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Chapter 4

Chapter 4 - Clinical Assessment Procedures.pdf

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University of Toronto Scarborough
Konstantine Zakzanis

PSYB32: Abnormal Psychology Meera Mehta Summer 2012 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 problems, and what steps may be taken to improve the individual’s condition Reliability and Validity in Assessment - psychometrics is a field that exists just for the study of reliability and validity RELIABILITY - in a general sense, reliability refers to consistency of measurement; there are several types of reliability o inter-rater reliability – the relationship between the judgments that at least 2 raters make independently about a phenomenon o test-rest reliability – the relationship between the scores that a person achieves when he/she takes the same test twice  I.O.W. it measures the extent to which people being observed twice or taking the same test twice score in generally the same way o alternate-form reliability – the relationship between scores achieved by people when they complete 2 versions of a test that are judged to be equivalent  I.O.W. this refers to the extent to which scores on the 2 forms of the test are consistent o internal consistency reliability – the degree to which different items of an assessment are related to one another - in each of these types of reliability, a correlation – a measure of how closely 2 variables are related – is calculated between raters or sets of items o the higher the correlation, the better the reliability VALIDITY - validity is generally related to whether a measure fulfills its intended purpose - validity is related to reliability: unreliable measures will not have good validity o because an unreliable measure does not yield consistent results, an unreliable measure will not relate very strongly to other measures - content validity – the extent to which a measure adequately samples the domain of interest o for example an interview used to make an axis I diagnosis has excellent content validity because it contains questions about all the symptoms that are involved in axis I diagnoses - criterion validity – the extent to which a measure is associated in an expected way with some other measure (the criterion) - sometimes these relationships may be concurrent (both variables are measured at the same point in time, and the resulting validity is sometimes referred to as concurrent validity) o for example, there is a measure of the distorted thoughts believed to play an important role in depression  criterion validity for this test could be established by showing that the test is actually related to depression; that is, depressed people score higher on the test than do non-depressed people - alternatively, criterion validity can be assessed by evaluating the measure’s ability to predict some other variable that is measured in the future; this kind of criterion validity is often called predictive validity o for example, IQ tests were originally developed to predict future school performance; similarly a measure of distorted thinking could be used to predict the development of episodes of depression in the future - construct validity – the extent to which scores or ratings on an assessment instrument relate to other variables or behaviours according to some theory or hypothesis - construct validity is relevant when we want to interpret a test as a measure of some characteristic or construct that isn’t simply defined - a construct is an inferred attribute, such as anxiousness or distorted cognition, that a test is trying to measure o consider an anxiety-proneness questionnaire as an example; the construct validity question is whether the variation we observe between people on a self-report test of anxiety proneness is really due to individual differences in anxiety proneness  just because we called our test a of measure anxiety-proneness and the items seem to be about the tendency to become anxious, it is not certain that the test is a valid measure of anxiety proneness o another example: people diagnosed as having an anxiety disorder and people without such a diagnosis could be compared on their scores on the self-report measure of anxiety-proneness  the self-report measure would achieve some construct validity if the people with anxiety disorders scored higher than a control group 1 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012  when the self-report measure is associated with the observational one, its construct validity is increased  if the measure has construct validity, we would expect scores of patients with anxiety disorders to become lower after a course of a therapy that is effective in reducing anxiety Psychological Assessment - psychological assessment techniques are designed to determine cognitive, emotional, personality, and behavioural factors in psychopathological functioning CLINICAL INTERVIEWS - we interpret the term interview as any interpersonal encounter, conversational in style, in which one person, the interviewer, uses language as the principal means of finding out about the interviewee CHARACTERISTICS OF CLINICAL INTERVIEWS - clinical interview – a conversation between a clinician and a patient that is aimed at determining diagnosis, history causes for problems, and possible treatment options - the paradigm within which an interviewer operates influences the type of information sought, how it is obtained, and how it is interpreted o Example: a psychoanalyst will definitely ask you about your childhood and your dreams - clinicians recognize the importance of establishing a relationship with the client; the interviewer must obtain the trust of the person so then the person can open up to them more easily o most clinicians empathize 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 - it is important to look at situational factors of the interview that may exert strong influences on what the patient says or does o Example: if a teen is asked “how long have you been smoking weed?”, they would likely be honest to a young, informally dressed psychologist rather than a 60-year-old psychologist in a business suit - interviews vary in the degree to which they are structured o exactly how information is collected is left largely up to the particular interviewer and also depends on the responsiveness + responses of the interviewee o to the extent that an interview is structured, the interviewer must rely on intuition and