQ test; EQ also important protective factor in terms of levels of adjustment; high levels of EQ are associated negatively with alexithymia: condition of reduced emotional awareness that is a risk factor for a Variety of adjustment problems; high levels of EQ also associated with greater levels of subjective well-being and reduced proneness to depression  Behavioural and cognitive Assessment o Use a system that involves the assessment of four sets of variables, sometimes referred to by SORC  S: Stimuli: environmental situations that precede problem  O: Organismic: referring to both physiological and psychological factors assumed to be operating “under the skin”  R: overt responses: probably receive most attention from behavioural clinicians, who determine what behaviour is problematic, as well as the behaviour’s frequency, intensity and form  C: consequent variables: events that appear to be reinforcing or punishing the behaviour in question o Cognitive-behavioural case formulation: A process in which a cognitive-behavioural therapist attempts to ascertain how the various problems experienced by a client are related in order to pick out target behaviours that will become the focus of the therapy o Place more emphasis on cognitive events such as people’s distorted thinking patterns, negative self-instructions, irrational automatic thoughts and beliefs and schemas o Information necessary for behavioural and cognitive assessment gathered by direct observation of behaviour in real life as well as in contrived settings, interviews and self report measure and various other methods of cognitive assessment  Direct observation of behaviour  Observer divides the uninterrupted sequence of behaviour into various parts and applied terms that make sense within a learning framework  Behavioural assessment has a link to intervention  Behavioural clinician’s way of conceptualizing a situation typically implies a way to try to change it  Therapist contrive artificial situations in their consulting rooms or in a lab so that they can observe how a client or a family acts under certain conditions  Behavioural assessment procedures yielded data that could be used to measure the effects of treatment  Operant framework, employing no inferential concepts  But observational techniques can also be applied within a framewo
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