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A GUIDE TO ASSESSMENTS THAT WORK
A GUIDE TO ASSESSMENTS
THAT WORK

S e c o n d E di t i o n

EDITED BY

John Hunsley and Eric J. Mash

1
 1
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 Contents

Foreword to the First Edition Part II Attention-​Deficit and Disruptive

by Peter E. Nathan vii Behavior Disorders

Preface xi 4. Attention-​Deficit/​Hyperactivity Disorder 47

CHARLOTTE JOHNSTON
About the Editors xv SARA COLALILLO

Contributors xvii 5. Child and Adolescent Conduct Problems 71

PAUL J. FRICK
Part I Introduction ROBERT J. McMAHON

1. Developing Criteria for Evidence-​Based Part III Mood Disorders and Self-​Injury
Assessment: An Introduction to Assessments
That Work 3 6. Depression in Children and Adolescents 99
JOHN HUNSLEY LEA R. DOUGHERTY
ERIC J. MASH DANIEL N. KLEIN
THOMAS M. OLINO
2. Dissemination and Implementation of
Evidence-​Based Assessment 17 7. Adult Depression 131
AMANDA JENSEN-​DOSS JACQUELINE B. PERSONS
LUCIA M. WALSH DAVID M. FRESCO
VANESA MORA RINGLE JULIET SMALL ERNST

3. Advances in Evidence-​Based Assessment: 8. Depression in Late Life 152

AMY FISKE
Using Assessment to Improve Clinical ALISA O’RILEY HANNUM
Interventions and Outcomes 32
ERIC A. YOUNGSTROM
ANNA VAN METER 9. Bipolar Disorder 173
SHERI L. JOHNSON
CHRISTOPHER MILLER
LORI EISNER
vi Contents

10. Self-​Injurious Thoughts and Behaviors 193 Part VI Schizophrenia and Personality
ALEXANDER J. MILLNER Disorders
MATTHEW K. NOCK
20. Schizophrenia 435
Part IV Anxiety and Related Disorders SHIRLEY M. GLYNN
KIM T. MUESER
11. Anxiety Disorders in Children and
Adolescents 217 21. Personality Disorders 464
SIMON P. BYRNE STEPHANIE L. ROJAS
ELI R. LEBOWITZ THOMAS A. WIDIGER
THOMAS H. OLLENDICK
WENDY K. SILVERMAN Part VII Couple Distress and Sexual
Disorders
12. Specific Phobia and Social Anxiety
Disorder 242 22. Couple Distress 489
KAREN ROWA DOUGLAS K. SNYDER
RANDI E. MCCABE RICHARD E. HEYMAN
MARTIN M. ANTONY STEPHEN N. HAYNES
CHRISTINA BALDERRAMA-​DURBIN
13. Panic Disorder and Agoraphobia 266
AMY R. SEWART 23. Sexual Dysfunction 515
MICHELLE G. CRASKE NATALIE O. ROSEN
MARIA GLOWACKA
14. Generalized Anxiety Disorder 293 MARTA MEANA
MICHEL J. DUGAS YITZCHAK M. BINIK
CATHERINE A. CHARETTE
NICOLE J. GERVAIS Part VIII Health-​Related Problems

15. Obsessive–​Compulsive Disorder 311 24. Eating Disorders 541

SHANNON M. BLAKEY ROBYN SYSKO
JONATHAN S. ABRAMOWITZ SARA ALAVI

16. Post-​Traumatic Stress Disorder in Adults 329 25. Insomnia Disorder 563
SAMANTHA J. MOSHIER CHARLES M. MORIN
KELLY S. PARKER-​GUILBERT SIMON BEAULIEU-​BONNEAU
BRIAN P. MARX KRISTIN MAICH
TERENCE M. KEANE COLLEEN E. CARNEY

Part V Substance-​Related and Gambling 26. Child and Adolescent Pain 583
Disorders C. MEGHAN McMURTRY
PATRICK J. McGRATH
17. Substance Use Disorders 359
DAMARIS J. ROHSENOW 27. Chronic Pain in Adults 608
THOMAS HADJISTAVROPOULOS
18. Alcohol Use Disorder 381 NATASHA L. GALLANT
ANGELA M. HAENY MICHELLE M. GAGNON
CASSANDRA L. BONESS
YOANNA E. McDOWELL Assessment Instrument Index 629
KENNETH J. SHER
Author Index 639
19. Gambling Disorders 412 Subject Index 721
DAVID C. HODGINS
JENNIFER L. SWAN
RANDY STINCHFIELD
 Foreword to the First Edition
I believe A Guide to Assessments that Work is the right
book at the right time by the right editors and authors.
The mental health professions have been intensively
engaged for a decade and a half and more in establish-
ing empirically supported treatments. This effort has led
to the publication of evidence-​based treatment guidelines
by both the principal mental health professions, clinical
psychology (Chambless & Ollendick, 2001; Division 12
Task Force, 1995), and psychiatry (American Psychiatric
Association, 1993, 2006). A substantial number of books
and articles on evidence-​ based treatments have also
appeared. Notable among them is a series by Oxford
University Press, the publishers of A Guide to Assessments
that Work, which began with the first edition of A Guide
to Treatments that Work (Nathan & Gorman, 1998), now
in its third edition, and the series includes Psychotherapy
Relationships that Work (Norcross, 2002) and Principles
of Therapeutic Change that Work (Castonguay &
Beutler, 2006).
Now we have an entire volume given over to evidence-​
based assessment. It doesn’t appear de novo. Over the
past several years, its editors and like-​minded colleagues
tested and evaluated an extensive series of guidelines for
evidence-​based assessments for both adults and children
(e.g., Hunsley & Mash, 2005; Mash & Hunsley, 2005).
Many of this book’s chapter authors participated in these
efforts. It might well be said, then, that John Hunsley, Eric
Mash, and the chapter authors in A Guide to Assessments
that Work are the right editors and authors for this, the first
book to detail the assessment evidence base.
There is also much to admire within the pages of the
volume. Each chapter follows a common format pre-
scribed by the editors and designed, as they point out,
“to enhance the accessibility of the material presented
throughout the book.” First, the chapters are syndrome-​
focused, making it easy for clinicians who want help in
assessing their patients to refer to the appropriate chapter
or chapters. When they do so, they will find reviews of the
assessment literature for three distinct purposes: diagno-
sis, treatment planning, and treatment monitoring. Each
of these reviews is subjected to a rigorous rating system
that culminates in an overall evaluation of “the scientific
adequacy and clinical relevance of currently available
measures.” The chapters conclude with an overall assess-
ment of the limits of the assessments available for the syn-
drome in question, along with suggestions for future steps
to confront them. I believe it can well be said, then, that
this is the right book by the right editors and authors.
But is this the right time for this book? Evidence-​based
treatments have been a focus of intense professional atten-
tion for many years. Why wouldn’t the right time for this
book have been several years ago rather than now, to
coincide with the development of empirically supported
treatments? The answer, I think, reflects the surprisingly
brief history of the evidence-​based medical practice move-
ment. Despite lengthy concern for the efficacy of treat-
ments for mental disorders that dates back more than
50 years (e.g., Eysenck, 1952; Lambert & Bergin, 1994;
Luborsky, Singer, & Luborsky, 1976; Nathan, Stuart, &
Dolan, 2000), it took the appearance of a Journal of the
viii Foreword to the First Edition
American Mental Association article in the early 1990s
advocating evidence-​based medical practice over medi-
cine as an art to mobilize mental health professionals to
achieve the same goals for treatments for mental disor-
ders. The JAMA article “ignited a debate about power,
ethics, and responsibility in medicine that is now threat-
ening to radically change the experience of health care”
(Patterson, 2002). This effort resonated widely within the
mental health community, giving impetus to the efforts of
psychologists and psychiatrists to base treatment decisions
on valid empirical data.
Psychologists had long questioned the uncertain reli-
ability and utility of certain psychological tests, even
though psychological testing was what many psychologists
spent much of their time doing. At the same time, the
urgency of efforts to heighten the support base for valid
assessments was limited by continuing concerns over the
efficacy of psychotherapy, for which many assessments
were done. Not surprisingly, then, when empirical sup-
port for psychological treatments began to emerge in the
early and middle 1990s, professional and public support
for psychological intervention grew. In turn, as psycho-
therapy’s worth became more widely recognized, the
value of psychological assessments to help in the plan-
ning and evaluation of psychotherapy became increas-
ingly recognized. If my view of this history is on target, the
intense efforts that have culminated in this book could
not have begun until psychotherapy’s evidence base had
been established. That has happened only recently, after a
lengthy process, and that is why I claim that the right time
for this book is now.
Who will use this book? I hope it will become a favor-
ite text for graduate courses in assessment so that new
generations of graduate students and their teachers will
come to know which of the assessment procedures they
are learning and teaching have strong empirical support.
I also hope the book will become a resource for practitio-
ners, including those who may not be used to choosing
assessment instruments on the basis of evidence base. To
the extent that this book becomes as influential in clinical
psychology as I hope it does, it should help precipitate a
change in assessment test use patterns, with an increase in
the utilization of tests with strong empirical support and a
corresponding decrease in the use of tests without it. Even
now, there are clinicians who use assessment instruments
because they learned them in graduate school, rather than
because there is strong evidence that they work. Now, a
different and better standard is available.
I am pleased the editors of this book foresee it provid-
ing an impetus for research on assessment instruments
that currently lack empirical support. I agree. As with
a number of psychotherapy approaches, there remain a
number of understudied assessment instruments whose
evidence base is currently too thin for them to be con-
sidered empirically supported. Like the editors, I believe
we can anticipate enhanced efforts to establish the limits
of usefulness of assessment instruments that haven’t yet
been thoroughly explored. I also anticipate a good deal
of fruitful discussion in the professional literature—​and
likely additional research—​on the positions this book’s
editors and authors have taken on the assessment instru-
ments they have evaluated. I suspect their ratings for
“psychometric adequacy and clinical relevance” will be
extensively critiqued and scrutinized. While the resul-
tant dialogue might be energetic—​even indecorous on
occasion—​as has been the dialogue surrounding the evi-
dence base for some psychotherapies, I am hopeful it will
also lead to more helpful evaluations of test instruments.
Perhaps the most important empirical studies we might
ultimately anticipate would be research indicating which
assessment instruments lead both to valid diagnoses and
useful treatment planning for specific syndromes. A dis-
tant goal of syndromal diagnosis for psychopathology has
always been diagnoses that bespeak effective treatments. If
the system proposed in this volume leads to that desirable
outcome, we could all celebrate.
I congratulate John Hunsley and Eric Mash and their
colleagues for letting us have this eagerly anticipated
volume.
Peter E. Nathan
(1935–2016)
References
American Psychiatric Association. (1993). Practice guidelines
for the treatment of major depressive disorder in adults.
American Journal of Psychiatry, 150 (4 Supplement),
1–​26.
American Psychiatric Association. (2006). Practice guidelines
for the treatment of psychiatric disorders: Compendium,
2006. Washington, DC: Author.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of thera-
peutic change that work. New York: Oxford University
Press.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically
supported psychological interventions: Controversies
and evidence. In S. T. Fiske, D. L. Schacter, & C.
Zahn-​Waxler (Eds.), Annual review of psychology
(Vol. 52, pp. 685–​716). Palo Alto, CA: Annual Review.
Division 12 Task Force. (1995). Training in and dissemina-
tion of empirically-​validated psychological treatments:

Report and recommendations. The Clinical Psychologist,
48, 3–​23.
Eysenck, H. J. (1952). The effects of psychotherapy: An eval-
uation. Journal of Consulting Psychology, 16, 319–​324.
Hunsley, J., & Mash, E. J. (Eds.). (2005). Developing guide-
lines for the evidence-​based assessment (EBA) of adult dis-
orders (special section). Psychological Assessment, 17(3).
Lambert, M. J., & Bergin, A. E. (1994). The effectiveness
of psychotherapy. In S. L. Garfield & A. E. Bergin
(Eds.), Handbook of psychotherapy and behavior change
(4th ed., pp. 143–​189). New York: Wiley.
Luborsky, L., Singer, B., & Luborsky, L. (1976). Comparative
studies of psychotherapies: Is it true that “everybody has won
and all must have prizes?” In R. L. Spitzer & D. F. Klein
(Eds.), Evaluation of psychological therapies (pp. 3–​22).
Baltimore, MD: Johns Hopkins University Press.
Foreword to the First Edition ix
Mash, E. J., & Hunsley, J. (Eds.). (2005). Developing
guidelines for the evidence-​based assessment of child
and adolescent disorders (special section). Journal of
Clinical Child and Adolescent Psychology, 34(3).
Nathan, P. E., & Gorman, J. M. (1998, 2002, 2007). A guide
to treatments that work. New York: Oxford University
Press.
Nathan, P. E., Stuart, S. P., & Dolan, S. L. (2000). Research
on psychotherapy efficacy and effectiveness: Between
Scylla and Charybdis? Psychological Bulletin, 126,
964–​981.
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships
that work: Therapist contributions and responsiveness to
patients. New York: Oxford University Press.
Patterson, K. (2002). What doctors don’t know (almost every-
thing). New York Times Magazine, May 5, 74–​77.
 Preface
BACKGROUND
Evidence-​based practice principles in health care systems
emphasize the importance of integrating information
drawn from systematically collected data, clinical exper-
tise, and patient preferences when considering health
care service options for patients (Institute of Medicine,
2001; Sackett, Rosenberg, Gray, Haynes, & Richardson,
1996). These principles are a driving force in most health
care systems and have been endorsed as a necessary foun-
dation for the provision of professional psychological ser-
vices (American Psychological Association Presidential
Task Force on Evidence-​Based Practice, 2006; Dozois
et al., 2014). As psychologists, it is difficult for us to imag-
ine how any type of health care service, including psycho-
logical services, can be provided to children, adolescents,
adults, couples, or families without using some type of
informal or formal assessment methods. Nevertheless,
until relatively recently, there was an almost exclusive
focus on issues related to developing, disseminating, and
providing evidence-​based interventions, with only cursory
acknowledgment of the role that evidence-​based assess-
ment (EBA) activities play in the promotion of evidence-​
based services.
Fortunately, much has changed with respect to EBA
since the publication of the first edition of this volume in
2008. A growing number of publications are now available
in the scientific literature that address the importance of
solid assessment instruments and methods. Special sec-
tions on EBA have been published in recent issues of top
clinical psychology journals (e.g., Arbisi & Beck, 2016;
Jensen-​Doss, 2015). The evidence base for the value of
monitoring treatment progress has increased substantially,
as have calls for the assessment of treatment progress to
become standard practice (e.g., Lambert, 2017). There
is also mounting evidence for assessment as a key com-
ponent for engaging clients in effective mental health
services (Becker, Boustani, Gellatly, & Chorpita, 2017).
Unfortunately, some long-​ standing problems evident
in the realm of psychological assessment remain. Many
researchers continue to ignore the importance of evaluat-
ing the reliability of the assessment data obtained from
their study participants (e.g., Vacha-​Haase & Thompson,
2011). Despite the demonstrated impact of treatment
monitoring, relatively few clinicians systematically and
routinely assess the treatment progress of their clients
(Ionita & Fitzpatrick, 2014), although it appears that stu-
dents in professional psychology programs are receiving
more training in these assessment procedures than was the
case in the past (e.g., Overington, Fitzpatrick, Hunsley,
& Drapeau, 2015). All in all, though, when viewed from
the vantage point of the early years of the 21st century, it
does seem that steady progress is being made with respect
to EBA.
As was the case with the first edition, the present vol-
ume was designed to complement the books published
by Oxford University Press that focus on bringing the best
of psychological science to bear on questions of clini-
cal importance. These volumes, A Guide to Treatments
that Work (Nathan & Gorman, 2015) and Psychotherapy
xii Preface

