Psychological Assessment in Different Setting

Psychological Assessment in Adult Mental Health Settings

Why conduct Psychological Assessment?

Psychological assessment is a problem-solving process in which psychological
tests, interviews, and other sources of data function as tools used to answer questions
(e.g., to address a referral request) and resolve perplexities (e.g., to assist in differential
diagnosis).

Purpose of Psychological Assessment in Adult Mental Health Settings

1. Evaluate patients’ cognitions, affect, behaviors, personality traits, strengths, and
weaknesses in order to make judgments, diagnoses, predictions, and treatment
recommendations concerning the clients
2. Provide information about clients’ symptoms including stable personality
characteristics , defensive patterns, identifications, interpersonal styles, self-
concept, and beliefs
3. Provide an accurate description of the client’s problems, determining what
interpersonal and environmental factors precipitated and are sustaining the
problems, and making predictions concerning outcome with or without
intervention.
4. Support or challenge clinical impressions and previous working diagnoses, as
well as identifying obstacles to therapy
5. Provide assistance in developing and evaluating the effectiveness of a treatment
plan consistent with the client’s personality and external resources, as well as
allowing the client to find out more about himself or herself.
6. Guide discharge planning and subsequent treatment of the individual as clients
continue to adapt and deal with their symptoms after their discharge.

Foundations of the General Approach to Psychological Assessment

1. Evidence- Based Assessment
Key Points in Evidence-Based Assessment
- Emphasizes the importance of systematic observation and the use of rules of
evidence in hypothesis testing.
- Psychologists can base their assessments and diagnoses on the best available
evidence
 - Affords the opportunity to integrate real clinical problems with critical
evaluation of the psychiatric research literature
- Premised on obtaining actual evidence from both structured interviews and
objective measures that have been empirically supported
- Enhance likelihood of making an accurate diagnosis and treatment based on
suggested patterns of symptoms associated with specific diagnoses through
empirical and clinical literature
Clinical Judgment – consists of decisions made in the clinician’s mind. In its most polar
form, this distinction is analogous to a dimension with objectivity (evidence-based) on
one end and subjectivity (clinical impression) at the other end.

Advantages of Clinical Judgment

The clinicians who base their assessments on clinical judgment highlight the
advantages of their technique.
1. Certain assessment tools, such as unstructured interviews and behavioral
observations, cannot be empirically evaluated or subjected to statistical analyses
required by the evidence-based model. In fact, clinical judgment is required to
evaluate the result of such tools.
2. Clinicians’ impressions and judgments structure the rest of the assessment and
provide a framework around which the client’s symptoms and difficulties are
conceptualized and understood.
3. Many clinicians contend that their clinical impressions and judgments are rarely
disputed by empirical test results. Thus, in the interest of conducting an efficient
assessment, they rely solely on their judgment gleaned form the information
obtained from unstructured interviews.
4. Some clinicians fear that by basing a diagnosis on empirical findings, they will be
treating the client nonoptimally through reliance on actual experience.
Furthermore, many clinicians often do not use actuarial-based data for fear that the
data themselves will involve significant error, thereby leading to misdiagnosis of a
client.
Disadvantage of Clinical Judgment
1. Clinicians often overvalue supportive evidence and undervalue evidence contrary
to their hypotheses.
2. Clinicians tend to fin evidence of abnormality in those they assess, regardless of
whether they are unable to learn whether their predictions were accurate and
their suggestions were helpful
Evidence Based Approach vs. Clinical Judgment
- Clinical judgments and evidence-based models do not generate the same
conclusions.
- Human judgments and statistical predictions concerning diagnosis,
prognosis, and decisions based on the same set of information have a less
than perfect correlation
- With the same set of data, different actuarial procedures lead to the same
conclusion, whereas different human judgments may result in several
different conclusions.
- Clinicians’ diagnosis can fall prey to self-fulfilling prophecy in that their
predictions of diagnoses can influence their decisions about symptoms
prevalence and, later, diagnosis.
- Mathematical nature of actuarial procedures ensures that each variable has
predictive power and is related to the criterion in question
- Clinical judgment is prone to human error
Multimodal Assessment
Key points in Multimodal Assessment
- One assessment tool is not sufficient to tap into complex human processes
- Empirical support is critical to the validity of a psychological assessment
- Concordance among the results from the client’s history, structured interview,
self-reports, objective tests, and clinical impression.
- Increases reliability of the information gathered and helps corroborate
hypotheses
- Draws on the strengths of each test and reduces the limitations associated
with each test
- Relies on shared methods and thus minimizes any potential biases associated
with specific assessment methods or particular instruments
- Prevents the influence of a single perspective from biasing the results.
Goals of Psychological Assessment
1. Diagnostic Clarification
A primary reason for conducting psychological assessments of adults in a mental
health setting is to make or clarify a diagnosis based on the client’s presenting
symptomatology. This is a common issue when the client presents with
symptoms that are common to several diagnoses or when there is a concern that
the symptoms of one disorder may be masking the symptom of another disorder.
Benefits of Diagnostic Clarification
 Enhancing communication between clinicians about clients who share certain
features.
 Enhancing communication between a clinician and the client through a feedback
  Helping put the client’s symptoms into a manageable and coherent form for the
client
 Giving the client some understanding of his or her distress.
 Guiding treatment
 Enhancing research that, in turn, should feedback into clinical knowledge
…diagnosis involves several interconnected features that must be taken into account.
- Potential for shift within any diagnostic formulation
- Relationship between the presenting problem and the client’s personality
- Presence of various levels and types of pathology and their interconnections
- Impact of diagnostic features on the development of intervention strategies
and prognostic formulations
In essence, the diagnosis of the problem is not a discrete final step but, rather, a
process that begins with the referral question and continues through the
collecting of data from interviews and test results.
DSM – Although DSM-5 is the gold standard by which diagnoses of psychopathology are
made, there are problems inherent in making a diagnosis based on DSM-5.
- Based on a medical model and does not consider underlying processes (i.e., it
is concerned only with the signs and associations of the disorder) and overall
manifestations of disorders
- DSM-5 is categorical in nature, requiring a specified number of criteria to
meet a diagnosis.

