Chapter 4: Clinical Assessment, Diagnosis, and Treatment

Speaker: Hello everyone, and welcome.

Today we're going to be focusing on
chapter four, all about clinical

assessment, diagnosis and treatment.

When we are thinking about clinical
assessment, it's important for us

to consider what it means to understand
abnormal behaviors by being able to

collect information to reach a conclusion.

That's what an assessment helps us to do.

It's an idiographic information tool that
will allow us to gather symptoms and

behaviors so that we can better understand
the abnormal actions of the individual

before us.

It also helps us with a clinical
assessment, because when we're doing

a clinical assessment, we are using
that information so that we can figure

out the who, what, when, why, how, and
whether the person who is behaving

abnormally can be supported.

We want to find out the duration of
time, um, is this something that has

been occurring for a longer period
of time or shorter period of

time, meaning is it chronic or acute?

We want to find out what the actual
symptoms are.

We want to find out if this is something
that is also a pattern of behavior in

previous family members.

Is there subsequent issues that, um, like
medical issues, um, or other mental health

issues that may be impacting this, like
the use of substances, or disordered

eating, or a family history of violence.

So the clinical assessment will help us to
understand how and why a person

engages in the behaviors they do.

There are hundreds of clinical assessment
tools that have been developed, and they

typically fall into one of three
categories: there's clinical interviews,

tests, and observations.

And the specific tool that's used in an
assessment will depend on the

clinicians theoretical orientation.

When we look at the characteristics
of assessment tools, they typically have

to be standardized, and have to have clear
reliability and validity.

So what does all of this mean?

Well, in order for it to be standardized
or to have standardization, this is the

technique that involves setting up
common steps to be followed whenever

it's administered.

And that when you talk about the
standardized administration and there's

also scoring and interpretation that's
already laid out for the person

administering this assessment.

And then we have reliability.

This is the consistency of a
assessment tool.

And a good tool always yields the same
results in the same situation.

There's two types of reliability: there's
test/retest reliability, and interrater reliability.

Test/retest reliability yields the same
results every time it's given to the

same people.

Interrater reliability is where there are
difference where the person, or the people

who are administering this tool are
essentially looking at the results

independently, and they agree how to
score and interpret a particular tool.

Then we have validity.

And with validity, this is the accuracy
of the tools results.

And typically, an assessment tool must
measure what it's supposed to measure.

And there's three specific types of
validity: there's face valid-- face

validity, excuse me, which is a tool
that appears to measure what its

supposed to measure, and it doesn't
necessarily include true validity.

There's predictive validity, which is
where a tool accurately predicts future

characteristics or behavior.

And concurrent validity, which is where
a tools results agree with the independent

measures assessing a similar
characteristic or behavior.

As noted earlier, we also have clinical
interviews, and these are typically

done face-to-face, whether it's
in-person or done virtually over

a HIPPA-compliant system.

And you gather basic background data
with specific theoretical focus, like

using a cognitive behavioral modality,
or, um, using assets from narrative

therapy, or, um, a psychoanalytic
perspective.

When you talk about clinical interviews,
they can be structured or unstructured.

An unstructured clinical interview is
where you don't have any preset questions.

A structured interview is where you have
the same questions that you would

administer to every person.

An example of a structured exam would
be the mental status exam.

When we think about clinical interviews,
there are some limitations.

In many situations, clinical interviews
lack validity or accuracy.

Simply because when you are looking
at the, the fact that you're using it as

either being structured or unstructured,
and we think about the definition of

validity, especially if it's unstructured,
it's not going to have a lot of accuracy

because you're asking different
questions to different people

based on what their responses are.

The interviewer may also be biased or
make mistakes in their interpretation of

the information presented to them, and
typically clinical interviews will lack reliability.

Then we have clinical tests, and this,
when we think about clinical tests, these

tests are used to gather information about
psychological functioning from where

broader information is inferred.

And you're going to find that there are
different types of tests that you can

administer; we have projective tests, and
these require client interpretation of

vague or ambiguous stimuli, or
open-ended instruction.

