Module 3.
Basic of Clinical Assessment, Diagnosis and Clinical Judgment Introduction and to people’s attention because she is different. Her clothes, appearance, and interests do not conform to
Overview
Clinical psychology is usually
thought of as an applied science.
Clinicians attempt to
apply empirically supported
psychological principles
to problems of adjustment and
abnormal behavior. Typically, this
involves finding successful ways
of changing the behavior, thoughts, and
feelings of clients. In this way,
clinical psychologists reduce their
clients’ maladjustment or
dysfunction or increase their levels of
adjustment. Before clinicians can
formulate and
administer interventions, however, they
must first assess their clients’ symptoms of psychopathology and levels of dysfunction or impairment.
Interestingly, the precise definitions of these and related terms can be elusive. Further, the manner in
which the terms are applied to clients is sometimes quite unsystematic. Clinical psychology has moved
beyond the primitive views that defined mental illness as possession by demons or spirits. Maladjustment
is no longer considered a state of sin. The 18th and 19th centuries ushered in the notion that “insane”
individuals are sick and require humane treatment. 
Clearly, clinical psychologists contemporary views are considerably more sophisticated than those of
their forebears. Yet many view current treatments such as electroconvulsive therapy (ECT) or
transcranial magnetic brain stimulation (TMS) with some skepticism and concern. Still others may see
the popularity of treatments using psychotropic medications (e.g., antipsychotic, antidepressant,
antimanic, or antianxiety medications) as less than enlightened. Finally, many forms of
“psychological treatment” (e.g., primal scream therapy, age regression therapy) are questionable at best.
All of these treatment approaches and views are linked to the ways clinical psychologists decide who
needs assessment, treatment, or intervention as well as the rationale for providing these services. These
judgments are influenced by the labels or diagnoses often applied to people.
Lesson 1.Nature and Process of Clinical Assessment
WHAT IS ABNORMAL BEHAVIOR?
Ask 10 different people for a definition of abnormal behavior and you may get 10 different
answers. Some of the reasons that abnormal behavior is so difficult to define are (a) no single descriptive
feature is shared by all forms of abnormal behavior, and no one criterion for “abnormality” is sufficient;
and (b) no discrete boundary exists between normal and abnormal behavior. Many myths about abnormal
behavior survive and flourish even in this age of enlightenment. For example, many individuals
still equate abnormal behavior with (a) bizarre behavior, (b) dangerous behavior, or (c) shameful
behavior.
Statistical Infrequency or Violation of Social Norms
When a person’s behavior tends to conform to prevailing social norms or when this particular behavior
is frequently observed in other people, the individual is  not likely to come to the attention of mental
health professionals. However, when a person’s behavior becomes patently deviant, outrageous, or
otherwise nonconforming, then he or  she is more likely to be categorized as “abnormal.” Let us consider
some examples. Both of these cases are examples of individuals commonly seen by clinical
psychologists for evaluation or treatment. The feature that immediately characterizes both cases is that
Dmitri’s and Juanita’s behaviors violate norms. Dmitri may be considered abnormal because his IQ and
school performance depart considerably from the mean. This aspect of deviance from the norm is very
clear in Dmitri’s case because it can be described statistically and with numbers. Once this numerical
categorization is accomplished, Dmitri’s assignment to the deviant category is assured. Juanita also came
the norms typical of girls or women in her culture.
Subjective Distress
Here the basic data are not observable deviations of behavior, but the subjective feelings and sense
of well-being of the individual. Whether a person feels happy or sad, tranquil or troubled, and fulfilled or
barren are the crucial considerations. If the person is anxiety-ridden, then he or she is
maladjusted regardless of whether the anxiety seems to produce overt behaviors that are deviant in some
way.
Disability, Dysfunction, or Impairment
A third definition of abnormal behavior invokes the concepts of disability, dysfunction, or impairment.
For behavior to be considered abnormal, it must create some degree of social (interpersonal) or
occupational (or educational) problems for the individual. Dysfunction in these two spheres is often quite
apparent to both the individual and the clinician. For example, a lack of friendships or of relationships
because of a lack of interpersonal contact would be considered indicative of social dysfunction, whereas
the loss of one’s job or failing grades because of emotional problems (e.g., depression) would suggest
occupational dysfunction. According to the disability/dysfunction/ impairment definition, both of these
cases would suggest the presence of abnormal behavior. Richard is completely dependent on his wife
(social dysfunction), and this, coupled with his litany of somatic complaints and his inability to cope with
stress, has left him unemployed (occupational dysfunction). Phyllis’s drug habit has interfered with
her occupational (in this case, school) functioning.