Relationships that Work (Norcross, 2011), address inter- to (a) understanding the patient’s or client’s needs and
vention issues; the present volume specifically addresses (b) accessing the scientific literature on evidence-​based
the role of assessment in providing evidence-​based ser- treatment options. We also recognize that many patients
vices. Our primary goal for the book was to have it address or clients will present with multiple problems; to that end,
the needs of professionals providing psychological services the reader will find frequent references within a chapter
and those training to provide such services. A secondary to the assessment of common co-​occurring problems that
goal was to provide guidance to researchers on scientifi- are addressed in other chapters in the volume. To be opti-
cally supported assessment tools that could be used for mally useful to potential readers, we have included chap-
both psychopathology research and treatment research ters that deal with the assessment of the most commonly
purposes. Relatedly, we hope that the summary tables pro- encountered disorders or conditions among children,
vided in each chapter will provide some inspiration for adolescents, adults, older adults, and couples.
assessment researchers to try to (a) develop instruments Ideally, we want readers to come away from each chap-
for specific assessment purposes and disorders for which, ter with a sense of the best scientific assessment options
currently, few good options exist and (b) expand our lim- that are clinically feasible and useful. To help accomplish
ited knowledge base on the clinical utility of our assess- this, we were extremely fortunate to be able to assemble a
ment instruments. stellar group of contributors for this volume. The authors
are all active contributors to the scientific literature on
assessment and share a commitment to the provision of
ORGANIZATION EBA and treatment services.
To enhance the accessibility of the material presented
All chapters and tables in the second edition have been throughout the book, we asked the authors, as much as pos-
revised and updated by our expert authors to reflect recent sible, to follow a common structure in writing their chap-
developments in the field, including the publication of ters. Without being a straitjacket, we expected the authors
the fifth edition of the Diagnostic and Statistical Manual to use these guidelines in a flexible manner that allowed for
of Mental Disorders (DSM-​ 5; American Psychiatric the best possible presentation of assessment work relevant
Association, 2013). For the most part, the general cover- to each disorder or clinical condition. The chapter format
age and organization of the first edition, which our read- generally used throughout the volume is as follows:
ers found useful, has been retained in the second edition. Introduction: A brief overview of the chapter content.
Consistent with a growing developmental psychopathol- Nature of the Disorder/​ Condition: This section
ogy perspective in the field, the scope of some chapters includes information on (a) general diagnostic consid-
has expanded in order to provide more coverage of assess- erations, such as prevalence, incidence, prognosis, and
ment issues across the lifespan (e.g., attention-​ deficit/​ common comorbid conditions; (b) evidence on etiology;
hyperactivity disorder in adults). The most important and (c) contextual information such as relational and
changes in organization involve the addition of two new social functioning and other associated features.
chapters, one dealing with the dissemination and imple- Purposes of Assessment: To make the book as clinically
mentation of EBA (Chapter 2) and the other dealing with relevant as possible, authors were asked to focus their
new developments in EBA (Chapter 3). The contents of review of the assessment literature to three specific assess-
these chapters highlight both the important contributions ment purposes: (a) diagnosis, (b) case conceptualization
that assessment can make to the provision of psychological and treatment planning, and (c) treatment monitoring
services and the challenges that mental health profession- and evaluation. We fully realize the clinical and research
als face in implementing cost-​effective and scientifically importance of other assessment purposes but, rather than
sound assessment strategies. attempting to provide a compendium of assessment mea-
Consistent with evidence-​ based psychology and sures and strategies, we wanted authors to target these
evidence-​based medicine, the majority of the chapters three key clinical assessment purposes. We also asked
in this volume are organized around specific disorders authors to consider ways in which age, gender, ethnicity,
or conditions. Although we recognize that some clients and other relevant characteristics may influence both the
do not have clearly defined or diagnosable problems, the assessment measures and the process of assessment for the
vast majority of people seeking psychological services disorder/​condition.
do have identifiable diagnoses or conditions. Accurately For each of the three main sections devoted to spe-
assessing these disorders and conditions is a prerequisite cific assessment purposes, authors were asked to focus on

assessment measures and strategies that either have demon-
strated their utility in clinical settings or have a substantial
likelihood of being clinically useful. Authors were encour-
aged to consider the full range of relevant assessment meth-
ods (interviews, self-​report, observation, performance tasks,
computer-​based methods, physiological, etc.), but both sci-
entific evidence and clinical feasibility were to be used to
guide decisions about methods to include.
Assessment for Diagnosis: This section deals with
assessment measures and strategies used specifically for
formulating a diagnosis. Authors were asked to focus
on best practices and were encouraged to comment on
important conceptual and practical issues in diagnosis
and differential diagnosis.
Assessment for Case Conceptualization and Treatment
Planning: This section presents assessment measures
and strategies used to augment diagnostic information
to yield a full psychological case conceptualization that
can be used to guide decisions on treatment planning.
Specifically, this section addresses the domains that the
research literature indicates should be covered in an EBA
to develop (a) a clinically meaningful and useful case con-
ceptualization and (b) a clinically sensitive and feasible
service/​treatment plan (which may or may not include
the involvement of other professionals).
Assessment for Treatment Monitoring and Treatment
Outcome: In this third section, assessment measures and
strategies were reviewed that can be used to (a) track the
progress of treatment and (b) evaluate the overall effect of
treatment on symptoms, diagnosis, and general function-
ing. Consistent with the underlying thrust of the volume,
the emphasis is on assessment options that have support-
ing empirical evidence.
Within each of the three assessment sections, standard
tables are used to provide summary information about
the psychometric characteristics of relevant instruments.
Rather than provide extensive psychometric details in
the text, authors were asked to use these rating tables to
convey information on the psychometric adequacy of
instruments. To enhance the utility of these tables, rather
than presenting lists of specific psychometric values for
each assessment tool, authors were asked to make global
ratings of the quality of the various psychometric indices
(e.g., norms, internal reliability, and construct validity)
as indicated by extant research. Details on the rating sys-
tem used by the authors are presented in the introductory
chapter. Our goal is to have these tables serve as valuable
summaries for readers. In addition, by using the tables to
present psychometric information, the authors were able
to focus their chapters on both conceptual and practical
Preface xiii
issues without having to make frequent detours to discuss
psychometrics.
At the conclusion of each of these three main sec-
tions there is a subsection titled Overall Evaluation that
includes concise summary statements about the scientific
adequacy and clinical relevance of currently available
measures. This is where authors comment on the avail-
ability (if any) of demonstrated scientific value of follow-
ing the assessment guidance they have provided.
Conclusions and Future Directions: This final section
in each chapter provides an overall sense of the scope
and adequacy of the assessment options available for the
disorder/​condition, the limitations associated with these
options, and possible future steps that could be taken to
remedy these limitations. Some authors also used this sec-
tion to raise issues related to the challenges involved in
trying to ensure that clinical decision-​making processes
underlying the assessment process (and not just the assess-
ment measures themselves) are scientifically sound.
ACKNOWLEDGMENTS
To begin with, we express our gratitude to the authors. They
diligently reviewed and summarized often-​ voluminous
assessment literatures and then presented this informa-
tion in a clinically informed and accessible manner. The
authors also worked hard to implement the guidelines we
provided for both chapter structure and the ratings of vari-
ous psychometric characteristics. Their efforts in construct-
ing their chapters are admirable, and the resulting chapters
consistently provide invaluable clinical guidance.
We also thank Sarah Harrington, Senior Editor for clini-
cal psychology at Oxford University Press, for her continued
interest in the topic and her ongoing support for the book.
We greatly appreciate her enthusiasm and her efficiency
throughout the process of developing and producing this
second edition. We are also indebted to Andrea Zekus,
Editor at Oxford University Press, who helped us with the
process of assembling the book from start to finish. Her assis-
tance with the myriad issues associated with the publication
process and her rapid response to queries was invaluable.
Finally, we thank all the colleagues and contributors
to the psychological assessment and measurement litera-
tures who, over the years, have shaped our thinking about
assessment issues. We are especially appreciative of the
input from those colleagues who have discussed with us
the host of problems, concerns, challenges, and promises
associated with efforts to promote greater awareness of the
need for EBA within professional psychology.
xiv Preface

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 About the Editors
John Hunsley, PhD, is Professor of Psychology in the
School of Psychology at the University of Ottawa and
is a Fellow of the Association of State and Provincial
Psychology Boards and the Canadian Psychological
Association. He has served as a journal editor, an edito-
rial board member for several journals, and an editorial
consultant for many journals in psychology. He has pub-
lished more than 130 articles, chapters, and books related
to evidence-​based psychological practice, psychological
assessment, and professional issues.
Eric J. Mash, PhD, is Professor Emeritus in the
Department of Psychology at the University of Calgary. He
is a Fellow of the American Psychological Association, the
Canadian Psychological Association, and the American
Psychological Society. He has served as an editor, edito-
rial board member, and consultant for many scientific
and professional journals and has written and edited many
books and journal articles related to child and adolescent
mental health, assessment, and treatment.
 Contributors
Jonathan S. Abramowitz, PhD: Department of
Psychology and Neuroscience, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina
Sara Alavi: Eating and Weight Disorders Program, Icahn
School of Medicine at Mt. Sinai, New York, New York
Martin M. Antony, PhD: Department of Psychology,
Ryerson University, Toronto, Ontario, Canada
Christina Balderrama-​Durbin, PhD: Department of
Psychology, Binghamton University—State University of
New York, Binghamton, New York
Simon Beaulieu-​Bonneau, PhD: École de psychologie,
Université Laval, Quebec City, Quebec, Canada
Yitzchak M. Binik, PhD: Department of Psychology,
McGill University, Montreal, Quebec, Canada
Shannon M. Blakey, MS: Department of Psychology and
Neuroscience, University of North Carolina at Chapel
Hill, Chapel Hill, North Carolina
Cassandra L. Boness, MA: Department of Psychological
Sciences, University of Missouri, Columbia, Missouri
Simon P. Byrne, PhD: Yale Child Study Center, Yale
School of Medicine, New Haven, Connecticut
Colleen E. Carney, PhD: Department of Psychology,
Ryerson University, Toronto, Ontario, Canada
Catherine A. Charette: Département de psychoé-
ducation et de psychologie, Université du Québec en
Outaouais, Gatineau, Quebec, Canada
Sara Colalillo, MA: Department of Psychology,
University of British Columbia, Vancouver, British
Columbia, Canada
Michelle G. Craske, PhD: Department of Psychology,
University of California at Los Angeles, Los Angeles,
California
Lea R. Dougherty, PhD: Department of Psychology,
University of Maryland, College Park, Maryland
Michel J. Dugas, PhD: Département de psychoéducation
et de psychologie, Université du Québec en Outaouais,
Gatineau, Québec, Canada
Lori Eisner, PhD: Needham Psychotherapy Associates,
LLC
xviii Contributors
Juliet Small Ernst: Cognitive Behavior Therapy and
Science Center, Oakland, California
Amy Fiske, PhD: Department of Psychology, West
Virginia University, Morgantown, West Virginia
David M. Fresco, PhD: Department of Psychological
Sciences, Kent State University, Kent, Ohio; Department
of Psychiatry, Case Western Reserve University School of
Medicine, Cleveland, Ohio
Paul J. Frick, PhD: Department of Psychology, Louisiana
State University, Baton Rouge, Louisiana; Learning
Sciences Institute of Australia; Australian Catholic
University; Brisbane, Australia
Michelle M. Gagnon, PhD: Department of
Psychology, University of Saskatchewan, Saskatoon,
Saskatchewan, Canada
Natasha L. Gallant, MA: Department of Psychology,
University of Regina, Regina, Saskatchewan, Canada
Nicole J. Gervais, PhD: Department of Psychology,
University of Toronto, Toronto, Ontario, Canada
Maria Glowacka: Department of Psychology and
Neuroscience, Dalhousie University, Halifax, Nova
Scotia, Canada
Shirley M. Glynn, PhD: VA Greater Los Angeles
Healthcare System and UCLA Department of Psychiatry
and Biobehavioral Sciences, David Geffen School of
Medicine, Los Angeles, California
Thomas Hadjistavropoulos, PhD: Department of
Psychology, University of Regina, Regina, Saskatchewan,
Canada
Angela M. Haeny, MA: Department of Psychological
Sciences, University of Missouri, Columbia, Missouri
Alisa O’Riley Hannum, PhD, ABPP: VA Eastern
Colorado Healthcare System, Denver, Colorado
Stephen N. Haynes, PhD: Department of Psychology,
University of Hawai’i at Mānoa, Honolulu, Hawaii
Richard E. Heyman, PhD: Family Translational Research
Group, New York University, New York, New York
David C. Hodgins, PhD: Department of Psychology,
University of Calgary, Calgary, Alberta, Canada
John Hunsley, PhD: School of Psychology, University of
Ottawa, Ottawa, Ontario, Canada
Amanda Jensen-​Doss, PhD: Department of Psychology,
University of Miami, Coral Gables, Florida
Sheri L. Johnson, PhD: Department of Psychology,
University of California Berkeley, Berkeley, California
Charlotte Johnston, PhD: Department of Psychology,
University of British Columbia, Vancouver, British
Columbia, Canada
Terence M. Keane, PhD: VA Boston Healthcare System,
National Center for Posttraumatic Stress Disorder, and
Boston University School of Medicine, Boston, Massachusetts
Daniel N. Klein, PhD: Department of Psychology, Stony
Brook University, Stony Brook, New York
Eli R. Lebowitz, PhD: Yale Child Study Center, Yale
School of Medicine, New Haven, Connecticut
Kristin Maich, MA: Department of Psychology, Ryerson
University, Toronto, Ontario, Canada
Brian P. Marx, PhD: VA Boston Healthcare System,
National Center for Posttraumatic Stress Disorder,
and Boston University School of Medicine, Boston,
Massachusetts
Eric J. Mash, PhD: Department of Psychology, University
of Calgary, Calgary, Alberta, Canada
Randi E. McCabe, PhD: Anxiety Treatment and
Research Clinic, St. Joseph’s Healthcare, Hamilton, and
Department of Psychiatry and Behavioral Neurosciences,
McMaster University, Hamilton, Ontario, Canada
Yoanna E. McDowell, MA: Department of Psychological
Sciences, University of Missouri, Columbia, Missouri

Patrick J. McGrath, PhD: Centre for Pediatric
Pain Research, IWK Health Centre; Departments
of Psychiatry, Pediatrics and Community Health &
Epidemiology, Dalhousie University; Halifax, Nova
Scotia, Canada
Robert J. McMahon, PhD: Department of
Psychology, Simon Fraser University, Burnaby, British
Columbia, Canada; BC Children’s Hospital Research
Institute, Vancouver, British Columbia, Canada
C. Meghan McMurtry, PhD: Department of Psychology,
University of Guelph, Guelph; Pediatric Chronic Pain
Program, McMaster Children’s Hospital, Hamilton;
Department of Paediatrics, Schulich School of Medicine
& Dentistry, Western University, London; Ontario,
Canada
Marta Meana, PhD: Department of Psychology,
University of Nevada Las Vegas, Las Vegas, Nevada
Christopher Miller, PhD: VA Boston Healthcare System,
Center for Healthcare Organization and Implementation
Research, and Harvard Medical School Department of
Psychiatry, Boston, Massachusetts
Alexander J. Millner, PhD: Department of Psychology,
Harvard University, Cambridge, Massachusetts
Charles M. Morin, PhD: École de psychologie,
Université Laval, Quebec City, Quebec, Canada
Samantha J. Moshier, PhD: VA Boston Healthcare
System and Boston University School of Medicine,
Boston, Massachusetts
Kim T. Mueser, PhD: Center for Psychiatric
Rehabilitation and Departments of Occupational
Therapy, Psychological and Brain Sciences, and
Psychiatry, Boston University, Boston, Massachusetts
Matthew K. Nock, PhD: Department of Psychology,
Harvard University, Cambridge, Massachusetts
Thomas M. Olino, PhD: Department of Psychology,
Temple University, Philadelphia, Pennsylvania
Contributors xix
Thomas H. Ollendick, PhD: Department of Psychology,
Virginia Polytechnic Institute and State University,
Blacksburg, Virginia
Kelly S. Parker-​Guilbert, PhD: Psychology Department,
Bowdoin College, Brunswick, ME and VA Boston
Healthcare System, Boston, Massachusetts
Jacqueline B. Persons, PhD: Cognitive Behavior
Therapy and Science Center, Oakland, California and
Department of Psychology, University of California
at Berkeley, Berkeley, California
Vanesa Mora Ringle: Department of Psychology,
University of Miami, Coral Gables, Florida
Damaris J. Rohsenow, PhD: Center for Alcohol and
Addiction Studies, Brown University, Providence, Rhode
Island
Stephanie L. Rojas, MA: Department of Psychology,
University of Kentucky, Lexington, Kentucky
Natalie O. Rosen, PhD: Department of Psychology and
Neuroscience, Dalhousie University, Halifax, Nova Scotia,
Canada
Karen Rowa, PhD: Anxiety Treatment and Research
Clinic, St. Joseph’s Healthcare, Hamilton, and
Department of Psychiatry and Behavioral Neurosciences,
McMaster University, Hamilton, Ontario, Canada
Amy R. Sewart, MA: Department of Psychology, University
of California Los Angeles, Los Angeles, California
Kenneth J. Sher, PhD: Department of Psychological
Sciences, University of Missouri, Columbia, Missouri
Wendy K. Silverman, PhD: Yale Child Study Center,
Yale School of Medicine, New Haven, Connecticut
Douglas K. Snyder, PhD: Department of Psychology,
Texas A&M University, College Station, Texas
Randy Stinchfield, PhD: Department of Psychiatry,
University of Minnesota, Minneapolis, Minnesota
xx Contributors
Jennifer L. Swan: Department of Psychology, University
of Calgary, Calgary, Alberta, Canada
Robyn Sysko, PhD: Eating and Weight Disorders
Program, Icahn School of Medicine at Mt. Sinai,
New York, New York
Anna Van Meter, PhD: Ferkauf Graduate School of
Psychology, Yeshiva University, New York, New York
Lucia M. Walsh: Department of Psychology, University
of Miami, Coral Gables, Florida
Thomas A. Widiger, PhD: Department of Psychology,
University of Kentucky, Lexington, Kentucky
Eric A. Youngstrom, PhD: Department of Psychology
and Neuroscience, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina
 Part I