And this is definitely a
psychodynamic orientation.

The four major tests that we find that
are projective are the Rorschach test, the

TAT, or thematic appreciation test, the
sentence completion test, and drawing.

So what we see here before us is the--
how the works of art may sometimes be

used as an informal projective test.

When we're thinking about this thematic,
um, assessment, we can think, you know,

as part of this sentence completion test
could be, or excuse me, the thematic

appreciation test on the left-hand side,
you are asking someone to interpret

what is happening in this conversation.

And the outcomes will vary.

And it's really up to the person who
is administering the test, or the

thematic appreciation test, to make a
determination based on the respondents

responses, whether it is something that is
viable or not.

When you look at the sentence completion
test in the right-hand side, you would

give them something like "I wish..." or
"my father...".

And based on the respondents answer, the
person administering the test would then

give their interpretation of those
answers, and very rarely are two

answers for the complete thematic
appreciation test or the sentence

completion test absolutely the same
from-- between respondents, there

are similarities, but I've never known
where every question that has been

asked where every response is
completely the same between

two people.

We think about drawing tasks.

They're commonly used to assess the
psychological functioning of children.

And when we look at the therapy
program that's administered by UNICEF,

we're seeing here that this young Nigerian
refuge draws an attack scene.

And when we think about this, the program
that was developed by UNICEF is provided

in Bagasola, which is a town in
western Chad that welcomes people

who have fled extremist groups in
northeastern Nigeria.

So when we see these depictions by
a young man, like what you see before

us, um, with the Nigerian refuge, this
is not unfortunately an uncommon

scene, but it gives the interpreters the
understanding of some of the violence

that may, that these young individuals
have undergone, therefore we can

then provide supports for them to help
them process, and then live healthy lives.

And there's strengths and limitations.

And you're going to see, um, in table 4.1
more information about some multicultural

hotspots in assessment and diagnosis.

But when we're looking at the strengths
and limitations, some strengths are that

it's-- these are some commonly used
tests for personality assessments, and it

can help us as interpreters and as helpers
to gain some supplementary information

that we might not get from asking someone,
you know, a specific question related to

whatever their concern is.

But you're giving them an opportunity
to process externally, not internally.

And by processing externally, it takes
some of the emotion that's tied to it

and brings it outside of themselves.

But, limitations are that reliability and
validity is not consistent.

And it can be biased against minority
ethnic groups, and again, table 4.1 in

your book will show you, um, some more
information about that.

Something else to think about too is
in 2009, there were some leaks, so to speak.

So in an emergency room, there was a
physician who had posted all 10 of the

Rorschach cards on the, um, on Wikipedia.

And many psychologists argued that the
test response of the patients who had

been previously, um, who have, might have
gone to Wikipedia to-- to see these

Rorschach cards, which were once guarded
and protected, that those results can't be

trusted because now they've been able to
see information about it, and from people

posting their personal responses to it, it
now allows them to-- to essentially make

up their own story, or to make up a
response that is quote, unquote most

closely aligned with what they believe the
psychologist wants.

So when you think about this, do you think
that the Rorschach debate has led to an

increase in the distribution of
psychological tests?

I want you to process that and think
about that.

Now let's look at inventories.

So when we think about personality
inventories, these are designed to

measure broad personality
characteristics.

And they look at things like behaviors,
beliefs, and feelings.

And it's usually based on self-reported
responses.

The most widely used personality inventory
is the MMPI-2.

And the MMPI-2 is the Minnesota
Multiphasic Personality Inventory, so

the MMPI-2, which arrived in '89,
it's typically used on adults, and the

MMPI-A is for adolescents.

And what it does is it looks at 10
clinical scales.

What you see before us.

And you look at the scoring from this,
and the score is from 0 to 120.

If the individual or the respondent has
a score of 70 or above, they are

considered deviant.

And then they have to be graphed to
create what's known as profile.

So what are some of the strengths and
limitations of this?