MENTAL ILLNESS
The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2000), known as DSM-IV-TR, is the official diagnostic
system for mental disorders in the United States. It states that a mental disorder  "is conceptualized as a
clinically significant behavioral or psychological syndrome or pattern that occurs in an individual
and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one
or more important areas of functioning) or with a significantly increased risk of suffering, death,
pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely
an expectable and culturally sanctioned response to a particular event, for example, the death of a loved
one. Whatever its original cause, it must currently be considered a manifestation of a behavioral,
psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., religious,
political, or sexual) nor conflicts that are primarily between the individual and society are mental
disorders unless the deviance or conflict is a symptom of the dysfunction in the individual as described
above.
The Importance of Diagnosis
Before uncritically accepting this definition or taking for granted the utility of diagnosing and
classifying individuals, we need to answer a basic question: Why should we use mental disorder
diagnoses? Diagnosis is a type of expert-level categorization. Categorization is essential to our
survival because it allows us to make important distinctions (e.g., a mild cold vs. viral pneumonia, a
malignant vs. a benign tumor). The diagnosis of mental disorders is an expert level of categorization used
by mental health professionals that enables us to make important distinctions (e.g., schizophrenia vs.
bipolar disorder with psychotic features). There are at least four major advantages of diagnosis. First, and
perhaps most important, a primary function of diagnosis is communication. A wealth of information
can be conveyed in a single diagnostic term. For example, a patient with a diagnosis of paranoid
schizophrenia was referred to one of the authors by a colleague in New York City. Immediately, without
knowing anything else about the patient, a symptom pattern came to mind (delusions, auditory
hallucinations, severe social/occupational dysfunction, continuous signs of the illness for at least 6
months). Diagnosis can be thought of as “verbal shorthand” for representing features of a particular
mental disorder. Using standardized diagnostic criteria(e.g., those that appear in the DSM-IV)
ensures some degree of comparability with regard to mental disorder features among patients
diagnosed in California, Missouri, North Carolina, Texas, Manhattan, New York, or Manhattan,
Kansas. Diagnostic systems for mental disorders are especially useful for communication because these
classificatory systems are largely descriptive. That is, behaviors and symptoms that are characteristic of
the various disorders are presented without any reference to theories regarding their causes. As a result, a
diagnostician of nearly any theoretical persuasion can use them. If every psychologist used a different,
theoretically based system of classification, a great number of communication problems would likely
result. Second, the use of diagnoses enables and promotes empirical research in psychopathology.
Clinical psychologists define experimental groups in terms of individuals’ diagnostic features, thus
allowing comparisons between groups with regard to personality features, psychological test
performance, or performance on an experimental task. Further, the way diagnostic constructs are defined
and described will stimulate research on the disorders’ individual criteria, on alternative criteria sets, and
on the comorbidity (co-occurrence) between disorders. Third, and in a related vein, research into
the etiology, or causes, of abnormal behavior would be almost impossible to conduct without a
standardized diagnostic system. To investigate the importance of potential etiological factors for a given
psychopathological syndrome, we must first assign subjects to groups whose members share diagnostic
features. For example, several years ago, it was hypothesized that the experience of childhood sexual
abuse may predispose individuals to develop features of borderline personality disorder (BPD). The first
empirical attempts to evaluate the veracity of this hypothesis involved assessing the prevalence of
childhood sexual abuse in well defined groups of subjects with borderline personality disorder as well as
in non-borderline psychiatric controls. These initial studies indicated that childhood sexual abuse does
occur quite frequently in BPD individuals and that these rates are significantly higher than those found in
patients with other (non-BPD) mental disorder diagnoses. Thus, it is worth investigating whether it is an
important etiological factor in BPD. Before we could reach these types of conclusions, there had to be a
reliable and systematic method of assigning subjects to the BPD category. Finally, diagnoses are
important because, at least in theory, they may suggest which mode of treatment is most likely to be
effective. Indeed, this is a general goal of a classification system for mental disorders (Blashfield &
Draguns, 1976). As Blashfield and Draguns (1976) stated, “The final decision on the value of a
psychiatric classification for prediction rests on an empirical evaluation of the utility of classification for
treatment decisions”.