general experience - thus, reliability for initial clinical interviews is probably low; that is, 2 interviewers may well reach different conclusions about the same patient o both reliability and validity may be low for a single clinical interview that is conducted in an unstructured fashion, but clinicians usually do more than 1 interview with a given patient, and hence a self-corrective process is probably at work STRUCTURED INTERVIEWS - structured interview – an interview in which the questions are set out in a prescribed fashion for the interviewer; assists professionals in making diagnostic decisions based upon standardized criteria - the Structured Clinical Interview Diagnosis (SCID) is a branching interview; that is, the client’s response to one question determines the next question that is asked o it also 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 symptom ratings into diagnoses - the use of structured interviews is a major factor in the improvement of diagnostic reliability o with adequate training of clinicians, inter-rater reliability for structured interviews is generally good - Rogers argued that structured clinical interviews are essential to improve the validity of diagnoses - The International Personality Disorder Examination has been translated into 10 languages, and as a result, is suited for use across different cultures. - The main point made by Rogers is that many structured clinical interviews are available and should have high clinical utility across assessment situations. PSYCHOLOGICAL TESTS - psychological tests – standardized procedures designed to measure a person’s performance on a particular task or to assess his/her personality - if the results of a diagnostic interview are inconclusive, psychological tests can provide information that can be used in a supplementary way to arrive at a diagnosis 2 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - psychological tests further structure the process of assessment - the same test is administered to many people at different times, and the responses are analyzed to indicate how certain kinds of people tend to respond - standardization – the process of constructing an assessment procedure that has norms and meets the various psychometric criteria for reliability and validity - there are 3 main types of psychogical tests: self-report personality inventories, projective personality tests, and tests of intelligence PERSONALITY INVENTORIES - personality inventory – a self-report questionnaire by which an examinee indicates whether statements assessing habitual tendencies apply to him/her - Minnesota Multiphasic Personality Inventory (MMPI) – a lengthy personality inventory by which individuals are diagnosed through their true-false replies to groups of statements indicating states such as anxiety, depression, masculinity femininity, and paranoia o MMPI is the best-known and most frequently used and researched psychological test in the US o MMPI is called multiphasic because it was designed to detect a number of psychological problems o there are 10 scales  4 for testing validity of test  However, being aware of these validity scales can enable people to effectively fake a normal profile.  The remaining scales are numbered clinical or content scales - the MMPI-2 has several changes designed to improve its validity and acceptability o the new version was standardized using a sample that was much larger and more representative of 1980 US census figures 3 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 o several items containing allusions to sexual adjustment, bowel and bladder functions, and excessive religiosity were removed because they were judged in some testing contexts to be needlessly intrusive and objectionable; sexist wording was removed, along with outmoded items - MMPI is reliable and has adequate criterion validity when it is related to ratings made by spouses or clinicians PROJECTIVE PERSONALITY TESTS - projective test – a psychological assessment device employing a set of standard but vague stimuli on the assumption that unstructured material will allow unconscious motivations and fears to be uncovered; the Rorschach series of inkblots is an example o the assumption is that because the stimulus materials are unstructured, the patient’s responses will be determined primarily by unconscious processes and will reveal his/her true attitudes, motivations, and modes of behaviour  this notion is referred to as the projective hypothesis - projective hypothesis – the notion that highly unstructured stimuli, as in the Rorschach inkblot test, are necessary to bypass defenses in order to reveal unconscious motives and conflicts - Rorschach Inkblot Test – a projective test in which the examinee is instructed to interpret a series of 10 inkblots reproduced on cards o half the inkblots are in black, white, and shades of grey, 2 also have red splotches, and 3 are in pastel colours - Thematic Apperception Test (TAT) – a projective test consisting of a set of black-and-white pictures reproduced on cards, each depicting a potentially emotion-laden situation; the examinee, presented with the cards one at time, is instructed to make up a story about each situation - projective techniques are derived from the psychoanalytic paradigm o the use of projective tests assumes that the respondent would be either unable or unwilling to express his/her true feelings if asked directly o the psychoanalytic assumption that people protect themselves from unpleasant thoughts and feelings by repressing them into the unconscious o thus, the real purposes of a test are best left unclear so as to bypass the defense mechanism of repression and get to the basic causes of distress - the content of a person’s responses was viewed as symbolic of internal dynamics - other uses of the Rorschach test, however, concentrate more on the form of the person’s responses o the test is considered more as a perceptual-cognitive task, and the person’s responses are viewed as a sample of how he/she perceptually and cognitively organizes real-life situations - According to Exner: people who see a great deal of human movement in the Rorschach inkblots tend to use inner resources when coping with their needs, whereas those whose Rorschach responses involve colour are more likely to seek interaction with the environment - The Rorschach test appears to have a high degree of validity in some tests, but a low degree in others o Considerable validity in identifying people with schizophrenia