Introduction
 1
Developing Criteria for
Evidence-​Based Assessment:
An Introduction to Assessments That Work
John Hunsley
Eric J. Mash
For many professional psychologists, assessment is
viewed as a unique and defining feature of their expertise
(Krishnamurthy et al., 2004). Historically, careful atten-
tion to both conceptual and pragmatic issues related to
measurement has served as the cornerstone of psychologi-
cal science. Within the realm of professional psychology,
the ability to provide assessment and evaluation services
is typically seen as a required core competency. Indeed,
assessment services are such an integral component of
psychological practice that their value is rarely questioned
but, rather, is typically assumed. However, solid evidence
to support the usefulness of psychological assessment is
lacking, and many commonly used clinical assessment
methods and instruments are not supported by scientific
evidence (e.g., Hunsley, Lee, Wood, & Taylor, 2015;
Hunsley & Mash, 2007; Norcross, Koocher, & Garofalo,
2006). Indeed, Peterson’s (2004) conclusion from more
than a decade ago is, unfortunately, still frequently
true: “For many of the most important inferences profes-
sional psychologists have to make, practitioners appear
to be forever dependent on incorrigibly fallible inter-
views and unavoidably selective, reactive observations as
primary sources of data” (p. 202). Furthermore, despite
the current emphasis on evidence-​based practice, profes-
sional psychologists report that the least common purpose
for which they use assessment is to monitor treatment
progress (Wright et al., 2017).
In this era of evidence-​based health care practices,
the need for scientifically sound assessment methods
and instruments is greater than ever (Barlow, 2005).
Assessment is the key to the accurate identification of
3
clients’ problems and strengths. Whether construed as
individual client monitoring, ongoing quality assurance
efforts, or program evaluation, assessment is central to
efforts to gauge the impact of health care services pro-
vided to ameliorate these problems (Brown, Scholle, &
Azur, 2014; Hermann, Chan, Zazzali, & Lerner, 2006).
Furthermore, the increasing availability of research-​
derived treatment benchmarks holds out great promise
for providing clinicians with meaningful and attainable
targets for their intervention services (Lee, Horvath, &
Hunsley, 2013; Spilka & Dobson, 2015). Importantly,
statements about evidence-​ based practice and best-​
practice guidelines have begun to specifically incor-
porate the critical role of assessment in the provision
of evidence-​ based services (e.g., Dozois et al., 2014).
Indeed, because the identification and implementation
of evidence-​based treatments rests entirely on the data
provided by assessment tools, ignoring the quality of
these tools places the whole evidence-​based enterprise in
jeopardy.
DEFINING EVIDENCE-​BASED ASSESSMENT
There are three critical aspects that should define
evidence-​
based assessment (EBA; Hunsley & Mash,
2007; Mash & Hunsley, 2005). First, research findings
and scientifically supported theories on both psycho-
pathology and normal human development should be
used to guide the selection of constructs to be assessed
and the assessment process. As Barlow (2005) suggested,
4 Introduction
EBA measures and strategies should also be designed to
be integrated into interventions that have been shown to
work with the disorders or conditions that are targeted
in the assessment. Therefore, while recognizing that
most disorders do not come in clearly delineated neat
packages, and that comorbidity is often the rule rather
than the exception, we view EBAs as being disorder-​or
problem-​specific. A problem-​specific approach is consis-
tent with how most assessment and treatment research is
conducted and would facilitate the integration of EBA
into evidence-​ based treatments (cf. Mash & Barkley,
2007; Mash & Hunsley, 2007; Weisz & Kazdin, 2017).
This approach is also congruent with the emerging
trend toward personalized assessment and treatment
(e.g., Fisher, 2015; Ng & Weisz, 2016; Sales & Alves,
2016; Seidman et al., 2010; Thompson-​Hollands, Sauer-​
Zavala, & Barlow, 2014). Although formal diagnostic sys-
tems provide a frequently used alternative for framing the
range of disorders and problems to be considered, com-
monly experienced emotional and relational problems,
such as excessive anger, loneliness, conflictual relation-
ships, and other specific impairments that may occur in
the absence of a diagnosable disorder, may also be the
focus of EBAs. Even when diagnostic systems are used
as the framework for the assessment, clinicians need to
consider both (a) the potential value of emerging trans-
diagnostic approaches to treatment (Newby, McKinnon,
Kuyken, Gilbody, & Dalgleish, 2015) and (b) that a nar-
row focus on assessing symptoms and symptom reduction
is insufficient for treatment planning and treatment eval-
uation purposes (cf. Kazdin, 2003). Many assessments are
conducted to identify the precise nature of the person’s
problem(s). It is, therefore, necessary to conceptualize
multiple, interdependent stages in the assessment pro-
cess, with each iteration of the process becoming less
general in nature and increasingly problem-​specific with
further assessment (Mash & Terdal, 1997). In addition,
for some generic assessment strategies, there may be
research to indicate that the strategy is evidence-​based
without being problem-​specific. Examples of this include
functional assessments (Hurl, Wightman, Haynes, &
Virues-​Ortega, 2016) and treatment progress monitoring
systems (e.g., Lambert, 2015).
A second requirement is that, whenever pos-
sible, psychometrically strong measures should be
used to assess the constructs targeted in the assess-
ment. The measures should have evidence of reli-
ability, validity, and clinical utility. They should also
possess appropriate norms for norm-​ referenced inter-
pretation and/​or replicated supporting evidence for the
accuracy (sensitivity, specificity, predictive power, etc.)
of cut-​scores for criterion-​referenced interpretation (cf.
Achenbach, 2005). Furthermore, there should be sup-
porting evidence to indicate that the EBAs are sensitive
to key characteristics of the individual(s) being assessed,
including characteristics such as age, gender, ethnic-
ity, and culture (e.g., Ivanova et al., 2015). Given the
range of purposes for which assessment instruments
can be used (i.e., screening, diagnosis, prognosis, case
conceptualization, treatment formulation, treatment
monitoring, and treatment evaluation) and the fact that
psychometric evidence is always conditional (based on
sample characteristics and assessment purpose), support-
ing psychometric evidence must be considered for each
purpose for which an instrument or assessment strategy is
used. Thus, general discussions concerning the relative
merits of information obtained via different assessment
methods have little meaning outside of the assessment
purpose and context. Similarly, not all psychometric ele-
ments are relevant to all assessment purposes. The group
of validity statistics that includes specificity, sensitivity,
positive predictive power, and negative predictive power
is particularly relevant for diagnostic and prognostic
assessment purposes and contains essential information
for any measure that is intended to be used for screening
purposes (Hsu, 2002). Such validity statistics may have
little relevance, however, for many methods intended to
be used for treatment monitoring and/​or evaluation pur-
poses; for these purposes, sensitivity to change is a much
more salient psychometric feature (e.g., Vermeersch,
Lambert, & Burlingame, 2000).
Finally, even with data from psychometrically
strong measures, the assessment process is inherently
a decision-​ making task in which the clinician must
iteratively formulate and test hypotheses by integrating
data that are often incomplete or inconsistent. Thus,
a truly evidence-​based approach to assessment would
involve an evaluation of the accuracy and usefulness
of this complex decision-​making task in light of poten-
tial errors in data synthesis and interpretation, the costs
associated with the assessment process, and, ultimately,
the impact that the assessment had on clinical out-
comes. There are an increasing number of illustrations
of how assessments can be conducted in an evidence-​
based manner (e.g., Christon, McLeod, & Jensen-​Doss,
2015; Youngstrom, Choukas-​ Bradley, Calhoun, &
Jensen-​Doss, 2015). These provide invaluable guides
for clinicians and provide a preliminary framework that
could lead to the eventual empirical evaluation of EBA
processes.
 Developing Criteria for Evidence-Based Assessment
FROM RESEARCH TO PRACTICE: USING
A “GOOD-​E NOUGH” PRINCIPLE
Perhaps the greatest single challenge facing efforts to
develop and implement EBAs is determining how to
start the process of operationalizing the criteria we just
outlined. The assessment literature provides a veritable
wealth of information that is potentially relevant to EBA;
this very strength, however, is also a considerable liability,
for the size of the literature is beyond voluminous. Not
only is the literature vast in scope but also the scientific
evaluation of assessment methods and instruments can be
without end because there is no finite set of studies that
can establish, once and for all, the psychometric proper-
ties of an instrument (Kazdin, 2005; Sechrest, 2005). On
the other hand, every single day, clinicians must make
decisions about what assessment tools to use in their prac-
tices, how best to use and combine the various forms of
information they obtain in their assessment, and how to
integrate assessment activities into other necessary aspects
of clinical service. Moreover, the limited time available
for service provision in clinical settings places an onus
on using assessment options that are maximally accurate,
efficient, and cost-​effective. Thus, above and beyond the
scientific support that has been amassed for an instru-
ment, clinicians require tools that are brief, clear, clini-
cally feasible, and user-​friendly. In other words, they need
instruments that have clinical utility and that are good
enough to get the job done (Barlow, 2005; Lambert &
Hawkins, 2004; Weisz, Krumholz, Santucci, Thomassin,
& Ng, 2015; Youngstrom & Van Meter, 2016).
As has been noted in the assessment literature, there
are no clear, commonly accepted guidelines to aid clini-
cians or researchers in determining when an instrument
has sufficient scientific evidence to warrant its use (Kazdin,
2005; Sechrest, 2005). The Standards for Educational and
Psychological Testing (American Educational Research
Association, American Psychological Association, &
National Council on Measurement in Education,
2014) sets out generic standards to be followed in devel-
oping and using psychological instruments but is silent
on the question of specific psychometric values that an
instrument should have. The basic reason for this is that
psychometric characteristics are not properties of an
instrument per se but, rather, are properties of an instru-
ment when used for a specific purpose with a specific
sample. Quite understandably, therefore, assessment
scholars, psychometricians, and test developers have been
reluctant to explicitly indicate the minimum psycho-
metric values or evidence necessary to indicate that an
5
instrument is scientifically sound (cf. Streiner, Norman,
& Cairney, 2015). Unfortunately, this is of little aid to the
clinicians and researchers who are constantly faced with
the decision of whether an instrument is good enough,
scientifically speaking, for the assessment task at hand.
Prior to the psychometric criteria we set out in the
first edition of this volume, there had been attempts to
establish criteria for the selection and use of measures for
research purposes. Robinson, Shaver, and Wrightsman
(1991), for example, developed evaluative criteria for
the adequacy of attitude and personality measures, cov-
ering the domains of theoretical development, item
development, norms, inter-​ item correlations, internal
consistency, test–​retest reliability, factor analytic results,
known groups validity, convergent validity, discriminant
validity, and freedom from response sets. Robinson and
colleagues also used specific psychometric criteria for
many of these domains, such as describing a coefficient
α of .80 as exemplary. A different approach was taken by
the Measurement and Treatment Research to Improve
Cognition in Schizophrenia Group to develop a consen-
sus battery of cognitive tests to be used in clinical trials
in schizophrenia (Green et al., 2004). Rather than setting
precise psychometric criteria for use in rating potential
instruments, expert panelists were asked to rate, on a nine-​
point scale, each proposed tool’s characteristics, includ-
ing test–​retest reliability, utility as a repeated measure,
relation to functional outcome, responsiveness to treat-
ment change, and practicality/​tolerability. An American
Psychological Association Society of Pediatric Psychology
task force used a fairly similar strategy. The task force
efforts, published at approximately the same time as the
first edition of this volume, focused on evaluating psycho-
social assessment instruments that could be used in health
care settings (Cohen et al., 2008). Instrument character-
istics were reviewed by experts and, depending on the
available empirical support, were evaluated as promising,
approaching well-​established, or well-​established. These
descriptors closely resembled those that had been used to
identify empirically supported treatments.
Clearly, any attempt to develop a method for deter-
mining the scientific adequacy of assessment instruments
is fraught with the potential for error. The application
of criteria that are too stringent could result in a solid
set of assessment options, but one that is so limited in
number or scope as to render the whole effort clinically
worthless. Alternatively, using excessively lenient criteria
could undermine the whole notion of an instrument or
process being evidence based. So, with a clear awareness
of this assessment equivalent of Scylla and Charybdis, a
6 Introduction
decade ago we sought to construct a framework for the
chapters included in the first edition of this volume that
would employ good-​enough criteria for rating psycho-
logical instruments. In other words, rather than focus-
ing on standards that define ideal criteria for a measure,
our intent was to provide criteria that would indicate the
minimum evidence that would be sufficient to warrant
the use of a measure for specific clinical purposes. We
assumed, from the outset, that although our framework
is intended to be scientifically sound and defensible, it is
a first step rather than the definitive effort in designing a
rating system for evaluating psychometric adequacy. Our
framework, described later, is unchanged from the first
edition because there have been no developments in the
measurement and assessment literatures that have caused
us to reconsider our earlier position. Indeed, as we indi-
cate in the following sections of this chapter, several criti-
cal developments have served to reinforce our views on
the value of the framework.
In brief, to operationalize the good-​enough principle,
specific rating criteria are used across categories of psycho-
metric properties that have clear clinical relevance; each
category has rating options of adequate, good, and excel-
lent. In the following sections, we describe the assessment
purposes covered by our rating system, the psychometric
properties included in the system, and the rationales for
the rating options. The actual rating system, used in this
volume by all authors of disorder/​problem-​oriented chap-
ters to construct their summary tables of instruments, is
presented in two boxes later in this chapter.
ASSESSMENT PURPOSES
Although psychological assessments are conducted for
many reasons, it is possible to identify a small set of inter-
related purposes that form the basis for most assessments.
These include (a) diagnosis (i.e., determining the nature
and/​or cause[s]‌of the presenting problems, which may or
may not involve the use of a formal diagnostic or catego-
rization system), (b) screening (i.e., identifying those who
have or who are at risk for a particular problem and who
might be helped by further assessment or intervention),
(c) prognosis and other predictions (i.e., generating pre-
dictions about the course of the problems if left untreated,
recommendations for possible courses of action to be
considered, and their likely impact on the course of
the problems), (d) case conceptualization/​ formulation
(i.e., developing a comprehensive and clinically rele-
vant understanding of the client, generating hypotheses
regarding critical aspects of the client’s biopsychosocial
functioning and context that are likely to influence the
client’s adjustment), (e) treatment design/​planning (i.e.,
selecting/​developing and implementing interventions
designed to address the client’s problems by focusing on
elements identified in the diagnostic evaluation and the
case conceptualization), (f) treatment monitoring (i.e.,
tracking changes in symptoms, functioning, psychologi-
cal characteristics, intermediate treatment goals, and/​or
variables determined to cause or maintain the problems),
and (g) treatment evaluation (i.e., determining the effec-
tiveness, social validity, consumer satisfaction, and/​or cost-​
effectiveness of the intervention).
The chapters in this volume provide summaries of
the best assessment methods and instruments available
for commonly encountered clinical assessment purposes.
While recognizing the importance of other possible
assessment purposes, chapters in this volume focus on
(a) diagnosis, (b) case conceptualization and treatment
planning, and (c) treatment monitoring and treatment
evaluation. Although separable in principle, the purposes
of case conceptualization and treatment planning were
combined because they tend to rely on the same assess-
ment data. Similarly, the purposes of treatment monitor-
ing and evaluation were combined because they often,
but not exclusively, use the same assessment methods
and instruments. Clearly, there are some overlapping
elements, even in this set of purposes; for example, it is
relatively common for the question of diagnosis to be
revisited as part of evaluating the outcome of treatment.
In the instrument summary tables that accompany each
chapter, the psychometric strength of instruments used
for these three main purposes are presented and rated.
Within a chapter, the same instrument may be rated for
more than one assessment purpose and thus appear in
more than one table. Because an instrument may possess
more empirical support for some purposes than for others,
the ratings given for the instrument may not be the same
in each of the tables.
The chapters in this volume present information on
the best available instruments for diagnosis, case con-
ceptualization and treatment planning, and treatment
monitoring and evaluation. They also provide details on
clinically appropriate options for the range of data to col-
lect, suggestions on how to address some of the challenges
commonly encountered in conducting assessments, and
suggestions for the assessment process. Consistent with
the problem-​specific focus within EBA outlined previ-
ously, most chapters in this volume focus on one or more
specific disorders or conditions. However, many clients
 Developing Criteria for Evidence-Based Assessment
present with multiple problems and, therefore, there
are frequent references within a given chapter to the
assessment of common co-​occurring problems that are
addressed in other chapters in the volume. To be opti-
mally useful to potential readers, the chapters are focused
on the most commonly encountered disorders or condi-
tions among children, adolescents, adults, older adults,
and couples. With the specific focus on the three critical
assessment purposes of diagnosis, case conceptualization
and treatment planning, and treatment monitoring and
treatment, within each disorder or condition, the chapters
in this volume provide readers with essential information
for conducting the best EBAs currently possible.
PSYCHOMETRIC PROPERTIES
AND RATING CRITERIA
Clinical assessment typically entails the use of both idio-
graphic and nomothetic instruments. Idiographic mea-
sures are designed to assess unique aspects of a person’s
experience and, therefore, to be useful in evaluating
changes in these individually defined and constructed
variables. In contrast, nomothetic measures are designed
to assess constructs assumed to be relevant to all indi-
viduals and to facilitate comparisons, on these constructs,
across people. Most chapters include information on
idiographic measures such as self-​monitoring forms and
individualized scales for measuring treatment goals. For
such idiographic measures, psychometric characteristics
such as reliability and validity may, at times, not be easily
evaluated or even relevant (but see Weisz et al., 2011). It
is crucial, however, that the same items and instructions
are used across assessment occasions—​without this level
of standardization it is impossible to accurately determine
changes that may be due to treatment (Kazdin, 1993).
The nine psychometric categories rated for the instru-
ments in this volume are norms, internal consistency,
inter-​rater reliability, test–​retest reliability, content valid-
ity, construct validity, validity generalization, sensitivity
to treatment change, and clinical utility. Each of these
categories is applied in relation to a specific assessment
purpose (e.g., case conceptualization and treatment plan-
ning) in the context of a specific disorder or clinical con-
dition (e.g., eating disorders, self-​injurious behavior, and
relationship conflict). Consistent with our previous com-
ments, factors such as gender, ethnicity, and age must be
considered in making ratings within these categories. For
each category, a rating of less than adequate, adequate,
good, excellent, not reported, or not applicable was
7
possible. The precise nature of what constituted adequate,
good, and excellent varied, of course, from category to cat-