Well, when you think about personality
inventories, it's easier, cheaper and

faster to administer than than
projective tests.

And there's typically an objectivity
around scoring and standardization.

And it has greater validity than
projective tests, but still can't

be considered highly valid because
every individual who responds is different.

The measured traits often can't be
directly examined and many of these

tests don't allow for cultural differences
in responses.

Which leads us to response inventories.

And it's usually based on specifically
reported responses that are

self-identified by the respondent.

And it typically focuses on once
specific area of functioning.

So it could be affective inventories like
the BDI-2, or Beck Depression Inventory Two.

The social skills inventory, or a
cognitive inventory.

When we think about these response
inventories, they typically have very

strong validity because they've been
utilized consistently for longer

periods of time, meaning that there's more
people who have utilized these types

of tests, and in utilizing these tests,
there's more empirical evidence

to back it up.

Not all of these response inventories,
however, have been subjected to

careful standardization, reliability,
and/or validity procedures.

So, for example, the Beck Depression
Inventory Two and some others are

a few exceptions because they've
been used so much and have a lot

of empirical evidence to back it up.

When we look at psychological, um,
some additional clinical tests, we also

have psychophysiological tests.

And these measure the physiological
responses as an indication of

psychological problems, so that's going
to include changes in heat rate, blood

pressure, body temperature, uh, skin
response, and muscular contraction.

An example of this would be a
polygraph test.

Polygraphs, for example, another
psychophysiological test, they

require expensive equipment that must
be tuned and maintained, but they can

also be inaccurate and unreliable.

When we think about polygraphs, these
are used, um, these are still used today

but they are much less trusted, so, uh,
you'll see that people like the FBI,

cops, um, and other law enforcement
agencies in the criminal justice system

will use some of these responses that you
can easily, you can easily fake your scores.

Meaning that you can train yourself to not
have as much of an emotional response,

meaning that you won't have the
psychological or emotional response,

meaning you then won't have, once you've
trained yourself, you won't have as much

physiological response, so you can have
a lot of false scores.

Something else to think about, too, is
that despite the evidence that these

tests are invalid, they are still widely
used, and what you see before us is

a business in Columbia that the employee
has, you know, is essentially taking this

test, but they can still fudge their
outcomes.

Between one and four out of ten truths
are called lies on the polygraph results,

yet polygraphs are still used by the FBI
and other law enforcement agencies

and even public sector institutions,
so you've got me.

Then we look at clinical tests.

And when we think about clinical
tests, we're going to find that these

are neurological tests that directly
assess brain function by directly

assessing brain structure and activity.

And some of these are going to include
an EEG, and a PET scan, a CT scan, an

MRI, and a functioning MRI.

When you look at the brain, what you
see here is different images that will

produce different aspects of
functioning within the brain, and that

can also help us to get a better
understanding of how the individual

is functioning.

Neurophysiological tests are indirectly,
um, assessing these brain functions

because they look at cognitive, perceptual
and motor functioning.

So, an example of this could be the
Bender Visual, um, Motor Gestalt Test.

And when we are thinking about this test,
we are noting that as a psychological

or neuropsychological test, it helps to
assess visual-motor functioning,

developmental disorders, and other
neurological impairments, especially

in children three years of age and older,
and what ends up happening is that there

are, uh, different tests, and these tests
consist of nine index cards where you

put different geometric designs, and the
cards are presented individually, and test

subjects are asked to copy the design
before the next card is shown.

Test results are scored based on the
accuracy and organization of their

reproduction of this, um, of these
representations of the cards.

Clinicians will often use a battery of
tests when they're trying to find out

certain key pieces of information in
neuropsychological testing one of them.

We also have intelligence tests.

And these are designed to indirectly
measure intellectual ability.

And they consist of a series of tests
that are both verbal and non-verbal in

assessing their skills and in utilizing
these skills.

When you look at the outcome, the
general score is called the intelligence

quotient or IQ, and this represents the
ratio of a person's mental age to their

chronological age.

When you think about intelligence tests,
they are among the most carefully

produced of all clinical tests.