or at risk of developing schizophrenia  Could be due to fact that a person’s responses on the test are highly related to the communication disturbances that are an important symptom of schizophrenia o However, Hunsley and Bailey argue that even in this case, it’s possible that the info provided by the Rorschach could have been obtained more simply and directly (ex. through an interview) - The Roberts Apperception Test for Children illustrates how the use of projective tests has evolved to provide more standardized, objectively scored assessment tools o Pictures of children and families are presented to the child, who tells a story about each one o The Roberts Test provides objective criteria for scoring, along with normative data to determine whether the child’s pattern of responses is abnormal  Scales provide info about child’s coping skills  Ex. the response “The boy asked his mother for help with his homework, and she helped him get started on his story” would be scored for both “Reliance on Others” and “Support from Others”. - Wood et al. suggest that the Rorschach, TAT, and other projective tests are used in a substantial number of legal cases o These tests overpathologize the respondents, making them appear psychologically ill or dangerous in a way that might fit the agenda of some lawyers.  Thus, these tests are often used despite concerns about their validity and reliability - Allen and Dana argue that the usefulness of the Rorschach across cultural groups has been overstated because there is a need for improved normative data (don’t have enough empirical evidence to support the test’s usefulness at the moment) 4 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - Frequency of use of projective tests: o British psychiatrists use them 1% of the time; use more objective measures 20% of the time, and structured interviews 69% of the time o In US schools, projective tests continue to be used to determine eligibility for certain programs and to indicate intervention needs.  “moderately useful” in schools INTELLIGENCE TESTS - intelligence test – a standardized means of assessing a person’s current mental ability; for example, the Standford-Binet test and the Wechsler Adult Intelligence Scale; often referred to as IQ (intelligence quotient) tests - Binet originally constructed mental tests to help Parisian school board predict which children were in need of special schooling - the intelligence tests are all based on the assumption that a detailed sample of an individual’s current intellectual functioning can predict how well he/she will perform in school - intelligence tests are also used: o in conjunction with achievement tests to diagnose learning disabilities and to identify areas of strengths and weaknesses for academic planning o to help determine whether a person is mentally retarded o to identify intellectually gifted children so that appropriate instruction can be provided to them in school o as part of neuropsychological evaluations; for example, the periodic testing of a person believed to be suffering from a degenerative dementia so that deterioration of mental ability can be followed over time - IQ tests 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 - scores on most IQ tests are standardized so that 100 is the mean and 15 or 16 is the standard deviation (a measure of how scores are dispersed above and below the average) o about 65% of the population receive scores between 85-115 o those with a score below 70 are 2 standard deviations below the mean of the population and are considered to have “significant subaverage general intellectual functioning” o those with scores above 130 (2 standard deviations above the mean) are considered “intellectually gifted” o about 2.5% of the population falls at each of these extremes - IQ tests are highly reliable and have good criterion validity o However, they only explain a small part of the differences in people’s school performance - there is also “emotional intelligence”; reflected in such abilities as delaying gratification and being sensitive to the needs of others o high levels of emotional intelligence are associated negatively with alexithymia, a condition of reduced emotional awareness that is a risk factor for a variety of adjustment problems o high levels of emotional intelligence are associated with greater levels of subjective well-being and reduced proneness to depression BEHAVIOURAL AND COGNITIVE ASSESSMENT - traditional assessment concentrates on measuring underlying personality structures and traits, such as obsessiveness, paranoia, coldness, aggressiveness, etc. - behavioural and cognitively oriented clinicians, on the other hand, often use a system that involves the assessment of 4 sets of variables, sometimes referred to by the acronym SORC o S = stimuli – the environmental situations that precede the problem o O = organismic – referring to both physiological and psychological factors assumed to be operating “under the skin” o R = overt responses – these probably receive the most attention from behavioural clinicians, who must determine what behaviour is problematic, as well as the behaviour’s frequency, intensity, and form o C = consequent variables – events that appear to be reinforcing or punishing the behaviour in question - a behaviourally oriented clinician attempts to specify SORC factors for a particular client o O variables are not emphasized enough by Skinnerians, who focus more on observable stimuli and responses o C variables receive less attention from cognitively oriented behaviour therapists than do O variables because these therapists’ paradigms does not emphasize reinforcement 5 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - 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 therapy o these approaches place considerably more emphasis on cognitive events such as people’s distorted thinking patterns, negative self-instructions, irrational automatic thoughts and beliefs, and schemas Focus on Discovery 4.1 – Cognitive-Behavioural Case Formulation - Persons and Davidson described an approach that formulates an individualized cognitive-behavioural theory about a particular case with a view to helping a therapist develop and effective and efficient plan for treatment. o there are 5 components of their approach: problem list, diagnosis, working hypothesis, strengths and assets, and treatment plan - problem list – this includes difficulties the client is having in various domains: psychological, interpersonal, occupational, medical, financial, housing, legal, and leisure - diagnosis – a psychiatric diagnosis is not a required part of cognitive-behavioural case formulations; it is included because a diagnosis can lead to initial hypotheses about how to formulate the case and provide information about possible interventions - working hypothesis – this is the “heart” of Persons and Davidson’s formulation o the mini-theory of the case develops through adaptation of a general theory and describes relations among the problems o for example, according to Beck’s theory, stressful events activate schemas (core beliefs) to produce problems and symptoms o thus, the working hypothesis would describe the hypotheses about the negative schemas (eg: beliefs about self, others, the world, and the future) that appear to cause problems – external precipitants (eg: a poor work evaluation) or activating situations (eg: attending meetings with the boss) that activate internal structures (schemas) – and the origins or historical incidents or circumstances that contributed to the development of the schemas or functional relationships - strengths and assets – information about strengths and assets (eg: social skills, sense of humor, financial resources, social support, stable lifestyle) can help the therapist to develop the working hypothesis, enhance the treatment plan, and assist in the determination of realistic treatment goals - treatment plan – the treatment plan is based directly on the cognitive-behavioural case formulation and has 6 components: goals, modality, frequency, initial interventions, adjunct therapies, and obstacles o the goals and obstacles components are especially crucial DIRECT OBSERVATION OF BEHAVIOUR - behavioural observation – a form of behavioural assessment that entails careful observation of a person’s overt behaviour in a particular situation - behavioural assessment often involves direct observation of behaviour o in formal behavioural observation, the observer divides the uninterrupted sequence of behaviour into various parts and applies terms that make sense within a learning framework - the behavioural clinician’s way of conceptualizing a situation typically implies a way to try to change it intervention - it is important to use multiple informants, including the children themselves, when attempting to predict children’s real life behaviour SELF-OBSERVATION - self-monitoring – in behavioural assessment, a procedure whereby the individual observes and reports certain aspects of his/her own behaviour, thoughts, or emotions - ecological momentary assessment (EMA) – a form of self-observation involving collection of data in real time (eg: diaries) regarding thoughts, moods, and stressors o the main reason for using EMA is that the retrospective recall of moods, thoughts, or experiences may be inaccurate o memory researchers have shown not only that simple forgetting leads to inaccurate retrospective recall, but also that recalled information can be biased  for example, a report of a person’s mood for a whole day is overly influenced by moods the person has experienced most recently o EMA may also be useful in clinical settings, revealing information that traditional assessment procedures might miss 6 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - although some research indicates that self-monitoring or EMA can provide accurate measurement of such behaviour, considerable research indicates that behaviour may be altered by the very fact that it is being self-monitored; that is, the self-consciousness required for self-monitoring affects the behaviour - reactivity – the phenomenon whereby behaviour is changed by the very fact that it is being observed o in general, desirable behaviour, such as engaging in social conversation, often increases in frequency when self- monitored, whereas behaviour the person wishes to reduce, such as cigarette smoking, diminishes o such findings suggest that therapeutic interventions can take advantage of the reactivity that is a natural by- product of self-monitoring INTERVIEWS AND SELF-REPORT INVENTORIES - within a trusting relationship, the behaviour therapist’s job is to determine, by skillful questioning and careful observation of the client’s emotional reactions during the interview, the factors that help the therapist conceptualize the client’s problems - behaviour therapists also make use of self-report inventories - the most widely employed cognitive assessment methods are also self-report questionnaires that tap to a wide range of cognitions, such as fear of negative evaluation, a tendency to think irrationally, and a tendency to make negative inferences about life experiences o a recent example is the Cognitive Style Questionnaire (CSQ), a measure of the cognitive vulnerability factor featured in the hopelessness theory of depression  created by Abramson and Metalsky  reliable measure of cognitive vulnerability with a high degree of construct validity, at least in college samples - new cognitive-behavioural self-report measures are regularly constructed and must be subjected to psychometric evaluation o Ex. Carleton et al. developed a brief Intolerance of Uncertainty Scale (IUS) to assess anxious and avoidance components of the tendency to consider the possibility of a negative event occurring to be unacceptable, irrespective of the probability of occurrence. SPECIALIZED APPROACHES TO COGNITIVE ASSESSMENT - the Dysfunctional Attitude Scale (DAS) relates to other aspects of cognition in ways consistent with Beck’s theory o supporting the theory of construct validity, researchers have shown that they can differentiate between depressed and non-depressed people on the basis of their scores on this scales and that the scores decrease (ie improve) after interventions that relieve depression o for example, it correlates with an instrument called the Cognitive Bias Questionnaire, which measures the ways in which depressed patients distort information - cognitive assessment focuses on the person’s perception of a situation since the same event can be perceived differently by different people or at different times - the Articulated Thoughts in Simulated Situations (ATSS) method of Davidson and his associates is one way to assess immediate thoughts in specific situations o in this procedure, a person pretends that he/she is a participant in a situation, such as listening to a teaching assistant criticize a term paper o presented on audi
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