2. Guide for Treatment

A psychological assessment offers the opportunity to link symptomatology,
personality attributes, and other information with certain treatment
modalities or therapeutic targets. Therefore, giving treatment planning
allows psychologists to proceed past the level of diagnosis and provide
suggestions about how to deal with the diagnosed disorder.
Treatment planning should take into account information about:
- Plans to immediately deal with the client’s acute symptoms, as
well as long-term treatment plans that address the client’s chronic
symptoms
- Symptom severity
- Stage of problem resolution
- General personality attributes
- Interpersonal style
- Coping mechanisms
- Patient resistance
 - Client’s psychiatric and medical history
- Current levels of stress
- Motivation levels
- History of prior treatments
- Physical condition
- Age, sex, intelligence, education, occupational status, and family
situation

The information is relevant to treatment planning in two ways :

1. Demographic variable and a history of prior treatments can dictate or modify
current treatment modalities
2. Other variables might help formulate certain etiological models that can turn
guide treatment

Psychological Assessment Tools

Interviews – Clinical interviews provide comprehensive and detailed analysis of clients’

past and current psychological symptomatology.
- Offer insight into clients’ personality feature, coping styles, interpersonal
styles, and behavior.
- Helps the clinician generate and evaluate hypotheses and then select
appropriate psychological tests to clarify diagnostic impressions.
- Plays a central role in the assessment process
- Unstructured interviews are often conducted to obtain a clinical impression
view of the client
- Semi-structured and structured interviews are often scored and interpreted
against normative data. Thus, they provide the potential for greater objectivity
and less bias in interpretation.
Objective Tests
Objective tests are used in three ways:
1. To assess the frequency and intensity of psychiatric symptoms
2. To determine a clinical diagnosis
3. To assess enduring traits that predict future behaviors, symptoms, or treatment
implications
Projective Tests
Projective tests, in general are unstructured and disguised. Although certain
administration and scoring systems allow for the quantification of response scoring,
extensive training is required.
Possible obstacles to the clinical utility of these test include:
- Low validity coefficients of the instruments
- Influence of situational factors on client’s responses
- Clinician subjectivity in scoring and interpreting responses
- More time to administer, score and interpret
Clinical Judgment
The use of unstructured interviews (and even structured interviews)
introduces clinical judgment into the assessment process, thereby allowing for
both expertise and greater flexibility in clarifying and delving inro areas that
can provide relevant information in the assessment. However, clinician bias
can never be eliminated, and clinician skills may affect interpretation. This, to
adhere to the evidence-based multimodal approach to assessment, clinicians
should use other assessment tools to evaluate and confirm their clinical
judgments.
Choosing the Tests to Use
Four major considerations important in selecting which tests to administer
are

1. The test’s psychometric properties

2. Clinical utility
3. Client factors
4. Clinician variables
The first two speak to the ability of the psychological tests to answer the
referral question based on an evidence-based approach, whereas the latter
two consider factors such as client ethnicity, age, level of education, functional
capacity, motivation, and clinician experience, all of which may be confound
test results or interpretation.
Other factors to account for include
- Client’s ability to speak the language in which the tests are written
- Client’s ability to remain focused for extended periods of time
- Length of time required to complete the test must be considered
Choosing the Number of Tests
Although the multimodal approach to assessment encourages the use of more
than one test, it does not specify the exact number of tests clinicians should use. The
clinician must prevent the assessment from becoming too cumbersome yet still obtain
enough information to provide an empirically supported diagnosis.
Although it is less time-consuming and costly to use fewer tests, taking a
multimodal approach and using several objective tests allows for cross validation,
assessment of a client’s responses to different situations, identification of previously
unrecognized problems, and provision of a more comprehensive evaluation.

Integration and Interpretation of Tests

After each of the test results has been discerned, it is important to interpret and
integrate the results. Although each test presents a discrete analysis of the client’s
psychological functioning, the results must be logically and coherently related to other
test results and to the individual as a whole. Test interpretation involves integrating all
the information from the various test results into a cohesive and plausible account.
Proficient integration of the tests should explain the presenting problem, answer the
referral question and offer additional information to clarify diagnoses and guide
treatment.