In summary, diagnosis and classification of psychopathology serve many useful functions. Whether they
are researchers or practitioners, contemporary clinical psychologists use some form of diagnostic system
in their work.  Organization, 1992). In the ICD‐9, the clinical descriptions are more detailed and more closely aligned
Classification Systems in Western Cultures  They are also less well structured and more verbose (cf. Mombour, 1995). There are about three times
Atheoretical Classification Systems Currently, the two most important international diagnostic systems
are the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association (APA) and the chapter about mental disorders in the International Classification of
Diseases, Injuries and Causes of Death, published by the World Health Organization. Clinicians and
researchers from different orientations use both categorical diagnostic systems worldwide. Standards, as
set by DSM and ICD, ensure reliable diagnoses and are useful for the definition of an official
classification of mental disorders. For both diagnostic systems, revisions have been published at irregular
intervals, so that the number of the edition is added to the abbreviation (e.g., “ICD‐10” refers to the tenth
edition of the ICD system, “DSM‐IV‐TR” to the fourth and text‐revised (TR) edition of the DSM). The
most recent and common versions are the DSM‐5, published by the American Psychiatric Association
(2013), and the ICD‐10, published by the World Health Organization (1992).
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
The history of DSM as a categorical classification system began with an awareness of the lack of
diagnostic reliability and the absence of standardized techniques for the classification of mental
disorders. Thus, the APA proceeded to revise the DSM based on the successful Research Diagnostic
Criteria (Feighner et al., 1972; Robins & Guze, 1970; Spitzer, Endicott, & Robins, 1977) for the
investigation of the psychophysiology of depression by the National Institute of Mental Health (for a
more detailed overview of the development of DSM, see Shorter, 2013). The DSM‐5 introduced changes
in the fundamental structure of the DSM, like the organization of chapters, and numerous content
revisions within diagnostic criteria were made. These ranged from minor changes (e.g., adding a 6‐month
criterion to anxiety disorders, the reduction of binge eating behavior in a defined time period in bulimia
nervosa, or adding a requirement for two different situations with fear or anxiety in agoraphobia) to
major revisions (e.g., dimensional assessment of alcohol use disorder and autism, revision of the
traumatic event criterion and other criteria of posttraumatic stress disorder or the summary of former
somatoform disorders to the new listed somatic symptom disorder) (for more details about the highlights
of changes form DSM‐IV‐TR to DSM‐5, see: American Psychiatric Association, 2013, pp. 809–816).
Furthermore, the distinction between disorders diagnosed in adulthood and “disorders usually first
diagnosed in infancy, childhood, or adolescence” was discarded and an alternative DSM‐5 model for
personality disorders was added. Whereas a multiaxial assessment (multiaxial assessment = judged on
several dimensions—so called axes—simultaneously) was the basic principle of the fourth edition of
DSM, DSM‐5 moved to a nonaxial documentation of diagnosis. Former Axis I (clinical disorders), Axis
II (personality disorders and mental retardation), and Axis III (general medical conditions) were
combined. DSM‐5 no longer contains a classification system for the assessment of psychosocial and
environmental problems (DSM‐IV, Axis IV: psychosocial and environmental problems). Instead, it
refers to a selected set of ICD‐9 and ICD‐10 codes. The global assessment of functioning scale that
was used in DSM‐IV to assess Axis V (global assessment of functioning) was excluded. The second
version of the WHO Disability Assessment Schedule is proposed for the assessment of global
functioning and is included in DSM‐5. This schedule is widely used in medicine and healthcare, so the
assessment of global functioning can be more easily compared to medical judgments.
The International Classification of Diseases, Injuries and Causes of Death (ICD) 
Since 1996, the current tenth edition of the ICD is obligatory for all member nations of the WHO.
However, official coding system of the ICD‐10 was quite recently scheduled for implementation in the
United States (October 1, 2015). ICD‐10 is strongly aligned with the DSM‐IV with respect to the chapter
on mental disorders. On the one hand, this is reflected in a detailed criteria‐based description of mental
disorders, a detailed description of required symptoms, and an annexation disorder concept (instead of
illness). On the other hand, there are still discrepancies with respect to several categories. Among others,
these affect the definition of schizophrenia and schizoaffective psychoses, the definition of a traumatic
event with respect to the criteria of posttraumatic stress disorder, and a different emphasis of agoraphobia
and panic attacks (which has, in turn, been annexed in DSM‐5). In addition, some mental disorders are
entirely missing (e.g., narcissistic personality disorder of bipolar disorder II). Another relevant
distinction is the fact that the ICD‐10 has been published in several different editions, whereas the most
relevant one seems to be the edition with clinical descriptions and diagnostic guidelines (World Health
with the DSM‐classification, but do not comprise diagnostic criteria that can be clearly operationalized.
more descriptions in ICD‐10 compared to the ICD‐9. The research criteria in ICD‐10 use an
alphanumerical instead of a numerical coding system. Mental disorders are coded starting with the letter
F (reflecting the fifth chapter of ICD) and followed by a maximum four‐digit numerical sequence.