They are highly standardized by a large
group of people, and they have very

high reliability and validity.

However, performance can be influenced by
non-intelligence.

Tests may contain cultural biases in
language or asking to complete certain tasks.

And members of minority groups may have
less experience and might be less

comfortable with these types of tests,
which influence their results.

When you are nervous or uncomfortable,
you typically tend to score lower on exams.

We also have clinical observations.

And we have naturalistic and
analog observations.

When we are looking at naturalistic
observations, they can occur in

everyday environments.

They can occur in homes, schools, and
institutions like hospitals and prisons.

And even community settings.

Most naturalistic observations will focus
on parent/child, sibling/child or

teacher/child interactions.

And there's reliability and validity
concerns that are raised by this because

the interpretation is based on the
individual administering this test.

If naturalistic observation is impractical
and you can't do it, then analog

observations used and conducted in
an artificial setting, so you will

simulate a similar experience of a
classroom or bedroom or kitchen in

a lab versus going to the person's house.

Or classroom.

This is self-monitoring.

And this is when people observe themselves
and carefully record their frequency of

behaviors or feelings or thoughts as they
occur over time.

And it's useful in assessing infrequency or
over frequency reporting behaviors.

And it can provide a mean of measuring
private thoughts or perceptions.

But validity is a concern because the
accuracy of filling out these, um, for

example a behavior modification chart,
might be not, they-- they might be

recording too much or not recording
enough, or that what you are intending

to record is not in fact what is
being recorded.

So, we get this information.

Let's talk about now taking the symptoms
and coming up with a diagnosis.

So typically, when we think about coming
up with a diagnosis, everything that's

completed is done with a classification
system.

You want to use all available information
in order to then make a diagnosis, and

what the clinician will then do is to
paint this clinical picture to talk about

what might be the issue or concern of
the client.

And a determination can talk about what
the symptoms or, um, what the information

that was presented, what might the
psychological problem be of the client?

And you take what you have found based
on the information that you've gathered

using an existing classification system
and influenced by the clinicians

theoretical orientation to not only paint
this picture but then to identify, okay,

this is the cluster of symptoms that fall
under this diagnosis.

In North America and around the world, we
use what's called a Diagnostic and

Statistics Manual, um, of Mental Disorders
or the DSM-5.

We also have two other diagnostic systems,
and that's the International Classification

of Disorders or ICD, and the Research
Domain Criteria or RDoC.

The DSM-5 and the ICD, um, 10, are
typically used in the United States

in order to talk about mesal-- uh, mental
health and medical, um, issues respectively.

As stated, the DSM-5 was, um, instituted
in October of 2013, but it was not made

a mandatory, um, tool to utilize until 2015.

But it is most often used in the U.S. and
it lists different categories, disorders

and symptom descriptions with guidelines
for how to assign different diagnoses.

And the focuses on clusters of symptoms
or syndromes versus individual issues

themselves, and the ICD-10 is used in
most other countries, but it can match

with some DSM-5 diagnoses.

The DSM-5 typically requires a clinician
to provide both categorical and

dimensional information as part of the
proper diagnosis.

So categorical information would be the
category or the disorder that's indicated

by the symptoms, and the dimensional
information is looking at the symptoms

and the severity of these symptoms, and
how much, um, based on the severity

of the symptoms, how much does it
impact a person's ability to function?

When you think about the DSM-5
categorical information as we will now

see in future chapters, we look at things
like anxiety disorders and depressive

disorders as just a few.

Um, examples of categorical information.

We think about the dimensional information.

We are looking at the severity and
the ratings.

So we want to see how does it impact
your ADL, your activities of daily living,

how does it impact your relationships,
um, romantic or interpersonal relationships,

family, friend, coworkers, work, etc.

So we look at the cross-cutting symptoms
measure, and the emotional distress

depression scale as some examples.

When we look at the efficacy of
classification systems, some things

to think about is if the framework or the
DSM-5 follows certain procedures in

their development of the new manual to
help ensure that the DSM-5 would have

greater reliability than previous DSM's.