egory. In general, however, a rating of adequate indicated
that the instrument meets a minimal level of scientific
rigor; good indicated that the instrument would generally
be viewed as possessing solid scientific support; and excel-
lent indicated there was extensive, high-​quality support-
ing evidence. Accordingly, a rating of less than adequate
indicated that the instrument did not meet the minimum
level set out in the criteria. A rating of not reported indi-
cated that research on the psychometric property under
consideration had not yet been conducted or published.
A rating of not applicable indicated that the psychomet-
ric property under consideration was not relevant to the
instrument (e.g., inter-​ rater reliability for a self-​
report
symptom rating scale).
When considering the clinical use of a measure, it
would be desirable to only use those measures that would
meet, at a minimum, the criteria for good. However,
because measure development is an ongoing process, the
rating system provides the option of the adequate rating
in order to fairly evaluate (a) relatively newly developed
measures and (b) measures for which comparable levels
of research evidence are not available across all psycho-
metric categories in the rating system. In several chapters,
authors explicitly commented on the status of some newly
developed measures, but by and large, the only instru-
ments included in chapter summary tables were those
that had adequate or better ratings on the majority of the
psychometric dimensions. Thus, the instruments pre-
sented in these tables represent only a subset of available
assessment tools.
Despite the difficulty inherent in promulgating sci-
entific criteria for psychometric properties, we believe
that the potential benefits of fair and attainable criteria
far outweigh the potential drawbacks (cf. Sechrest, 2005).
Accordingly, reasoned arguments from respected psycho-
metricians and assessment scholars, along with summaries
of various assessment literatures, guided the selection of
criteria for rating the psychometric properties associated
with an instrument. Box 1.1 presents the criteria used in
rating norms and reliability indices; Box 1.2 presents the
criteria used in rating validity indices and clinical utility.
Norms
When using a standardized, nomothetically based
instrument, it is essential that norms, specific criterion-​
related cutoff scores, or both are available to aid in
the accurate interpretation of a client’s test score
8 Introduction
BOX 1.1 Criteria at a Glance: Norms and
Reliability
NORMS
Adequate = Measures of central tendency and distribu-
tion for the total score (and subscores if relevant) based
on a large, relevant, clinical sample are available.
Good = Measures of central tendency and distribution
for the total score (and subscores if relevant) based
on several large, relevant samples (must include
data from both clinical and nonclinical samples) are
available.
Excellent = Measures of central tendency and distribu-
tion for the total score (and subscores if relevant)
based on one or more large, representative samples
(must include data from both clinical and nonclini-
cal samples) are available.
I N T E R NA L C O N S I S T E N C Y
Adequate = Preponderance of evidence indicates
α values of .70–​.79.
Good = Preponderance of evidence indicates α values
of .80–​.89.
Excellent = Preponderance of evidence indicates
α values ≥ .90.
I N T E R -​R AT E R R E L I A B I L I T Y
Adequate = Preponderance of evidence indicates κ
values of .60–​.74; the preponderance of evidence
indicates Pearson correlation or intraclass correla-
tion values of .70–​.79.
Good = Preponderance of evidence indicates κ val-
ues of .75–​ .84; the preponderance of evidence
indicates Pearson correlation or intraclass correla-
tion values of .80–​.89.
Excellent = Preponderance of evidence indicates κ
values ≥ .85; the preponderance of evidence indi-
cates Pearson correlation or intraclass correlation
values ≥ .90.
T E S T –​R E T E S T R E L I A B I L I T Y
Adequate = Preponderance of evidence indicates
test–​retest correlations of at least .70 over a period
of several days to several weeks.
Good = Preponderance of evidence indicates test–​
retest correlations of at least .70 over a period of
several months.
Excellent = Preponderance of evidence indicates
test–​retest correlations of at least .70 over a period
of a year or longer.
BOX 1.2 Criteria at a Glance: Validity and Utility
C O N T E N T VA L I D I T Y
Adequate = The test developers clearly defined
the domain of the construct being assessed and
ensured that selected items were representative of
the entire set of facets included in the domain.
Good = In addition to the criteria used for an
adequate rating, all elements of the instrument
(e.g., instructions and items) were evaluated
by judges (e.g., by experts or by pilot research
participants).
Excellent = In addition to the criteria used for a
good rating, multiple groups of judges were
employed and quantitative ratings were used by
the judges.
C O N S T R U C T VA L I D I T Y
Adequate = Some independently replicated evidence
of construct validity (e.g., predictive validity, con-
current validity, and convergent and discriminant
validity).
Good = Preponderance of independently repli-
cated evidence, across multiple types of validity
(e.g., predictive validity, concurrent validity, and
convergent and discriminant validity), is indica-
tive of construct validity.
Excellent = In addition to the criteria used for a good
rating, there is evidence of incremental validity
with respect to other clinical data.
VA L I D I T Y G E N E R A L I Z AT I O N
Adequate = Some evidence supports the use of this
instrument with either (a) more than one specific
group (based on sociodemographic characteristics
such as age, gender, and ethnicity) or (b) in mul-
tiple contexts (e.g., home, school, primary care set-
ting, and inpatient setting).
Good = Preponderance of evidence supports the
use of this instrument with either (a) more than
one specific group (based on sociodemographic
characteristics such as age, gender, and eth-
nicity) or (b) in multiple settings (e.g., home,
school, primary care setting, and inpatient
setting).
Excellent = Preponderance of evidence supports the
use of this instrument with more than one specific
group (based on sociodemographic characteristics
such as age, gender, and ethnicity) and across mul-
tiple contexts (e.g., home, school, primary care set-
ting, and inpatient setting).
 Developing Criteria for Evidence-Based Assessment
BOX 1.2 Continued
T R E AT M E N T S E N S I T I V I T Y
Adequate = Some evidence of sensitivity to change
over the course of treatment.
Good = Preponderance of independently replicated
evidence indicates sensitivity to change over the
course of treatment.
Excellent = In addition to the criteria used for a good
rating, evidence of sensitivity to change across dif-
ferent types of treatments.
CLINICAL UTILITY
Adequate = Taking into account practical consid-
erations (e.g., costs, ease of administration, avail-
ability of administration and scoring instructions,
duration of assessment, availability of relevant
cutoff scores, and acceptability to clients), the
resulting assessment data are likely to be clini-
cally useful.
Good = In addition to the criteria used for an
adequate rating, there is some published evi-
dence that the use of the resulting assessment
data confers a demonstrable clinical benefit
(e.g., better treatment outcome, lower treatment
attrition rates, and greater client satisfaction with
services).
Excellent = In addition to the criteria used for an
adequate rating, there is independently replicated
published evidence that the use of the resulting
assessment data confers a demonstrable clinical
benefit.
(American Educational Research Association, American
Psychological Association, & National Council on
Measurement in Education, 2014). For example,
norms can be used to determine the client’s pre-​and
post-​treatment levels of functioning and to evaluate
whether any change in functioning is clinically mean-
ingful (Achenbach, 2001; Kendall, Marrs-​Garcia, Nath,
& Sheldrick, 1999). Selecting the target population(s)
for the norms and then ensuring that the norms are
adequate can be difficult tasks, and several sets of norms
may be required for a measure. One set of norms may be
needed to determine the meaning of the obtained score
relative to the general population, whereas a different
set of norms could be used to compare the score to spe-
cific subgroups within the population (Cicchetti, 1994).
9
Regardless of the population to which comparisons are
to be made, a normative sample must be truly represen-
tative of the population with respect to demographics
and other important characteristics (Achenbach, 2001;
Wasserman & Bracken, 2013). Ideally, whether con-
ducted at the national level or the local level, this would
involve probability-​sampling efforts in which data are
obtained from the majority of contacted respondents. As
those familiar with psychological instruments are aware,
such a sampling strategy is rarely used for the devel-
opment of test norms. The reliance on data collected
from convenience samples with unknown response rates
reduces the accuracy of the resultant norms. Therefore,
at a minimum, clinicians need to be provided with
an indication of the quality and likely accuracy of the
norms for a measure. Accordingly, the ratings for norms
required, at a minimum for a rating of adequate, data
from a single, large clinical sample. For a rating of good,
normative data from multiple samples, including non-
clinical samples, were required; when normative data
from large, representative samples were available, a rat-
ing of excellent was applied.
Reliability
Reliability is a key psychometric element to be considered
in evaluating an instrument. It refers to the consistency of
a person’s score on a measure (Anastasi, 1988; Wasserman
& Bracken, 2013), including whether (a) all elements
of a measure contribute in a consistent way to the data
obtained (internal consistency), (b) similar results would
be obtained if the measure was used or scored by another
clinician (inter-​ rater reliability),1 or (c) similar results
would be obtained if the person completed the measure a
second time (test–​retest reliability or test stability). Not all
reliability indices are relevant to all assessment methods
and measures, and the size of the indices may vary on the
basis of the samples used.
Despite the long-​standing recognition of the central-
ity of reliability to all forms of psychological measure-
ment, there is a persistent tendency in psychological
research to make unwarranted assumptions about reli-
ability. For example, numerous reviews have found that
almost three-​fourths of research articles failed to provide
information on the reliability estimates of the measures
completed by participants in the studies (e.g., Barry,
Chaney, Piazza-​ Gardner, & Chavarria, 2014; Vacha-​
Haase & Thompson, 2011). Inattention to reliability, or
the use of an inappropriate statistic to estimate reliability,
has the potential to undermine the validity of conclu-
sions drawn from research studies. Concerns have been
10 Introduction
raised about the impact of these errors in a broad range of
research domains, including communication (Feng, 2015),
psychopathology (Rodebaugh et al., 2016), and clinical
diagnosis (Chmielewski, Clark, Bagby, & Watson, 2015).
As emphasized throughout this volume, a careful consider-
ation of reliability values is essential when selecting assess-
ment instruments for clinical services or clinical research.
With respect to internal consistency, we focused on
coefficient alpha (α), which is the most widely used index
(Streiner, 2003). Although there have been repeated
calls to abandon the use of coefficient α in favor of more
robust and accurate alternatives (e.g., Dunn, Baguley,
& Brunsden, 2014; Kelley & Pornprasertmanit, 2016),
it is rare to find an internal consistency coefficient
other than α used in the clinical assessment literature.
Recommendations in the literature for what constitutes
adequate internal consistency vary, but most authorities
seem to view .70 as the minimum acceptable value for α
(e.g., Cicchetti, 1994), and Charter (2003) reported that
the mean internal consistency value among commonly
used clinical instruments was .81. Accordingly, a rating of
adequate was given to values of .70–​.79; a rating of good
required values of .80–​.89; and, finally, because of cogent
arguments that an α value of at least .90 is highly desirable
in clinical assessment contexts (Nunnally & Bernstein,
1994), we required values ≥ .90 for an instrument to be
rated as having excellent internal consistency. Note that it
is possible for α to be too (artificially) high, as a value close
to unity typically indicates substantial redundancy among
items (cf. Streiner, 2003).
These value ranges were also used in rating evidence
for inter-​rater reliability when assessed with Pearson corre-
lations or intraclass correlations. Appropriate adjustments
were made to the value ranges when κ statistics were used,
in line with the recommendations discussed by Cicchetti
(1994; see also Charter, 2003). Note that although a num-
ber of statistics are superior to κ, it continues to be the
most commonly used inter-​rater reliability statistic (Xu
& Lorber, 2014). Importantly, evidence for inter-​ rater
reliability could only come from data generated among
clinicians or clinical raters—​estimates of cross-​informant
agreement, such as between parent and teacher ratings,
are not indicators of reliability.
In establishing ratings for test–​retest reliability values,
our requirement for a minimum correlation of .70 was
influenced by summary data reported on typical test–​
retest reliability results found with clinical instruments
(Charter, 2003) and trait-​ like psychological measures
(Watson, 2004). Of course, not all constructs or measures
are expected to show temporal stability (e.g., measures
of state-​like variables and life stress inventories), so test–​
retest reliability was only rated if it was relevant. A rating
of adequate required evidence of correlation values of .70
or greater, when reliability was assessed over a period of
several days to several weeks. We then faced a challenge
in determining appropriate criteria for good and excellent
ratings. In order to enhance its likely usefulness, the rating
system should be relatively simple. However, test–​retest
reliability is a complex phenomenon that is influenced by
(a) the nature of the construct being assessed (i.e., it can be
state-​like, trait-​like, or influenced by situational variables),
(b) the time frame covering the reporting period instruc-
tions (i.e., whether respondents are asked to report their
current functioning, functioning over the past few days,
or functioning over an extended period, such as general
functioning in the past year), and (c) the duration of the
retest period (i.e., whether the time between two admin-
istrations of the instrument involved days, weeks, months,
or years). In the end, rather than emphasize the value of
increasingly large test–​retest correlations, we decided to
maintain the requirement for .70 or greater correlation
values but require increasing retest period durations of
(a) several months and (b) at least 1 year for ratings of
good and excellent, respectively.
Validity
Validity is another central aspect to be considered when
evaluating psychometric properties. Recent editions of
the Standards for Educational and Psychological Testing
(American Educational Research Association, American
Psychological Association, & National Council on
Measurement in Education, 1999, 2014) explicitly state
that validity is a unitary concept and that it is not appro-
priate to consider different types of validity. Despite these
admonitions, research on validity continues to use con-
cepts such as content validity, predictive validity, and
incremental validity. Setting aside the wide range of con-
ceptual and practical issues associated with the lack of
consensus on the framing of test validity (for a detailed
discussion, see Newton & Shaw, 2013), there is a very
simple reason for incorporating several types of validity
into the rating system used in this book: The vast majority
of the literature on clinical assessment, both historically
and currently, does not treat validity as a unitary concept
(cf. Strauss & Smith, 2009). To strike a balance between
the unitary approach advocated by the Standards and
the multiplicity of validity types used in the literature,
we focused on content validity, construct validity, validity
generalization, and treatment sensitivity. In the following
 Developing Criteria for Evidence-Based Assessment
paragraphs, we explain further the rationale for our use of
four types of validity. As is readily apparent by reviewing
the summary tables of instruments in the following chap-
ters, the extent and strength of research evidence across
these types of validity can vary substantially for a given
assessment instrument.
Foster and Cone (1995) drew an important distinc-
tion between “representational” validity (i.e., whether a
measure really assesses what it purports to measure) and
“elaborative” validity (i.e., whether the measure has any
utility for measuring the construct). Attending to the
content validity of a measure is a basic, but frequently
overlooked, step in evaluating representational valid-
ity (Haynes, Richard, & Kubany, 1995). As discussed by
Smith, Fischer, and Fister (2003), the overall reliability
and validity of scores on an instrument is directly affected
by the extent to which items in the instrument adequately
represent the various aspects or facets of the construct the
instrument is designed to measure. Assuming that repre-
sentational validity has been established for an assessment
purpose, it is elaborative validity that is central to clini-
cians’ use of a measure. Accordingly, replicated evidence
for a measure’s concurrent, predictive, discriminative,
and, ideally, incremental validity (Hunsley & Meyer,
2003) should be available to qualify a measure for con-
sideration as evidence based. We have indicated already
that validation is a context-​sensitive concept—​inattention
to this fact can lead to inappropriate generalizations being
made about a measure’s validity. Thus, there should be
replicated elaborative validity evidence for each purpose
of the measure and for each population or group for which
the measure is intended to be used. This latter point is
especially relevant when considering an instrument for
clinical use, and thus it is essential to consider evidence
for validity generalization—​that is, the extent to which
there is evidence for validity across a range of samples and
settings (cf. Messick, 1995; Schmidt & Hunter, 1977).
In the rating system used in subsequent chapters, rat-
ings of content validity evidence required explicit consider-
ation of the construct facets to be included in the measure
and, as the ratings increased, involvement of content
validity judges to assess the measure (Haynes et al., 1995).
Unlike the situation for reliability, there are no commonly
accepted summary statistics to evaluate construct validity
(but see Markon [2013] and Westen & Rosenthal [2003]).
As a result, our ratings were based on the requirement of
increasing amounts of replicated evidence of elements of
construct validity such as predictive validity, concurrent
validity, convergent validity, and discriminant validity; in
addition, for a rating of excellent, evidence of incremental
11
validity was also required. As was the case when we intro-
duced the rating system in the first edition of this book, we
were unable to find any clearly applicable standards in the
literature to guide us in developing criteria for validity gen-
eralization or treatment sensitivity (a dimension rated only
for instruments used for the purposes of treatment moni-
toring and treatment evaluation). Therefore, adequate
ratings for these dimensions required some evidence of,
respectively, the use of the instrument with either more
than one specific group or in multiple contexts and evi-
dence of sensitivity to change over the course of treatment.
Consistent with ratings for other dimensions, good and
excellent ratings required increasingly demanding levels
of evidence in these areas.
Utility
It is also essential to know the utility of an instrument for
a specific clinical purpose. The concept of clinical util-
ity, applied to both diagnostic systems (e.g., Keeley et al.,
2016; Kendell & Jablensky, 2003; Mullins-​Sweatt, Lengel,
& DeShong, 2016) and assessment tools (e.g., di Ruffano,
Hyde, McCaffery, & Bossuyt, 2012; Yates & Taub, 2003),
has received increasing attention in recent years. Although
definitions vary, they have in common an emphasis on gar-
nering evidence regarding actual improvements in both
decisions made by clinicians and service outcomes experi-
enced by clients. Unfortunately, despite thousands of studies
on the reliability and validity of psychological instruments,
there is only scant attention paid to matters of utility in most
assessment research studies (McGrath, 2001). This has
directly contributed to the current state of affairs in which
there is very little replicated evidence that psychological
assessment data have a direct impact on improved provision
and outcome of clinical services. Currently, therefore, for
the majority of psychological instruments, a determination
of clinical utility must often be made on the basis of likely
clinical value rather than on empirical evidence.
Compared to the criteria for the psychometric dimen-
sions presented thus far, our standards for evidence of
clinical utility were noticeably less demanding. This was
necessary because of the paucity of information on the
extent to which assessment instruments are acceptable
to clients, enhance the quality and outcome of clinical
services, and/​or are worth the costs associated with their
use. Therefore, we relied on authors’ expert opinions to
classify an instrument as having adequate clinical utility.
The availability of any supporting evidence of utility was
sufficient for a rating of good, and replicated evidence of
utility was necessary for a rating of excellent.
12 Introduction