Screening
Given their expertise in measurement and psychometrics, psychologists are often called on to assist in
the development or implementation of screening measures. Depending on the nature of the screening and
the screening site, psychologists may or may not be directly involved in conducting screening
assessments. The purpose of screening for a disorder, condition, or characteristic is to identify, as
accurately as possible, individuals who may have problems of a clinical magnitude or who may be at risk
for developing such problems. Individuals who are screened may not have sought out assessment
services; rather, they are receiving the assessment as part of the routine operations of a clinic, school,
hospital, or employment setting. For example, there are now a number of instruments that are routinely
used in schools to identify youth with mental health problems. Psychological services are then offered to
those who have been identified as having problems (Levitt, Saka, Romanelli, & Hoagwood, 2007).
screening: a procedure to identify individuals who may have problems of a clinical magnitude or who
may be at risk for developing such problems.
People may also actively seek out a screening assessment. In the United States, there are national
screening days for a number of psychological disorders, including the National Alcohol Screening Day
and the National Depression Screening Day. These screening days have many sponsors, including the
American Psychological Association. The screening can be done online or in person at many
community-based health care settings such as general hospitals, mental health clinics, and specialty
health care providers’ offices. Hundreds of thousands of Americans each year are screened for mental
health problems in this manner. Information on the websites for these screening services is included at
the end of this chapter.
The goal of screening is to identify those who may require services, with the expectation that steps will
be taken to facilitate the provision of services to the individuals identified in the screening process. To
this end, in 2015, the U.S. Preventive Services Task Force (USPSTF) released two reviews of the
research evidence regarding the value of screening for depression in the general population. Based on a
review of the published research on screening for depression, the USPSTF (2015a) recommended that
depression screening be undertaken in the general adult population, especially with pregnant women and
with women in the postpartum period. The task force members anticipated that such screening efforts
would allow for the early identification and treatment of depression in these individuals. The USPSTF
(2015b) reached a different conclusion for children and adolescents. They found no evidence that
screening for depression was beneficial for children or for adolescents, but because of evidence that good
screening tools and treatments exist for adolescent depression, they cautiously suggested that general
screening might be useful in adolescent populations.
Although screening is useful in identifying those at risk, it is important to remember that screening tools
are not the same as tools used in diagnosis. So, for example, if you score high on a depression-screening
instrument, it does not mean that you would necessarily meet diagnostic criteria for depression.
Diagnosis/Case Formulation
Assessment data are used to formulate a clinical diagnosis such as those listed in the DSM-5. Interview
data, psychological test data, and reports from significant others provide information on the symptoms
the person is experiencing. Information on symptoms is compared with diagnostic criteria to determine
whether the symptom profile matches criteria for DSM diagnoses.
Knowing the diagnosis for a person helps clinicians communicate with other health professionals and
search the scientific literature for information on associated features such as etiology and prognosis.
Diagnostic information can also provide key information on the types of treatment options that have been
found to be effective in clinical trials (Nelson-Gray, 2003). Thus, diagnosis can provide an initial
framework for a treatment plan that can be modified to fully address the client’s concerns and life
circumstances.
Historically, the term diagnosis was used to describe the entire process of conducting a psychological
assessment and formulating a clinical picture of the client. The term originated when diagnostic criteria
for psychological and psychiatric disorders were ambiguous and relatively uninformative for clinical
purposes (i.e., during the era of DSM-I and DSM-II). Thus, in the
past, diagnosis or psychodiagnosis referred to the process in which the psychologist used interview and
testing data to render a comprehensive representation of the patient’s psychological makeup (cf.