The number of new diagnostic criteria and
categories were developed with the

expectation that the new criteria and
categories would be reliable.

And some critics continue to have concerns
about the procedures that we're used in

the development of the DSM-5, and should
be noted that the APA was sued before the

DSM-5 even came out to start reorganizing
and recategorizing and adding additional

pieces of information within the DSM-5.

So what we see here are some of the top
five DSM-5 concerns.

So, based on these concerns that you
can read, there's been call in change.

So, Major Depressive Disorder and recent
bereavement should be separated.

Premenstrual Dysphoric Disorder should
have it's own separate category.

Sematic Symptom Disorder should have
it's own category.

There should be a combination of patterns
into Single Substance Use Disorder.

Gambling Disorder categories should be
placed, um, within the DSM-5.

Autism Spectrum Disorder should have its
own separate category.

And finally, that there needs to be Mild
Neurocognitive Disorder and Aging.

That should be separate.

As we've talked about previously, can
diagnosis and labeling cause harm?

Yes, so, the way in which we utilize
language, and the way in which we

offer a diagnosis can certainly cloud
or impact a person's functioning.

Because they will take these, they will
take these diagnoses, and it can become

a crutch, or it can become part of their
identity, which might not be helpful for

the client, and the language in which we
use can actually be damaging or harmful

to the client and their self-concept and
their self-esteem.

It can also lead to stigmas and
self-fulfilling prophecies, well if you

think this is what I am, I may not think
this is what I am, but if you say I am,

then I might as well live up to it.

When we think about treatment, right, so
we've now done the diagnose, we've

gotten the information, we, in the
assessments, we have gotten the

diagnosis information, and now it's
talking about how to treat that.

So how do we even begin?

So, you begin with the assessment
information and then you take the

diagnostic decisions to help formulate
a treatment plan.

And remember, that you are using
information from the assessment

and from the diagnosis in order to come
up with the treatment plan.

It also must be co-collaborative, meaning
that you need to get buy-in from the

client that you are working with or
clients that you're working with

because without this information, there's
really not going to be any progress in, um,

there's not going to be any progress in
their treatment.

You also need to include other things
like what does the current research say

is helpful for treatment?

What does the therapist theoretical
orientation?

And looking at empirically supported and
evidence-based treatment options as well

as complimentary and alternative options.

So when we think about therapy outcomes,
which factors should contribute to therapy?

Well, according to research, a clients
progress in therapy will relate only

partially to the specific strategies used
by their therapist, in fact, factors like

the clients expectations in the
therapeutic relationship and

concurrent events in the clients life
actually have more influence on the

outcome of treatment which is what we
see here.

So, when we think about the efficacy,
you want to think about how do we

define success?

How is-- how are we going to
measure improvement?

And how does the, uh, the variety and
complexity of treatments influence the

effectiveness of the evaluation?

So these outcome studies typically will
ask these three questions: is the therapy

that we want to use effective?

Are there par-- therapies that are
generally effective?

And are there particular therapies that
are effective for particular problems?

These are all things that you're going to
have to research when formulating

a treatment plan.

So when we think about the clinical
assessment, and we are actually

coming up with a physical treatment
plan, what lies ahead?

We need to look at properly being able
to diagnose and effectively treat

individuals, and the clinical assessment
is definitely helpful in properly

diagnosing and effectively treating
someone.

And we also can consider that brain
scanning techniques continue to offer

sensitive information about an increasing
range of psychological disorders,

especially those who have cognitive
impairments and/or are older.

By being able to have brain scanning
techniques that we can be able to see

where there's potential decline so we
can now support our client and

potentially their loved ones.

It's also important for us to think, too,
that there are rising costs and health

care concerns, and economic factors
that may limit the use of certain

assessment tools.

So we may have to begin to become
creative when we are interviewing,

assessing, diagnosing, and treating
our clients.

I hope that this is helpful for you, as
always if you have any questions,

comments or concerns, please feel free
to reach out to me via email.

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