The instrument summary tables also contain one final For information on important developments on rating
column, used to indicate instruments that are the best systems used in many areas of health care research, the
measures currently available to clinicians for specific pur- interested reader can consult the website of the Grading
poses and disorders and, thus, are highly recommended of Recommendations Assessment, Development and
for clinical use. Given the considerable differences in Evaluation (GRADE) working group (http://​www.grade-
the state of the assessment literature for different disor- workinggroup.org).
ders/​conditions, chapter authors had some flexibility in The second issue has to do with the responsible clini-
determining their own precise requirements for an instru- cal use of the guidance provided by the rating system.
ment to be rated, or not rated, as highly recommended. Consistent with evaluation and grading strategies used
However, to ensure a moderate level of consistency in through evidence-​ based medicine and evidence-​ based
these ratings, a highly recommended rating could only be psychology initiatives, many of our rating criteria relied
considered for those instruments having achieved ratings on the consideration of the preponderance of data rel-
of good or excellent in the majority of its rated psycho- evant to each dimension. Such a strategy recognizes both
metric categories. Although not required in our system, if the importance of replication in science and the fact
several instruments had comparable psychometric merits that variability across studies in research design elements
for a given assessment purpose, some chapter authors con- (including sample composition and research setting) will
sidered the cost and availability of an assessment instru- influence estimates of these psychometric dimensions.
ment when making this recommendation (see also Beidas However, we hasten to emphasize that reliance on the
et al., 2015). preponderance of evidence for these ratings does not
imply or guarantee that an instrument is applicable for all
clients or clinical settings. Our intention is to have these
SOME FINAL THOUGHTS ratings provide indications about scientifically strong mea-
sures that warrant consideration for clinical and research
We are hopeful that the rating system described in this use. As with all evidence-​based efforts, the responsibility
chapter, and applied in each of the chapters of this book, rests with the individual professional to determine the
will continue to aid in advancing the state of evidence-​ suitability of an instrument for the specific setting, pur-
based psychological assessment. We also hope that it will pose, and individuals to be assessed.
serve as a stimulus for others to refine and improve upon Third, as emphasized throughout this volume, focus-
our efforts (cf. Jensen-​Doss, 2011; Youngstrom et al., in ing on the scientific evidence for specific assessment tools
press). Whatever the possible merits of the rating system, should not overshadow the fact that the process of clinical
we close this chapter by drawing attention to three critical assessment involves much more than simply selecting and
issues related to its use. administering the best available instruments. Choosing
First, although the rating system used for this volume the best, most relevant, instruments is unquestionably an
is relatively simple, the task of rating psychometric proper- important step. Subsequent steps must ensure that the
ties is not. Results from many studies must be considered instruments are administered in an appropriate manner,
in making such ratings, and precise quantitative standards accurately scored, and then individually interpreted in
were not set for how to weight the results from studies. accordance with the relevant body of scientific research.
Furthermore, in the spirit of evidence-​based practice, it However, to ensure a truly evidence-​based approach to
is also important to note that we do not know whether assessment, the major challenge is to then integrate all the
these ratings are, themselves, reliable. Reliance on indi- data within a process that is, itself, evidence-​based. This
vidual expert judgment, no matter how extensive and will likely require both (a) a reframing of the assessment
current the knowledge of the experts, is not as desirable process within the larger health and social system context
as basing evidence-​based conclusions and guidance on in which it occurs and (b) the use of new technologies
systematic reviews of the literature conducted according to enable complex decision-​making and integration of
to a consensually agreed upon rating system. However, large amounts of assessment information in both tradi-
for all the potential limitations and biases inherent in our tional and nontraditional health service delivery settings
approach, reliance on expert review of the scientific lit- (Chorpita, Daleiden, & Bernstein, 2015). Much of our
erature is the current standard in psychology and, thus, focus in this chapter has been on evidence-​based meth-
was the only feasible option for the volume at this time. ods and instruments, in large part because (a) methods
 Developing Criteria for Evidence-Based Assessment
and specific measures are more easily identified than are
processes and (b) the main emphasis in the assessment lit-
erature has been on psychometric properties of methods
and instruments. As we indicated early in the chapter, an
evidence-​based approach to assessment should be devel-
oped in light of evidence on the accuracy and usefulness
of this complex, iterative decision-​making task. Although
the chapters in this volume provide considerable assis-
tance for having the assessment process be informed by
scientific evidence, the future challenge will be to ensure
that the entire process of assessment is evidence based.
Note
1. Although we chose to use the term “inter-​rater reli-
ability,” there is some discussion in the assessment literature
about whether the term should be “inter-​rater agreement.”
Heyman et al. (2001), for example, suggested that because
indices of inter-​rater reliability do not contain information
about individual differences among participants and only
contain information about one source of error (i.e., differ-
ences among raters), they should be considered to be indices
of agreement, not reliability.
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17
Dissemination and Implementation
of Evidence-​Based Assessment
Amanda Jensen-​Doss
Lucia M. Walsh
Vanesa Mora Ringle
During the past two decades, there has been a major
push to increase the use of evidence-​based practices in
clinical settings. The American Psychological Association
Presidential Task Force on Evidence-​ Based Practice
(2006) defines evidence-​ based practice in psychology
(EBPP) as “the integration of the best available research
with clinical expertise in the context of patient character-
istics, culture, and preferences” (p. 271) and states that
the goal of EBPP is to improve public health through
the application of research-​ supported assessment, case
formulation, therapeutic relationship, and treatment
approaches. Although EBPP is defined broadly, many
efforts to improve practice have focused on treatment,
with less attention paid to other aspects of practice. There
is a particular need to focus on increasing use of evidence-​
based assessment (EBA), as assessment cuts across all of
these other areas of practice. For example, assessment
results should form the foundation of case conceptualiza-
tion; inform decisions about which treatments to use; and
provide data about whether treatment is working, whether
therapy alliance is strong, and when to end treatment.
There are several reasons why a focus on EBA will
increase the likelihood that EBPP will lead to improved
public health. First, EBA can improve the accuracy of
diagnoses, which is one important component of case
conceptualization and treatment selection (Christon,
McLeod, & Jensen-​Doss, 2015). Research linking diag-
nostic accuracy to improved treatment engagement and
outcomes (Jensen-​Doss & Weisz, 2008; Klein, Lavigne,
& Seshadri, 2010; Kramer, Robbins, Phillips, Miller, &
17
Burns, 2003; Pogge et al., 2001) suggests that improved
diagnostic assessment could have a positive effect across
the treatment process. As detailed throughout this book,
evidence-​based diagnostic assessment typically involves
the use of structured diagnostic interviews or rating scales.
Studies have demonstrated that when clinicians use
structured diagnostic interviews, they assign more accu-
rate diagnoses (Basco et al., 2000), better capture comor-
bidities (Matuschek et al., 2016), assign more specific
diagnoses (Matuschek et al., 2016), reduce psychiatrist
evaluation time (Hughes et al., 2005), and decrease the
likelihood that a psychiatrist will increase a patient’s medi-
cation dose (Kashner et al., 2003).
Using EBA for progress monitoring can support clinical
judgment by creating an ongoing feedback loop to support
ongoing case conceptualization (Christon et al., 2015) and,
if data suggest clients are at risk for treatment failure, revise
the treatment plan (Claiborn & Goodyear, 2005; Lambert,
Hansen, & Finch, 2001; Riemer, Rosof-​Williams, & Bickman,
2005). Gold standard progress monitoring of this nature typi-
cally involves administering rating scales every session or two
and then incorporating the feedback into clinical decisions.
This differs from what we refer to here as “outcome monitor-
ing,” or administering outcome measures before and after
treatment to determine treatment effectiveness. Although use-
ful for many purposes, this type of outcome monitoring does
not support clinical decision-​making during service provision.
Several monitoring and feedback systems (MFSs) have
been developed to support ongoing progress monitoring;
they typically include a battery of progress measures and
18
18 Introduction
generate feedback reports that often include warnings
if a client is not on track for positive outcomes (Lyon,
Lewis, Boyd, Hendrix, & Liu, 2016). Extensive research
with adult clients suggests that clinician use of MFSs can
improve outcomes, particularly for those “not on track”
for positive outcomes (Krägeloh, Czuba, Billington,
Kersten, & Siegert, 2015; Shimokawa, Lambert, & Smart,
2010); similar results have been found for youth clients
(Bickman, Kelley, Breda, De Andrade, & Riemer, 2011;
Stein, Kogan, Hutchison, Magee, & Sorbero, 2010),
although effects vary based on organizational support for
progress monitoring (Bickman et al., 2016).
The purpose of this chapter is to make the case that
significant work is needed to encourage the dissemina-
tion of information about EBA and its implementation in
clinical practice. First, we discuss “assessment as usual,”
how it differs from EBA, and reasons for these differences.
Then, we describe efforts to increase use of EBA through
dissemination and implementation efforts. Finally, we
present some ideas for future work needed to further
advance the use of EBA. Consistent with the other chap-
ters in this book, we focus on assessment of psychopathol-
ogy and its application to clinical diagnosis and progress
monitoring. Although similar issues likely exist for other
forms of assessment, such as psychoeducational assess-
ment, discussion of those is beyond the scope of this book.
Finally, although assessment tools to support case con-
ceptualization are described in the subsequent chapters
of this book, most of the literature studying clinician case
conceptualization practices and how to improve them has
focused on whether clinicians can apply specific theoreti-
cal models to client data and the validity of case concep-
tualizations (e.g., Abbas, Walton, Johnston, & Chikoore,
2012; Flinn, Braham, & das Nair, 2015; Persons &
Bertagnolli, 1999) rather than on how to collect and inte-
grate EBA data to generate a case conceptualization. As
mentioned previously, both diagnostic assessment and
progress monitoring can support case conceptualiza-
tion; therefore, much of the literature we discuss here
has implications for case conceptualization. However, in
the Future Directions section, we address steps needed to
advance assessment-​based case conceptualization.
IS THERE A RESEARCH–​P RACTICE
GAP IN ASSESSMENT?
Despite the proliferation of excellent assessment tools,
available data suggest there are significant training and
practice gaps in both diagnostic assessment and progress
monitoring. As discussed in the following sections, these
gaps have important implications for the accuracy of
clinician-​generated diagnoses and the accuracy of clini-
cian judgments about treatment progress.
Research–​Practice Gaps in Diagnostic Assessment
As detailed throughout the chapters in this book,
evidence-​based diagnostic assessment for most disorders
relies on standardized diagnostic interviews and/​or rat-
ing scales. Unfortunately, surveys of training programs
suggest that clinicians are not being prepared to conduct
these assessments during their graduate training. Several
surveys of psychology programs have been conducted in
the past three decades (e.g., Belter & Piotrowski, 2001;
Childs & Eyde, 2002), with the two most recent (Mihura,
Roy, & Graceffo, 2016; Ready & Veague, 2014) finding
that training in assessment has generally remained con-
stant, but there has been an increase in training focused
on assessment of treatment outcomes, psychometrics,
and neuropsychology. However, these two studies found
inconsistent results regarding the use of clinical inter-
viewing. Ready and Veague reported only half to three-​
fourth of programs included clinical interviewing as a
focus of training. However, Mihura et al. found that 92%
of programs queried included clinical interviewing as a
required topic. These differences might reflect a change
during the 3 years that passed between the two studies.
However, it is also likely that the two studies also obtained
information from different programs, as Mihura and col-
leagues included more programs than Ready and Veague
and each study only obtained data from approximately
one-​third of all of the American Psychological Association
(APA)-​accredited programs.
Two studies have examined training in diagnostic
assessment specifically. Ponniah et al. (2011) surveyed
clinical training directors from social work, clinical psy-
chology PhD and PsyD, and psychiatric residency pro-
grams regarding training in structured assessment based
on Diagnostic and Statistical Manual of Mental Disorders
(DSM) criteria. Only one-​ third of surveyed programs
reported providing both didactics and supervision in
diagnostic assessment, with clinical psychology PhD and
psychiatry residency programs being most likely to do so
and social work programs the least likely. These results are
concerning because master’s level clinicians represent the
majority of those providing services to those with mental
health disorders in the United States (Garland, Bickman,
& Chorpita, 2010). Focusing on clinical psychology PhD
and PsyD programs exclusively, Mihura et al. (2016)
19
Dissemination and Implementation of Evidence-Based Assessment
found that less than half of the programs required a course
and less than one-​fourth required an applied practicum
on any structured diagnostic interview. Differences in
required structured diagnostic interview courses were
found between training models: 73% of clinical science
and 63% of scientist-​ practitioner programs required a
course, whereas only 35% of practitioner-​ focused pro-
grams had a similar requirement.
Not surprisingly based on these training gaps, available
data suggest that clinicians are not engaged in EBA for
diagnostic assessment. Existing surveys across a range of
clinicians indicate that unstructured interviews are com-
monly relied on for diagnosis (e.g., Anderson & Paulosky,
2004), that evidence-​based tools are infrequently used
(e.g., Gilbody, House, & Sheldon, 2002; Whiteside,
Sattler, Hathaway, & Douglas, 2016), and diagnostic
practices often do not map on to best practice guidelines
(e.g., Demaray, Schaefer, & Delong, 2003; Lichtenstein,
Spirito, & Zimmermann, 2010).
Unfortunately, these gaps between “best practice”
and “as usual” assessment practices have implications for
the accuracy of diagnoses generated in routine practice.
Studies comparing clinician-​generated diagnoses to those
generated through comprehensive, research-​ supported
methods consistently find low rates of agreement between
the two (Rettew, Lynch, Achenbach, Dumenci, &
Ivanova, 2009; Samuel, 2015). Studies examining the
validity of clinician-​generated diagnoses also suggest that
these diagnoses are less valid than the evidence-​based diag-
noses (Basco et al., 2000; Jewell, Handwerk, Almquist, &
Lucas, 2004; Mojtabai, 2013; Samuel et al., 2013; Tenney,
Schotte, Denys, van Megen, & Westenberg, 2003).
Research–​Practice Gaps in Progress Monitoring
Most of what is known about graduate training in progress
monitoring focuses on trainee psychologists. As described
throughout this volume, most progress monitoring tools
are standardized rating scales, so many of the assessment
training gaps discussed previously also are relevant for
progress monitoring. However, other surveys have focused
on whether trainees are trained in utilizing these scales
for ongoing progress monitoring, rather than for diagnos-
tic assessment. With regard to APA accredited psychol-
ogy programs, Ready and Veague (2014) found that only
approximately half of programs offer courses focused on
progress monitoring, and Mihura et al. (2016) found only
10% of programs require their students to routinely use
outcome measures in their practical. Differing rates of
training in progress monitoring have been found between
19
different types of doctoral programs (e.g., counseling vs.
PsyD; Overington, Fitzpatrick, Hunsley, & Drapeau,
2015) and training program models (e.g., practitioner-​
scholar models vs. clinical-​scientist models; Overington
et al., 2015), although little is known about progress moni-
toring training in master’s programs. Similar to training
programs, fewer than half of internship directors report
having their trainees use progress monitoring (Ionita,
Fitzpatrick, Tomaro, Chen, & Overington, 2016; Mours,
Campbell, Gathercoal, & Peterson, 2009), and nearly
one-​third of directors have never heard of progress moni-