Rapaport, Gill, & Schafer, 1968). Although the term psychodiagnosis is still used by some clinicians
(primarily those with a psychodynamic orientation), the term case formulation is now more commonly
used to describe the use of assessment data to develop a comprehensive and clinically relevant
conceptualization of a patient’s psychological functioning. Typically, a case formulation provides
information on the patient’s life situation, current problems, and a set of hypotheses linking psychosocial
factors with the patient’s clinical condition.
case formulation: a description of the patient that provides information on his or her life situation,
current problems, and a set of hypotheses linking psychosocial factors with the patient’s clinical
condition.
Prognosis/Prediction
Whether or not it is stated explicitly, psychological assessment always implies some form of prediction
about the patient’s future. For example, recommendations that the person seek psychotherapy to address
bulimic symptoms or that special academic tutoring is needed to compensate for a learning disability
imply that, without some form of intervention, the present problems will either continue or worsen. A
dentist would not recommend implants to deal with a lack of teeth in a patient aged six months—it would
be assumed that, in time, the teeth would grow. Similarly, if the psychologist believed that bingeing was
simply related to an adolescent growth spurt, or that a child’s reading difficulties were an inevitable part
of the learning process, then it would be unnecessary to recommend intervention—the passage of time
would be sufficient to correct the problem.
Prognosis
Refers to the use of assessment data, in combination with relevant empirical literature, to make
predictions about the future course of a patient’s psychological functioning. Although the
psychopathology literature provides information for this task, it must always be remembered that these
studies deal with future outcomes at the group level. The clinician’s task is to use this probabilistic
information (e.g., “60% of patients with this diagnosis experience a recurrence of their symptoms within
two years”) in a manner that takes into account the unique circumstances of the patient being assessed.
prognosis: predictions made about the future course of a patient’s psychological functioning, based on
the use of assessment data in combination with relevant empirical literature.
One of the biggest challenges for clinicians is to predict possible client outcomes as accurately as
possible. In considering ways to enhance the accuracy of predictions, the psychologist must weigh a
number of variables such as time and cost, the consequences of inaccurate decisions, and the base rate of
the predicted outcome. Although it is always possible to collect more and more assessment data, this is
not always desirable. Time spent on assessment may mean less time is available to provide an
intervention for the patient. The cost of an assessment should not be underestimated: more time spent on
assessment means that someone (e.g., the client) or some organization (e.g., the client’s health insurance
plan) must cover these costs. The clinician must therefore strike a balance between the desire to obtain
more information and the need to be conscious of the very real constraints that influence the scope of the
assessment.
All of these types of errors are influenced by the base rate of a problem or diagnosis: that is, the
frequency with which the problem/diagnosis occurs in the population. In a nutshell, the less frequently a
problem occurs, the more likely a prediction error will occur. As many of the predictions that clinical
psychologists make are about rare conditions or low base rate events—such as the presence of an eating
disorder, the likelihood that the person will be violent in the future, or the likelihood of a future suicide
attempt—the consequences of error must be seriously considered.
base rate: the frequency with which a problem or diagnosis occurs in the population.
Errors in clinical prediction can occur in many assessment activities, including screening, diagnosis, and
case formulation. To better understand how clinical psychologists attempt to address the issue of error, it
is necessary to understand some of the basic concepts of decision theory. To begin, there is, of course,
the situation in which the prediction is accurate. This can mean either that the prediction that an event
will occur was accurate (true positive) or that the prediction of a non-event was accurate (e.g., that no
diagnosis was warranted or that a specific event such as a suicide attempt would not occur—true
negative). However, just as a prediction can be correct in two distinct ways, there are two types
of incorrect predictions. A false positive occurs when the psychologist predicts that an event will occur,
but in fact, it does not occur (e.g., the psychologist diagnoses ADHD in a child who does not have the
disorder). Conversely, a false negative occurs when an event occurs that was not predicted by the
psychologist (e.g., the psychologist fails to diagnose someone who has a personality disorder).
sensitivity: proportion of true positives identified by the assessment.
specificity: proportion of true negatives identified by the assessment.
Treatment Planning
A great deal of psychological assessment is designed to inform treatment-related decisions. Once the
psychologist and client have reached a decision that some treatment is required, the next step is to
determine what exactly the treatment should be. Treatment planning is the process by which
information about the client’s context (including sociodemographic and psychological
characteristics, diagnoses, and life circumstances) is used in combination with the scientific
literature on psychotherapy to develop a proposed course of action that addresses the client’s
needs and circumstances. Treatment planning provides a clear focus for treatment and gives the client
realistic expectations about the process and likely outcome of treatment. The plan also establishes a
standard against which treatment progress can be measured.
Within the context of health service provision, a treatment plan is a valuable tool that facilitates
communication among professionals working with the client, provides a clear statement about the nature
of the planned services to agencies that may need to authorize and/or pay for the services, and provides a
document that can be reviewed as part of an agency’s quality assurance activities to ensure that
appropriate services are being provided. The collaborative effort between psychologist and client to
develop and implement a treatment plan should also establish a good foundation that will help in
navigating the subsequent challenges of psychotherapy. A formal treatment plan ensures that a client can
provide truly informed consent for the procedures he or she is about to undertake, rather than simply
agree to a vague statement about therapy.
Treatment Monitoring
Once a clear treatment plan is in place, the psychologist closely monitors the impact of treatment.
Treatment monitoring is a crucial element of effective treatment, as it enables the psychologist to
change the treatment plan based upon the patient’s response to treatment. If a patient is
progressing extremely well, it may be possible to shorten treatment or to focus subsequent phases
of treatment on other issues of concern to the patient. Alternatively, if the treatment is less than
optimally effective, close monitoring of treatment progress provides an opportunity to alter the
treatment. All clinicians have an implicit sense of how the patient is progressing, but treatment
monitoring refers to explicitly tracking progress through the use of specific questions or psychological
measures. By providing data on problems in the process of treatment (such as difficulties in the
therapeutic relationship) and obstacles the patient is encountering in following through on therapeutic
activities (such as not doing assigned tasks outside the therapy session), treatment monitoring can
provide an opportunity to reorient treatment efforts to avoid potential treatment failure (Mash & Hunsley,
1993).
Psychologist Michael Lambert, a major contributor to the research on assessing changes due to
treatment, demonstrated that routine treatment monitoring can substantially affect treatment outcome. In
a meta-analysis of three large-scale studies, Lambert et al. (2003) found that by using monitoring data to
alert clinicians to treatment progress (or lack of progress), the likelihood of client deterioration was
reduced and the positive effects of psychotherapy were enhanced. In these studies, treatment monitoring
data were routinely collected on more than 2,500 patients in a range of treatment settings such as
university counselling centres and outpatient treatment clinics. Services were provided by qualified
professionals who espoused the full range of theoretical orientations typically found in practice settings.
The same very simple experimental manipulation was used in all studies: patient and clinician dyads
were randomly assigned to a “no feedback condition” in which the treatment monitoring data were not
provided to the clinician, or to a “feedback condition” in which the clinician was given the data. Across
the studies, in the no feedback condition, Lambert and colleagues found that 21% of patients
deteriorated, and 21% experienced clinically important improvements in functioning. However, in the
feedback condition, the number of clients who experienced deterioration was reduced by a third (to
13%), and the proportion of successful treatment cases increased by two-thirds (to 35%). Similar results
have been reported in subsequent large-scale studies of individual psychotherapy outcome (Shimokawa,
Lambert, & Smart, 2010). Moreover, there is growing research demonstrating that monitoring progress in
couples therapy also has an extremely positive effect on treatment outcome (Anker, Duncan, & Sparks,
2009; Reese, Toland, Slone, & Norsworthy, 2010). These results present a convincing argument that
clinical psychologists have an ethical responsibility to routinely gather treatment monitoring data in order
to enhance the likelihood of successful treatment outcome.
Treatment Evaluation
In most clinical psychology settings, treatment outcome data are collected to determine the extent to
which psychological services such as psychotherapy are effective in achieving stated goals. A
comparison of outcome data with intake data provides an indication of how much change, if any, has
occurred during treatment of a particular individual. You might wonder why such data are necessary—
surely health care providers know how much their patients have improved or whether they have
deteriorated. 
Data Collection, Review on Diagnosis, Analysis and Interpretation of Data
Data Collection
Case study research typically includes multiple data collection techniques and data are collected from
multiple sources. Data collection techniques include interviews, observations (direct and participant),
questionnaires, and relevant documents (Yin, 2014). The use of multiple data collection techniques and
sources strengthens the credibility of outcomes and enables different interpretations and meanings to be
included in data analysis. This is known as triangulation (Flick, 2014).
In case study research, the data collected are usually qualitative (words, meanings, views) but can also be
quantitative (descriptive numbers, tables). Qualitative data analysis may be used in theory building and
theory testing. Theory building may use the grounded theory approach. Theory testing typically involves
pattern matching (Yin, 2014). This is based on the comparison of predicted outcomes with observed data.