toring measures (Ionita et al., 2016).
Similar to diagnostic assessment, there are low rates
of progress monitoring among practicing clinicians.
Much of the research in this area is focused on outcome
monitoring (Cashel, 2002; Hatfield & Ogles, 2004), with
relatively less focus given to ongoing progress monitor-
ing. Surveys suggest that many clinicians report track-
ing client progress (Anderson & Paulosky, 2004; Gans,
Falco, Schackman, & Winters, 2010). However, many
of them are not using validated measures, instead rely-
ing on tools developed within the clinic, unstructured
interviews, reports from clients, and clinical judgment
(Anderson & Paulosky, 2004; Gans et al., 2010; Johnston
& Gowers, 2005). This finding has been supported in
two recent large surveys of psychologists and master’s
level clinicians, in which fewer than 15% of clinicians
engaged in ongoing progress monitoring (Ionita &
Fitzpatrick, 2014; Jensen-​Doss et al., 2016). Clinicians
who do use progress monitoring measures appear to be
using these measures to track progress internally and
for administrative purposes, but they rarely report using
them to plan treatment or monitor progress (Garland,
Kruse, & Aarons, 2003).
This lack of formal progress monitoring is concern-
ing in light of data showing that it is difficult for clini-
cians to accurately judge client progress based on clinical
judgment alone. For example, when Walfish, McAlister,
O’Donnell, and Lambert (2012) asked a multidisciplinary
sample of clinicians to rate their own level of skills, none of
them ranked themselves as below average, and one-​fourth
of them rated themselves at the 90th percentile of clinical
skill relative to their peers. These therapists estimated that
three-​fourths of their clients improved in therapy, with
less than 5% deteriorating; nearly half of them said that
none of their clients ever deteriorated. The study authors
point out that these estimates deviated wildly from pub-
lished estimates of improvement and deterioration rates.
Interestingly, available data suggest that even when clini-
cians are trained to engage in progress monitoring, this
20
20 Introduction
does not improve their ability to rate progress based on
clinical judgment alone. Hannan and colleagues (2005)
removed feedback reports from a setting that had been
using an MFS and asked clinicians to predict their clients’
outcomes. Those clinicians underestimated how many
clients would deteriorate or not improve, and they over-
estimated how many would improve.
WHY IS THERE A RESEARCH–​P RACTICE GAP
IN ASSESSMENT?
As detailed previously, lack of training is likely one factor
that contributes to clinicians’ not utilizing best assessment
practices. In addition, research has identified other clini-
cian and organizational variables that might be contribut-
ing to this research–​practice gap.
Several studies have focused on clinician attitudes
that might be driving assessment practices. Jensen-​Doss
and Hawley (2010, 2011) conducted a national, multi-
disciplinary survey to assess clinicians’ attitudes toward
standardized assessment tools, with a particular focus on
diagnostic assessment. On average, clinicians reported
neutral to positive attitudes toward standardized assessment
tools, although this varied by discipline, with psychologists
reporting more positive attitudes compared to psychiatrists,
marriage and family therapists, social workers, and mental
health counselors (Jensen-​Doss & Hawley, 2010). Attitudes,
particularly beliefs about the practicality of standardized
assessment tools, predicted self-​reported use of these tools.
Other studies have found that clinicians have concerns that
structured diagnostic interviews would be unacceptable
to clients (Bruchmüller, Margraf, Suppiger, & Schneider,
2011), although data gathered directly from clients do not
support this view (Suppiger et al., 2009).
Studies have also examined clinician attitudes toward
progress monitoring. Across studies, attitudes toward these
measures have varied from neutral to positive, although
concerns regarding the validity of the measures (e.g.,
whether they accurately reflected client progress) are com-
mon (Cashel, 2002; Gilbody et al., 2002; Hatfield & Ogles,
2007; Ionita et al., 2016; Johnston & Gowers, 2005). As
with diagnostic assessment, clinicians often report practi-
cal concerns about progress monitoring, including lim-
ited access to affordable measures, measures being too
long, difficulties reaching clients to fill out measures, and
little time to administer measures and keep track of when
to fill out measures (Gleacher et al., 2016; Hatfield &
Ogles, 2004; Ionita et al., 2016; Johnston & Gowers, 2005;
Kotte et al., 2016; Meehan, McCombes, Hatzipetrou, &
Catchpoole, 2006; Overington et al., 2015). Clinicians also
report anxiety about progress monitoring data being used
for performance evaluation, use of these measures ruining
rapport, concern regarding how to present results correctly
to clients, and a general lack of knowledge about progress
monitoring (Ionita et al., 2016; Johnston & Gowers, 2005;
Meehan et al., 2006). In a study that separately asked about
attitudes toward the practice of progress monitoring and
attitudes toward standardized progress measures, clinicians
reported very positive attitudes toward the idea of monitor-
ing progress but more neutral attitudes toward the mea-
sures themselves (Jensen-​Doss et al., 2016), suggesting that
clinicians are open to engaging in the practice if their con-
cerns about the measures themselves can be addressed.
Consistent with research on diagnostic assessment, more
positive attitudes toward progress monitoring are associ-
ated with higher rates of self-​reported progress monitor-
ing practices (Hatfield & Ogles, 2004; Jensen-​Doss et al.,
2016; Overington et al., 2015).
A number of organizational barriers and facilitators of
EBA have also been identified in the literature. Lack of
organizational support is a barrier frequently mentioned by
clinicians, including both active discouragement from super-
visors and administration regarding the use of measures and
little guidance given by organizational leaders of when and
how often to use them (Connors, Arora, Curtis, & Stephan,
2015; Gilbody et al., 2002; Ionita et al., 2016; Overington
et al., 2015). Many of the practical concerns described previ-
ously also speak to organizational factors, such as the amount
of time clinicians are allowed to spend on assessment and the
budget available for purchasing assessment tools. Clinicians
also often report that administrators are more interested in
tracking administrative outcomes (e.g., length of wait list, cli-
ent turnover, and number of sessions) than outcomes such
as functioning and symptom reduction (Gilbody et al., 2002;
Johnston & Gowers, 2005). Conversely, clinicians who indi-
cate their organizations have policies or rules about assess-
ment are more likely to report using progress monitoring
(Jensen-​Doss et al., 2016). Clinician assessment practices
also vary across organizational settings; providers working
in private practice settings are less likely to use standardized
diagnostic and progress monitoring tools than are those work-
ing in other settings (Jensen-​Doss et al., 2016; Jensen-​Doss &
Hawley, 2010).
EFFORTS TO IMPROVE ASSESSMENT PRACTICES
The studies reviewed previously indicate that although
effective assessment tools exist, they often are not making
21
Dissemination and Implementation of Evidence-Based Assessment
their way into practice settings. As such, several efforts
have been made to bridge this research–​practice gap,
some focused on specific evidence-​based measures (e.g.,
rating scales for trauma; National Child Traumatic Stress
Network, 2016) and others focused on EBA processes
(e.g., using an MFS to gather data and using feedback to
make decisions about treatment; Bickman et al., 2016).
Efforts to improve clinician assessment practices can be
divided into dissemination efforts, or efforts to inform
clinicians about EBA tools, and implementation efforts
that seek to support clinicians in their use of such tools.
Implementation efforts can be subdivided into those
focused on training clinicians in EBA; those focused on
implementing EBA in individual organizations; and those
focused on integrating EBA into mental health systems,
such as state public mental health systems. Although a
comprehensive review of all of these efforts is beyond the
scope of this chapter, we highlight some illustrative exam-
ples of each approach.
Dissemination Efforts
Assessment-​focused dissemination efforts have typically
created sources for clinicians to identify evidence-​based
measures or guides for them to engage in EBA processes.
This volume is an example of an EBA dissemination
effort, as are publications in EBA special journal issues
(Hunsley & Mash, 2005; Jensen-​Doss, 2015; Mash &
Hunsley, 2005) and review papers, such as Leffler, Riebel,
and Hughes’ (2015) review of structured diagnostic inter-
views for clinicians. The DSM board has also embarked
on efforts to improve diagnostic practices and accuracy by
outlining steps for diagnosis and creating decision trees
to support differential diagnosis (First, 2013). Although
these dissemination efforts have typically focused on
what clinicians should do, Koocher and Norcross have
also published articles identifying discredited assessment
methods (Koocher, McMann, Stout, & Norcross, 2015;
Norcross, Koocher, & Garofalo, 2006).
There are also efforts to disseminate EBA informa-
tion online. For example, there is a website dedicated
to information about measures relevant to the assess-
ment of traumatized youth (http://​www.nctsn.org/​
resources/​online-​research/​measures-​review; National
Child Traumatic Stress Network, 2016), a repository of
information about assessment tools relevant to child wel-
fare populations (http://​www.cebc4cw.org/​assessment-​
tools/​measurement-​tools-​highlighted-​on-​the-​cebc; The
California Evidence-​ Based Clearinghouse for Child
Welfare, 2017), and the PROMIS website with measures
21
that assess outcomes for various health domains that pro-
mote and facilitate outcome and progress monitoring
(http://​www.healthmeasures.net/​explore-​measurement-​
systems/​promis; Cella et al., 2010; HealthMeasures,
2017; Pilkonis et al., 2011). In a novel approach to dis-
semination, the APA has recently funded a grant to update
assessment pages on Wikipedia, with a focus on assess-
ments that are freely available (Youngstrom, Jensen-​Doss,
Beidas, Forman, & Ong, 2015–​2016).
Training Efforts
Some groups are moving beyond dissemination to pro-
vide training in EBA to clinicians. Relative to the numer-
ous studies focused on training clinicians in treatments
(Herschell, Kolko, Baumann, & Davis, 2010), there are
fewer EBA training studies. Documented EBA training
efforts to date have consisted of workshops, workshops
plus ongoing consultation, and courses. Didactic training
workshops have helped improve clinician progress moni-
toring attitudes (Edbrooke-​Childs, Wolpert, & Deighton,
2014; Lyon, Dorsey, Pullmann, Silbaugh-​ Cowdin, &
Berliner, 2015), self-​ efficacy (Edbrooke-​Childs et al.,
2014), and use (Persons, Koerner, Eidelman, Thomas, &
Liu, 2016).
Another training approach is to follow workshops with
ongoing consultation. For example, a training effort in
Washington state included 6 months of expert-​led phone
consultation and found that training impacted clini-
cian attitudes, skill, and implementation of standardized
assessment tools (Lyon et al., 2015).
Finally, online training has recently been applied to
EBA training. For example, Swanke and Zeman (2016)
created an online course in diagnostic assessment for mas-
ter’s level social work students. The course was based on a
problem-​based learning approach wherein students were
given diagnostic problems to solve by identifying symp-
toms and matching symptoms to DSM diagnoses. At the
end of the course, the average student grade on content
quizzes was 78.7% and the class was well-​received by the
students, although students’ levels of knowledge prior to
the course are not know, so it is difficult to determine
whether the course actually increased knowledge.
Organizational-​Level Implementation Efforts
Another approach to increasing use of EBA is for orga-
nizations to attempt to change assessment practices
organization-​wide. Several examples of such efforts have
been documented in the literature, including studies
2
22 Introduction
examining the impact of organizations incorporating
structured diagnostic interviews (e.g., Basco et al., 2000;
Lauth, Levy, Júlíusdóttir, Ferrari, & Pétursson, 2008;
Matuschek et al., 2016) and progress monitoring systems
(e.g., Bickman et al., 2011, 2016; Bohnenkamp, Glascoe,
Gracey, Epstein, & Benningfield, 2015; Strauss et al.,
2015; Veerbeek, Voshaar, & Pot, 2012).
One illustrative example of organizational-​ level
implementation work focused on progress monitoring is
the work of Bickman and colleagues. Following an ini-
tial successful randomized effectiveness trial showing that
using an MFS called Contextualized Feedback System
(CFS) improved client outcomes (Bickman et al., 2011),
Bickman and colleagues (2016) conducted a second ran-
domized trial within two mental health organizations. All
clinicians within the agencies were required to administer
CFS, and cases were randomly assigned to receive feed-
back as soon as measures were entered into the system
(i.e., clinicians immediately received feedback reports
summarizing the CFS data) or to receiving feedback
every 6 months. Before the trial began, the investiga-
tors conducted a “pre-​implementation contextualization
phase,” during which they held workgroups to understand
existing clinic procedures and brainstorm about how CFS
would fit into those procedures. Training and ongoing
consultation in CFS was provided to clinicians and to
agency administrators to ensure both clinical (i.e., using it
with individual clients) and organizational (e.g., ongoing
review of aggregated data to identify problems with CFS
implementation) use of CFS. After finding that only one
clinic demonstrated enhanced outcomes with CFS, the
authors determined that the two agencies differed in their
rates of questionnaire completion and viewing of feed-
back reports. To better understand these findings, they
then conducted qualitative interviews with the participat-
ing clinicians (Gleacher et al., 2016). Clinicians at the
clinic with better implementation and outcomes reported
more barriers to using CFS with their clients than did
clinicians at the other clinic, perhaps because they were
using it more often. However, they also reported fewer
barriers at the organizational level and more support from
their organizational leadership. The authors concluded
that organizational factors are strong drivers of implemen-
tation success.
System-​Level Efforts
Another approach to implementation is for mental health
systems, such as state public mental health agencies or
agencies like the Veteran’s Administration, to enact policies
requiring evidence-​based assessment. System-​level imple-
mentations documented in the literature have primarily
focused on progress monitoring. An early example was
the state of Michigan’s use of the Child and Adolescent
Functional Assessment Scale (CAFAS; Hodges & Wong,
1996). As described by Hodges and Wotring (2004), clini-
cians in the public mental health system were required
to use the CAFAS to track client outcomes. Data were
then used to provide clinicians and agencies feedback on
individual client and agency-​wide outcomes, including
comparison to agency and state averages.
Hawaii, which has been a pioneer in the advancement
of evidence-​based treatments (EBTs) in the public sec-
tor, has supported these efforts by developing and imple-
menting an MFS that is used statewide (Higa-​McMillan,
Powell, Daleiden, & Mueller, 2011; Kotte et al., 2016;
Nakamura et al., 2014). To date, both clinicians and case-
workers across various agencies in the state have been
trained in and are implementing the MFS. In an effort to
encourage the use of EBA, Higa-​McMillan et al. reported
the use of “Provider Feedback Data Parties” during which
client progress and clinical utilization of the data are dis-
cussed. Other studies on Hawaii’s EBA efforts observed
that the fit between the MFS and case manager character-
istics facilitated MFS implementation, whereas provider
concerns about the clinical utility and scientific merit of
the MFS were reported as barriers (Kotte et al., 2016).
Internationally, system-​ level efforts to implement
progress monitoring have been reported in the United
Kingdom and Australia. Efforts to implement routine
monitoring throughout the United Kingdom have been
ongoing for well over a decade (Fleming, Jones, Bradley,
& Wolpert, 2016; Hall et al., 2014; Mellor-​Clark, Cross,
Macdonald, & Skjulsvik, 2016). The Child Outcomes
Research Consortium (CORC; http://​www.corc.uk.net),
a learning and planning collaboration of researchers, ther-
apists, managers, and funders, has spearheaded most of
this work. CORC has made valid, reliable, brief, and free
measures available to all clinicians working in the United
Kingdom, provided training in the measures, and created
an MFS to support their use. These measures are reported
to be widely implemented, but not at an optimal level
(Mellor-​Clark et al., 2016), so efforts are now focused on
adopting more theory-​driven approaches to implement-
ing the system (Mellor-​Clark et al., 2016; Meyers, Durlak,
& Wandersman, 2012). In Australia, efforts to implement
progress monitoring have been ongoing since the late
1990s and include training and development of computer
systems to support data collection and analysis (Meehan
et al., 2006; Trauer, Gill, Pedwell, & Slattery, 2006).
23
Dissemination and Implementation of Evidence-Based Assessment
Outcome data are collected at all public clinics and are
aggregated at a national level to be used for comparison
by local clinics.
Finally, note that policies focused on other aspects of
care can also have implications for assessment. For exam-
ple, the Precision Medicine Initiative (The White House
Office of the Press Secretary, 2015) focuses on increasing
personalized medical treatments that take individual dif-
ferences in genes and environment into account. Such
tailored approaches are likely going to require increased