Qualitative data analysis is usually highly iterative. Visual displays of qualitative data using matrices
(classifications of data using two or more dimensions) may be used to discover connections between the
coded segments (Crabtree & Miller, 1999; Miles et al., 2014). Data analysis may be undertaken within a
case and also between cases in multiple case study research (Eisenhardt, 1989). Quantitative data is
typically presented in descriptive, tabular form and used to highlight characteristics of case study
organizations and interviewees. 
Evaluating Clinical Interventions and Treatments
Central to clinical psychology is the question of the effectiveness of specific clinical interventions as well
as complete psychological treatments (e.g., cognitive behavioral treatments, psychodynamic treatments).
The first step in the process of evaluating psychological interventions and treatments is an appropriate
definition of the program or intervention, and the identification of criteria that differentiate success from
failure. In psychotherapy research, for example, it is agreed that assessments of outcomes should not be
limited to a single dimension (e.g., depressive symptoms), even if the focus of the study is a specific
disorder (e.g., depression). While symptoms should be one of the primary outcomes, most studies collect
data along multiple dimensions (e.g., work/social adjustment, interpersonal problems etc.), and include
different perspectives (e.g., patient ratings, therapist ratings, third‐party ratings). While
psychophysiological and neurocognitive procedures have recently emerged as a new way of measuring
change, questionnaires are still the predominant method of choice (e.g., Ogles, 2013).
Analysis and Interpretation of Data
After psychologists develop a theory, form a hypothesis, make observations, and collect data, they end
up with a lot of information, usually in the form of numerical data. The term Statistics refers to the
analysis and interpretation of this numerical data. Psychologists use statistics to organize, summarize,
and interpret the information they collect.
Descriptive Statistics
To organize and summarize their data, researchers need numbers to describe what happened. These
numbers are called Descriptive Statistics. Researchers may use Histograms or Bar Graphs to show the
way data are distributed. Presenting data this way makes it easy to compare results, see trends in data,
and evaluate results quickly.

Process of Clinical Judgment

As a process, psychological assessment involves progressive decision making marked by a series of
operations (Ridley, Li, & Hill, 1998). We regard three operations, which we call subprocesses, as
prominent in clinical judgment. Here we draw from the work of Agnew and Pyke (2007). They asserted
the importance of reliable observations, critical thinking, and rigorous testing. Reliable observations
pertain to the process of gathering data. Regardless of their therapeutic orientations or clients’ problem
presentations, independent clinicians following the same observational process should gather the same
data about clients. Critical thinking pertains to the process of analyzing the data to reach tentative
conclusions. Clinicians attempt to identify patterns through the observations and make predictions about
clients’ future behavior. Rigorous testing pertains to the process of evaluating our conclusions. Clinicians
challenge their conclusions, ruling out the possibility of alternative explanations of the psychological
presentation.

In the work of novice clinicians, the absence of the adjectives reliable, critical, and rigorous—modifying
the subprocesses of clinical judgment— probably differentiates them from expert clinicians, whose
clinical judgments are more accurate. Clearly, novice clinicians make observations, think about the data
they gather, and test their conclusions. Their approach is what Agnew and Pyke (2007) termed common
sense versus scientific problem solving. We speculate that the clinical judgment of many clinicians
essentially is based on common sense rather than science. They make minimal or inconsistent efforts to
ensure that their (a) observations are reliable, (b) thinking is critical, and (c) testing is rigorous. However,
because of their clinical training and experience, they may incorporate some accoutrements of science or
inconsistently incorporate a scientific approach in rendering their clinical judgments. At best, their
strategy is pseudoscience, seldom, if ever, reaching the level of authentic scientific problem solving.
Therefore, we propose that pseudoscientific strategies emanating from the lack of a comprehensive
metatheory of clinical judgment may explain the marginal improvement in clinicians’ clinical judgment
accuracy.

Sources of Errors in Clinical Judgment

Intellectual Factors
 Overconfidence in oneself
 Finite capacity of the human brain
 Random chance and self-limited disease
Lack of Checking for Errors
 Reluctance to change initial opinions
 Unquestioning self-approval
 Unawareness of subtle failures

Environmental Factors
 Impracticality of looking for mistakes
 Propagation of Errors made by others
 Unawareness of limits of Judgment