use of psychosocial assessment in health care settings.
Similarly, the US Medicare and Medicaid system is mov-
ing increasingly toward value-​ based payment, where
reimbursement is based on quality, rather than quantity,
of care (Centers of Medicare & Medicaid Services, 2016).
As such, assessment of quality indicators within publicly
funded behavioral health settings is going to become
increasingly important. Finally, initiatives to implement
EBTs often lead to the development of assessment pro-
cesses to support those treatments, as evidenced by the
Hawaii initiative described previously.
FUTURE DIRECTIONS
As we hope this review has made clear, the literature
on EBA contains both good and bad news. On the one
hand, a number of excellent EBA tools exist and some
efforts are underway to encourage clinician use of those
tools. On the other hand, significant gaps continue to
exist between assessment best practices and what the
average clinician does in practice. To address these gaps,
we have several suggestions for future directions the field
should take.
1. Increase graduate-​level training in evidence-​based
diagnostic assessment and progress monitoring. Most of the
training and implementation efforts described previously
have primarily focused on retraining clinicians whose
graduate training likely did not include in-​depth training
in structured diagnostic assessment or progress monitor-
ing. Researchers focused on EBTs have called for an
increased focus on training at the graduate level because
training people well at the outset is likely easier and more
cost-​effective than trying to retrain them (e.g., Bearman,
Wadkins, Bailin, & Doctoroff, 2015).
One avenue for improving graduate training is increas-
ing the specificity of accreditation guidelines for training
programs (Dozois et al., 2014; Ponniah et al., 2011). For
both psychology and psychiatry training programs, past
accreditation standards stressed the need for students
23
to attain competence in diagnosis of clients via mea-
surement and interviews and to assess treatment effec-
tiveness, but they gave little guidance regarding what
constitutes appropriate assessment (APA, 2006; Canadian
Psychological Association, 2011; Ponniah et al., 2011).
A similar picture exists in accreditation guidelines for
mental health counseling (American Mental Health
Counselors Association, 2011), marriage and family
therapy (Commission on Accreditation for Marriage
and Family Therapy Education, 2014), and bachelor’s
and master’s level social work programs (Commission on
Accreditation & Policy, 2015), although these guidelines
do include training in progress monitoring as a way to per-
form program evaluation.
In January 2017, a new set of accreditation guide-
lines for the APA went into effect that include EBA as
a core competency (APA Commission on Accreditation,
2015). A recent Canadian task force focused on increas-
ing EBP use (Task Force on Evidence-​Based Practice of
Psychological Treatments; Dozois et al., 2014) empha-
sized monitoring progress and outcomes throughout treat-
ment. However, the Canadian Psychological Association
accreditation guidelines for doctoral programs have not
been updated to reflect this change as of this publication.
2. Increase “best practice” training strategies in EBA
dissemination and implementation efforts. Although
exceptions exist (Lyon et al., 2015), the primary approach
that has been taken to training clinicians in EBA is
what is sometimes referred to as a “train and pray”
approach: Bring clinicians together for a workshop and
then hope they take what they have learned and apply it
in practice. The literature on training in EBTs suggests
that such an approach is unlikely to lead to sustained
practice changes (Herschell et al., 2010). Rather, train-
ing needs to involve active learning strategies, ongoing
consultation in the practice, and attention to contextual
variables such as whether clinicians have adequate orga-
nizational support to continue using the practice (Beidas
& Kendall, 2010; Herschell et al., 2010). Examples of
strategies that could be incorporated into EBA trainings
include engaging clinicians in behavioral rehearsal dur-
ing training (Beidas, Cross, & Dorsey, 2014); providing
ongoing consultation after initial training (e.g., Bickman
et al., 2016; Lyon et al., 2015); increasing sustainability of
assessment practices through “train the trainer” models
that train agency supervisors to provide ongoing supervi-
sion assessment (Connors et al., 2015); and incorporat-
ing all levels of an agency into training through learning
collaborative models that address implementation at the
clinician, supervisor, and administrator levels (e.g., Ebert,
24
24 Introduction
Amaya-​Jackson, Markiewicz, Kisiel, & Fairbank, 2012;
Nadeem, Olin, Hill, Hoagwood, & Horwitz, 2014).
3. Increase our focus on pragmatic assessment. Studies
conducted with clinicians consistently suggest that
perceived lack of practicality is a major barrier to clini-
cian use of EBA (e.g., Ionita et al., 2016; Jensen-​Doss &
Hawley, 2010). In addition, the fact that many clinicians
who do gather assessment data do not actually incorpo-
rate that data into clinical decisions (Garland et al., 2003;
Johnston & Gowers, 2005) suggests that they may not
find the data clinically useful. Glasgow and Riley (2013)
have called for the field to focus on pragmatic measures,
which they define as measures “that [have] relevance to
stakeholders and [are] feasible to use in most real-​world
settings to assess progress” (p. 237). They propose criteria
for determining whether a measure is pragmatic, includ-
ing that is it important to stakeholders, such as clients,
clinicians, or administrators; that it is low burden to com-
plete; that it generates actionable information that can be
used in decision-​making; and that it is sensitive to change
over time. Expanding our reviews of EBA tools to include
dimensions such as these might help identify measures
most likely to make their way into practice. One example
of such a review was conducted by Beidas and colleagues
(2015), who identified brief, free measures and rated their
psychometric support for a range of purposes, including
screening, diagnosis, and progress monitoring.
Another opportunity for increasing the practical-
ity of assessment is to take advantage of recent policies
emphasizing increased data collection and accountability
in health care settings (e.g., the “Patient Protection and
Affordable Care Act,” 2010). Lyon and Lewis (2016) point
out the opportunity that these policies provide for increas-
ing use of progress monitoring. As agencies increasingly
incorporate health information technologies, such as
electronic medical records, into their settings to meet
data reporting requirements, there is an opportunity to
integrate electronic MFSs into these systems (Lyon et al.,
2016). If progress monitoring can be built into the daily
workflow of clinicians, this greatly increases its practicality.
4. Leverage technology to increase the use of EBA.
Another avenue for increasing the practicality of assess-
ment is to incorporate technologies such as electronic
health care records platforms and smartphone applica-
tions into the assessment process. With the rise of policies
emphasizing increased data collection and accountabil-
ity in health care settings (e.g., “Patient Protection and
Affordable Care Act,” 2010), mental health settings are
increasingly relying on health information technolo-
gies, such as electronic health care records, to meet data
reporting requirements. Lyon and Lewis (2016) point out
these shifts provide an opportunity to increase the use
of progress monitoring. In a recent review, Lyon, Lewis,
Boyd, Hendrix, and Liu (2016) identified 49 digital MFSs
that could be used by clinicians with access to comput-
ers or tablets to administer progress measures and rap-
idly receive feedback. However, fewer than one-​third of
those were able to be directly incorporated into electronic
health care records, and Lyon and colleagues concluded
that additional work is needed to develop digital MFSs
that can be incorporated into the daily workflow of prac-
tice in a way that is sustainable.
Another technological advance with great potential
to enhance assessment is smartphone technologies that
support data collection. Researchers have developed
applications to support real-​time data collection (Trull
& Ebner-​Priemer, 2009) and have begun to examine the
clinical utility of such applications for gathering informa-
tion such as mood (e.g., Schwartz, Schultz, Reider, &
Saunders, 2016) or pain ratings (Sánchez-​Rodríguez, de
la Vega, Castarlenas, Roset, & Miró, 2015). Such applica-
tions could facilitate self-​monitoring of symptoms between
sessions or efficient collection and scoring of progress
monitoring data in session. Many smartphone applications
to track psychological well-​being are already commercially
available (e.g., a November 15, 2016, search of the Google
Play store yielded more than 50 results for “mood track-
ing”), and an important next step is to determine how
these applications can be ethically developed and incorpo-
rated into clinical practice (Jones & Moffitt, 2016).
5. Develop theoretical models of organizational support
for EBA. Despite numerous studies suggesting that orga-
nizational context is critical to EBA (e.g., Gleacher et al.,
2016; Jensen-​Doss et al., 2016), there is a need for concep-
tual models that can guide organizational approaches to
improving assessment practices. Models of organizational
culture and climate have been developed to explain use
of EBTs (e.g., Williams & Glisson, 2014) and have been
translated into organizational interventions that improve
EBT uptake and client outcomes (e.g., Glisson, Williams,
Hemmelgarn, Proctor, & Green, 2016). Many aspects of
these models are likely applicable to the use of EBA, but
the constructs within them may need to be elaborated.
Although existing models might be helpful to guide
EBA implementation in agency settings such as clinics or
schools, these models are not as applicable to clinicians
working in private practice, who seem to be the clinicians
least likely to engage in EBA (Jensen-​Doss et al., 2016).
Additional work is needed to understand the needs of this
population.
Another random document with
no related content on Scribd:
sentiva spuntarsi una lacrima. Non poteva a meno di rievocare il
tempo in cui que’ suoi cari rallegravano il tetto domestico e
scherzavano sulle ginocchia materne. Ahimè, ormai la madre era
morta da un pezzo.... Involontariamente l’occhio del colonnello si
posava sulla parete ove sotto i ritratti di Vittorio Emanuele, di
Umberto, di Garibaldi, di Lamarmora, di Napoleone III, ecc., ecc.,
c’era un gruppo di fotografie di famiglia. La più antica e sbiadita era
appunto quella di sua moglie, una donna esile, dall’aria stanca e
sofferente. A fianco di lei Bedeschi in persona, in uniforme, con la
sua medaglia al valor militare sul petto, con la sua mano bravamente
piantata sull’elsa della sciabola. Qualche linea più sotto l’effigie di tre
giovinotti, Vittorio, Augusto, ed un terzo, minore di tutti.
Sicuro, c’era un terzo figliuolo, Federico, ed egli solo non s’era fatto
vivo in quel giorno, e da Londra, dove si trovava, non aveva spedito
nè una lettera, nè un dispaccio. Quando Bedeschi pensava a questo
ragazzo ch’era stato il suo preferito egli si doleva di aver ceduto una
volta tanto alle preghiere di sua moglie, la quale, impuntatasi
nell’idea che Federico fosse di salute cagionevole, aveva, tra gemiti
e singhiozzi, scongiurato il marito di non fargli abbracciar la carriera
militare come i fratelli, e strappatagliene un giorno a malincuore la
promessa, se l’era fatta rinnovare solennemente al letto di morte.
Federico era quindi rimasto in casa, aveva frequentate le scuole
pubbliche, ed era giunto senza gloria fino all’università. Non gli
mancava nè cuore nè ingegno, ma aveva uno spirito indisciplinato,
ripugnante a studi regolari, turbato piuttosto da vaghe inquietudini
d’artista. Onde nel bel mezzo del corso di legge gli era saltato il
ghiribizzo di darsi alla pittura, con grande sdegno del colonnello, il
quale nè amava l’arte, nè credeva a questa vocazione improvvisa.
N’eran seguite scene violente, per merito delle quali Federico aveva
finito col non studiar nè pittura nè legge e col menare una vita oziosa
e dissipata. Allora il padre gli aveva posto un dilemma. O mettersi in
grado di prendere la laurea entro un anno, o partire subito per
Londra, ove un antico compagno di cospirazioni del colonnello,
arricchitosi nel commercio, impiegava volentieri dei giovani italiani
per mandarli, dopo un tirocinio più o meno lungo, presso le sue case
filiali di San Francisco o di Sidney. Federico che della laurea non
voleva saperne accettò la seconda proposta; meglio far il minatore in
California o il pastore in Australia che incretinirsi su una scranna di
giudice o assottigliare il cervello nei cavilli avvocateschi.
E partì con una cert’aria spavalda che il colonnello, cattivo psicologo,
attribuì a perversità d’animo, mentre Federico, dal canto suo,
risentiva profondamente l’affettata indifferenza del padre. Come
avviene quando c’è un equivoco che non si chiarisce subito, la
freddezza reciproca andò a mano a mano crescendo; padre e
figliuolo si accusavano in silenzio di poco cuore e non si
scambiavano che lettere brevi, fredde e insignificanti.
Frattanto entrò in casa la Bice portando nella dimora solitaria un
nuovo alito di giovinezza, togliendole quell’aspetto triste e desolato
ch’essa aveva nelle prime settimane dell’assenza di Federico. Senza
volerlo, senza saperlo, la fanciulla nuoceva al cugino. Una frase
dello zio lo mise in guardia. — Non parliamo di quello scapato. —
egli le disse. — Ora sei tu che ne tieni il posto.
Tenere il posto di Federico? No, ciò non poteva, non doveva essere.
Ed ella dichiarò allo zio che prima che accadesse una cosa simile
sarebbe tornata in collegio, sicura di farvisi accettare dalla direttrice
come assistente.
Alla lunga si calmò, ma fermando il proposito di esercitar tutta la
propria influenza per sopire quel dissidio domestico. Pur non tardò
ad accorgersi che l’impresa era ardua ed esigeva infinite cautele.
Non le fu difficile mettersi in relazione con Federico, avendola lo zio
stesso incaricata talora di scrivergli in vece sua. E Federico le
rispose in principio diffidente e guardingo, poi, via via, più sciolto ed
espansivo. A lei rivelava la tristezza del suo esilio, l’acuta nostalgia
da cui era sovente assalito, la sua ripugnanza ad allontanarsi ancora
di più dall’Italia, la sua sfiducia assoluta di far buona prova nella
mercatura. Ma soprattutto le discorreva dell’arte, ch’egli aveva
ripreso ad amar con passione, che coltivava in segreto, e nella quale
avrebbe potuto forse non esser degli ultimi se gli fosse stato
permesso di dedicarvisi intero.
Il colonnello Bedeschi aveva tempra di despota, non d’inquisitore, e
avrebbe stimato inferiore alla sua dignità lo spiar le corrispondenze
della nipote. Delle lettere ch’ella riceveva da Federico egli sapeva
quel tanto che a lei piaceva di dirgliene, ed è naturale ch’ella gliene
presentasse un’edizione riveduta e corretta. Accennava alla
condotta regolare del giovine, al desiderio ch’egli manifestava di
riacquistare l’affetto e la stima del padre.... soggiungendo
timidamente che a parer suo non c’era ragione di tenerlo più oltre in
castigo a Londra, e meno che mai di spedirlo in capo al mondo.
La prima volta che la Bice toccò questo tasto, Bedeschi montò su
tutte le furie. — O ch’ella pretendeva di dargli lezioni? Ella, una
bambina, con quell’esperienza che aveva? Badasse ai casi suoi e
non s’impicciasse di ciò che non la riguardava. Se Federico le
scriveva delle sciocchezze, padrone; e padrona lei di rispondergliene
altrettante, ma non venisse a far la saccente. Aveva capito?
La fanciulla non si smarrì d’animo per questo rabbuffo nè perdette di
vista la sua meta. A ogni occasione opportuna ella tornava alla
carica, sopportando in santa pace le sfuriate dello zio, il quale, in
cuor suo, non si rammaricava troppo ch’ella difendesse il cugino. Ma
il colonnello aveva riputazione d’uomo forte, d’uomo inflessibile, e
certe riputazioni sono come un patrimonio da conservare. Bedeschi
non voleva che si dicesse ch’egli s’infemminiva cogli anni. Accadeva
poi un fatto curioso. Quantunque egli non osasse confessarlo a sè
stesso, la Bice gli diventava più cara per la sua generosità nel
prender le parti di Federico, e appunto col diventargli più cara gli
rendeva meno sensibile la mancanza del figlio.
S’era sbagliata strada. La Bice lo riconobbe e mutò tattica. Da due o
tre mesi ella non parlava di Federico che quand’era strettamente
necessario il parlarne, pareva rassegnata non solo alla relegazione
del cugino a Londra, ma anche alla sua partenza per Sidney o San
Francisco.
— È frivola e obliosa come tutte le donne, — pensava il vecchio
soldato. — Que’ suoi grandi ardori battaglieri sono sbolliti.
E non le sapeva grado della sua docilità. Era meno sicuro di aver
ragione dacchè nessuno gli dava torto.
Ella intanto ne pesava le parole, ne scrutava i silenzi, i gesti,
l’espressione della fisonomia, arrischiando di tratto in tratto con finta
ingenuità una frase, una domanda, come un generale che spinge
innanzi i suoi esploratori per esaminare il terreno.
— Se Federico deve lasciar l’Europa, — ella disse una mattina, —
suppongo che verrà prima a salutarci.
Bedeschi levò il capo con un movimento brusco. — Non so....
Forse.... Vedremo.... — E sentendo lo sguardo della nipote fisso
sopra di lui, si alzò da sedere e uscì dalla stanza.
La corrispondenza fra i due cugini durava non interrotta e non
vigilata. Federico tradiva spesso la sua impazienza, accusava la
Bice di non spiegar sufficiente energia per agevolargli il ritorno in
patria, dichiarava che assolutamente a Londra non ci poteva stare e
che avrebbe finito col fare un colpo di testa.... Poi, nella medesima
lettera, chiedeva scusa della sua petulanza e prometteva di seguire
a occhi chiusi i consigli della sua savia cuginetta, ch’egli si ricordava
in vestito da collegiale e che aveva giudizio da vendere a lui e a
molti altri meglio di lui.
E la savia cuginetta gli aveva scritto un giorno con gravità di esperta
diplomatica: — Un colpo di testa può anche esser necessario, ma
bisogna saper scegliere il momento di farlo. Il momento lo sceglierò
io.

II.

— Eccomi, — disse la Bice comparendo nel salotto ove si trovava lo

zio.
Egli gettò via il giornale L’Esercito che stava leggendo e si preparò a
darle una risciacquata di capo pel suo lungo ritardo. Ma l’aspetto
singolare in cui ella gli si presentava gli strappò invece un sorriso dal
labbro. E disse soltanto: — Finalmente!... E in quale arnese!
La ragazza aveva un lungo grembiale bianco che le scendeva dalle
ascelle ai piedi, le maniche del vestito rimboccate fino ai gomiti, le
mani e i polsi impiastricciati di farina, e teneva appunto le mani
aperte e le braccia larghe, discoste dai fianchi, per non insudiciarsi di
più. Aveva un po’ di farina anche sul viso e nei capelli.
— Eh, non ho terminato che adesso — ella rispose. — Sono in
tenuta di fatica.
— Vada a mutarsi dunque.... presto.
— Vado.... ma che cosa voleva, zio, che mi ha fatto chiamare?
È vero. Che cosa voleva? Non se lo rammentava neppur lui.... Ah sì,
voleva rimproverarla. E riprese: — Perder la giornata per fare un
dolce. Vergogna!
— Fare e rifare, caro zio.... Senza dubbio, la ricetta era sbagliata....
Si figuri che se non ci mettevo un bicchier di latte di più veniva fuori
qualcosa di duro come una palla di cannone....
— E ce l’hai aggiunto di tuo capo?
— Già.... La cuoca non vuole responsabilità. È un’impertinente. Sa
quel che ha detto? “Mi perdoni, ma io non intendo immischiarmi ne’
suoi pasticci.„
— Ha ragione.... Ma non forzerai neanche me a mangiarlo il tuo
pasticcio.
— Oh lo assaggerà almeno.... per poter suggerirmi le correzioni da
farsi domani.
— Domani?
— Ma scusi, non eravamo d’accordo? Quella d’oggi è una prova....
Domani poi che ci sono i veterani a pranzo.
La Bice chiamava così tre ufficiali in pensione, antichi commilitoni
dello zio, il quale li invitava a desinare un paio di volte all’anno.
— Per i veterani — interruppe il colonnello — manderemo a
prendere dall’offelliere un dolce che non sia duro come una palla di
cannone.
La ragazza fece un segno di protesta.
— E a proposito — ripigliò Bedeschi — che ghiribizzo è stato quello
di voler che invitassi i miei amici per domani e non per oggi?
— Volere? — disse la Bice con accento sommesso. — Ho pregato....
Mi pareva che la vigilia di Natale fosse meglio passarla in famiglia.
La fronte del colonnello si annuvolò. — Famiglia numerosa in verità
— egli borbottò fra i denti.
— Ma! — sospirò la Bice.
— Vatti a vestire, va, — soggiunse lo zio.
Ella non si moveva.
— Che c’è adesso?
— Nulla.... Pensavo.
— A che cosa?
— Pensavo a tanti anni fa.... l’anno prima ch’io andassi in collegio,
quando il Natale si festeggiò qui tutti uniti.... Che tavola allegra!
C’erano il mio babbo e la mia mamma, c’era la zia, e Vittorio e
Augusto, venuti in vacanza per una quindicina di giorni, e
Federico.... Noi due eravamo i più giovani.... Egli faceva mille
biricchinate e mi legò con la treccia alla spalliera della seggiola.... Oh
mi par ieri.... E ora gli uni son morti, gli altri dispersi pel mondo.
Si voltò commossa, con le pupille umide.
Lo zio, infastidito, le diede sulla voce. — Per carità, non mi far
piagnistei. I morti lasciamoli in pace, e quanto a quelli che sono
dispersi, due calcolo che siano con noi; il terzo, il tuo carissimo
Federico, è meglio dimenticarlo com’egli dimentica.
Ella fu in procinto di mettergli la mano sulla bocca per farlo tacere.
Ma si ricordò ch’era tutta infarinata e si trattenne in tempo,
sorridendo in mezzo alle lacrime: — Non le dica neanche per
ischerzo queste cose. Se Federico non ha ancora scritto, questo non
significa che abbia dimenticato.... Giurerei che la lettera è in viaggio.
Il colonnello fece una spallucciata. — Del resto, peggio per lui. A me
non importa proprio niente.
Balzò in piedi e ripetè alla nipote: — Vatti a vestire. A meno che oggi
non si debba rinunziare al pranzo....
La ragazza guardò l’orologio. — Pel pranzo ci vorrà un’oretta.... o
un’oretta e un quarto.... secondo il punto in cui sarà il dolce.
— Insomma, Bice, — saltò su lo zio aggrottando le ciglia, — ogni bel
gioco dura poco.... Vada e torni vestita entro venti minuti, e quando
torna, a qualunque punto sia il dolce, disponga perchè portino subito
in tavola.... Marsch.
— Oh, — esclamò il colonnello appena rimasto solo. — È
indispensabile di por ordine a questa faccenda. Colei con le sue
smorfiette ottiene sempre quello che vuole.
Il peggio si è ch’ella lo faceva diventar patetico, sentimentale, lui, il
colonnello Bedeschi! Non aveva dovuto rasciugarsi gli occhi, quella
sera stessa, nel guardare le fotografie di famiglia? Non era stato lì lì
per commoversi quando la Bice aveva evocato la memoria di quel
Natale lontano? Non si crucciava fuori di luogo e di modo perchè
quel caposcarico del figliuolo minore tardava a mandare gli auguri
per le feste? Non soffriva all’assenza di questo ragazzo più assai
che non volesse ammettere di soffrire? Non vedeva con un certo
sgomento avvicinarsi il tempo nel quale Federico avrebbe dovuto
andare di là dall’oceano? Non c’erano dei momenti in cui gli sarebbe
venuta una gran tentazione di richiamarlo?
No, così non poteva durare. Il colonnello aveva bisogno di ricuperar
la stoica impassibilità d’una volta, anche a costo di allontanar da sè
la nipote. Ell’aveva diciott’anni, era piacente, graziosa, possedeva un
quarantamila lire di suo, altre ventimila gliene avrebbe date lui, non
doveva esser difficile di trovarle un marito.... Trovarle marito, e poi
rimaner solo, con Battista, l’ordinanza, e coi veterani per commensali
nelle grandi solennità.... Che bella prospettiva! Tanto bella che il
colonnello, nell’eccesso della gioia, diede sulla tavola un pugno così
formidabile da far quasi cadere il lume. Indi se la prese col giornale
L’Esercito che gli parve indegno di avere nemmeno un associato;
stracciò in due pezzi il numero che aveva fra le mani e ne fece due
pallottole che scagliò a due angoli della stanza. Dopo le quali gesta
tirò fuori il suo cronometro per vedere se fossero trascorsi i venti
minuti ch’egli aveva assegnati alla Bice per la sua toilette.
— Venti minuti giusti, nè uno di più nè uno di meno, — disse la
giovinetta entrando proprio in quel punto. Ella vestiva un abito di
lana celeste con guarnizioni di peluche, portava al collo un filo di
corallo, e buccole pur di corallo agli orecchi. Nei folti e lucidi capelli
aveva intrecciato un nastrino di velluto rosso che ne faceva meglio
spiccare il colore castano scuro e dava risalto ai suoi occhi bruni e
vivaci. Del resto non aveva lineamenti regolarissimi, nè poteva dirsi
bella nello stretto senso della parola, ma la persona agile e svelta e
l’espressione della fisonomia dolce ed arguta ad un tempo la
rendevano preferibile a molte vantate bellezze.
— Sfido un’altra a far così presto, — ella continuò avanzandosi
verso lo zio, che, suo malgrado, era rimasto colpito dalla geniale
apparizione. Ma egli era armato contro le seduzioni e rispose in
tuono burbero: — Bene, bene.... E che necessità c’era di mettersi in
fronzoli?... Tutte civette, le donne....
— Oh zio, mi son messa il vestito buono e i coralli che mi ha
regalato lei il mese passato.... Dovevo lasciarli sempre chiusi in
cassetto?
— Non dico questo.... Se ci fosse qualcheduno a pranzo.... Domani,
per esempio....
— Oh, pegli estranei.... Se però esige che vada a mutarmi di
nuovo...?
— Sì, per non finirla più.... Hai dato gli ordini in cucina?
— No, veramente.... Volevo darli adesso....
Bedeschi mise un’esclamazione poco parlamentare e tirò con
violenza il campanello.
Si presentò Battista.
— Il pranzo è pronto? — chiese il colonnello con voce tuonante.
Il servo guardò la signorina.
— Non guardate la signorina, guardate me, e rispondete.
— Ma, — balbettò Battista. — Dev’esser pronto tutto.... tranne il
dolce.... che la cuoca dice che non sarà pronto mai....
— Gelosia di mestiere, — rimbeccò la Bice.
— Se tutto è pronto, tranne quello che non sarà pronto mai, —
ripigliò il colonnello, — scodellate la minestra immediatamente.
Battista voleva soggiungere qualcosa, ma la padroncina con un
gesto di rassegnazione lo pregò di tacere.
Di lì a poco, nel salotto da pranzo bene riscaldato ed illuminato, zio e
nipote sedevano a tavola l’uno di fronte all’altra e parevano entrambi
in poco felici disposizioni d’umore. Lo zio trovava da ridire su tutte le
pietanze, la nipote, d’ordinario chiacchierina e vivace, s’era
ammutolita ad un tratto, e in preda a una singolare inquietudine
s’agitava sulla sedia, tendeva l’orecchio ai più lievi rumori, e alzava
ogni tanto gli occhi verso la mostra d’un orologio.
La Bice arrossì come uno scolaro colto in fallo, e disse: —
Osservavo ch’è molto tardi.
— Bella scoperta! Di chi la colpa?
In quel momento si sentì una scampanellata alla porta di strada; la
Bice balzò fuori della stanza, e Battista, che quella sera serviva
peggio del solito, rovesciò una bottiglia di vino sulla tovaglia.
— Imbecille! — urlò il padrone. E avrebbe aggiunto chi sa quali altri
epiteti se non fosse stata la curiosità di saper chi era venuto.
— Andate di là, — egli ordinò al domestico che non se lo fece
ripetere due volte, — e tornate subito a dirmi chi è.
Ma Battista non tornò subito. Tornò invece la Bice con una strana
espressione nella fisonomia, e si fermò sulla soglia.
— Ebbene? Che cos’è successo? Siamo in un ospedale di pazzi? —
chiese il colonnello.
— Oh zio, — rispose la ragazza. — Se mi fa quei visacci non ho
coraggio....
— Finiamola.... Chi è venuto?
— È venuto.... un forastiero....
— Un forastiero.... Chi?....
La Bice esitava.
— Chi, in nome del cielo?
— Oh sa, faccio come nelle commedie, io.... Avanti, Federico.
E tirò a sè il battente dell’uscio, dietro a cui si trovava Federico in
persona.
Si ha un bell’esser corazzati contro le debolezze umane, si ha un bel
voler foggiarsi sul tipo inflessibile di Bruto primo e di Manlio, allorchè
un figliuolo che si credeva di non rivedere per un gran pezzo vi
compare dinanzi all’improvviso, e con uno sguardo più eloquente
d’ogni parola vi chiede perdono de’ suoi trascorsi e ridomanda la sua
parte di affetto e il suo posto al focolare domestico, è impossibile
non cedere al bisogno di spalancargli le braccia. Il tempo delle
riflessioni verrà, verrà forse il tempo di pentirsi dell’aver ceduto a
questo primo movimento; intanto il cuore, sia pur di sorpresa, riporta
una vittoria che non è mai senza conseguenze per l’avvenire.
Tutto ciò accadde al colonnello Bedeschi, il quale faceva inutili sforzi
per nascondere la propria emozione, e girando intorno a questo figlio
piovutogli dall’Inghilterra e divorandolo con gli occhi, tradiva la sua
sollecitudine con una sequela di domande: — Non sei mica malato,
eh? — Non hai mica patito freddo per viaggio? — Sei stanco? — Hai
ancora da pranzare?
E mentre Federico ch’era un florido giovinetto sui ventitrè anni gli
rispondeva che stava benissimo, che s’era rifocillato a Verona, ma
che nondimeno avrebbe preso volentieri una tazza di brodo, il
colonnello scoteva il braccio della Bice.... — Via, perchè non ti
muovi?... E dov’è quello stupido di Battista? O non c’è del brodo
caldo in cucina?
— Ce n’è, ce n’è.... Ecco Battista con la zuppiera. È provvisto alla
cena, alla camera, a tutto....
— Tu sapevi dunque?
— Naturalmente.
— E anche la servitù?
Battista evitava lo sguardo del padrone. Federico non alzava il naso
dal piatto. La Bice sola, imperterrita, affrontava il fuoco.
— Anche la servitù. Da questa mattina.... L’avevo detto io.
— Ma perchè tanti sotterfugi?
— Ecco.... — principiò Federico al quale sembrava poco
cavalleresco il non accorrere in aiuto a sua cugina.
Ma il padre lo interruppe. — Tu bada a mangiare. La Bice ha la
lingua sciolta.
— Oh, — ripigliò questa, — mi spiccio in due parole. Se Federico
scriveva a lei che non ne poteva più delle nebbie di Londra, che
provava un bisogno imperioso di riscaldarsi al sole d’Italia, di
rivedere la casa, la famiglia, insomma se le chiedeva il permesso, lei
non glielo avrebbe dato, e allora come si faceva a disubbidire?...
Invece di scrivere a lei, Federico scriveva a me.... Non era un
segreto la nostra corrispondenza....
— No, certo; però non mi sarei immaginato che ne usaste per
cospirare. Alle corte, quel permesso che forse non avrei dato io, l’hai
dato tu.
— Al momento opportuno ho incoraggiato Federico a perorar la sua
causa in persona. Lo assicuravo che suo padre era un uomo severo,
ma un cuore come ve ne son pochi....
— Basta, basta, — disse il colonnello. — È inutile dorare la pillola. —
Indi rivolgendosi al figliuolo: — E il mio amico Giraldi, il tuo
principale, è anche lui della congiura? Son sei o sette mesi che non
mi manda una riga.
Federico estrasse del taccuino una lettera e la porse al padre.
— Oh! — disse questo. — Son due lettere, una dentro dell’altra.
— Leggi e vedrai.
Giraldi scriveva ad Annibale Bedeschi lodandosi della condotta e
della intelligenza di Federico, ma soggiungendo che non gli pareva
uomo nato pel commercio, e che, secondo lui, era molto meglio
lasciargli studiar l’arte per la quale mostrava disposizioni singolari. In
prova di che inchiudeva un biglietto del celebre Whitty, uno dei primi
pittori di Londra, che aveva visto i disegni del giovine e ne traeva i
più lieti pronostici per l’avvenire.
Il colonnello diede un’occhiata al biglietto in questione. — È in
inglese! — egli esclamò. — O che che cosa devo capirci io?
Federico si offerse di tradurlo. Ma la Bice propose di rimetter le
spiegazioni al domani. Erano tutti stanchi, e Federico in particolare
cascava dal sonno.
— È vero, — assentì il colonnello. — Federico dovrebbe andarsene
a letto.
A questo punto la Bice si picchiò la fronte con la mano. — E il mio
dolce? Battista, fate il piacere di domandarne conto alla cuoca.
Il cugino mise un’esclamazione ammirativa. — Anche di pasticceria
te ne intendi?
— Un poco.
— Uhm! — fece il colonnello.
Battista rientrò in salotto con aria contrita, e depose davanti al
padrone un piatto che conteneva un oggetto informe.
— È questo il tuo dolce? — chiese ironicamente lo zio dopo alcuni
vani tentativi di fenderne la crosta col coltello.
La Bice, mortificata, non riconosceva più l’opera sua. — Così me lo
hanno ridotto?
Federico non potè trattenere una sonora risata.
— Hai torto di ridere, — disse la giovinetta. — Quella, vedi, è tutta
malizia della cuoca, invidiosa de’ miei trionfi. Un’altra volta....
— Non c’è altra volta che tenga, — protestò il colonnello. — Basta
una, ce n’è d’avanzo.
La Bice si strinse nelle spalle. — Il mio dolce avrà servito a ogni
modo a far ritardare il pranzo. Se la corsa fosse arrivata in orario,
Federico avrebbe desinato con noi, anzichè trovarci alle frutta.... E
adesso....
— O che c’è ancora?... Non volevi che tuo cugino andasse a
riposarsi?
— Sì, ma poichè rimane un sorso di vino nei bicchieri faccio un
brindisi ai due assenti Vittorio e Augusto.
— Con tutto il cuore, — risposero a una voce padre e figliuolo.
— Agli assenti e al reduce, — ella soggiunse.
— Sia pure.... Anche al reduce, — ripetè il colonnello avvicinando il
suo bicchiere a quello di Federico. — Abbiamo però sempre dei
conti da regolare.

· · · · · · · · · · · · · · · ·

Quando Federico si mosse per salire nella sua camera, la Bice lo

accompagnò fino sul pianerottolo. Egli non aveva parole abbastanza
per ringraziarla, per esaltare il suo spirito, la sua bravura.
— Non facciamoci illusioni — ella disse. — Non cantiamo vittoria
troppo presto.
— Con te, mia cara, si vinceranno tutte le battaglie, — replicò il
cugino. E dopo una breve pausa, abbassando la voce e
avvolgendola d’uno sguardo ch’esprimeva il più sincero entusiasmo:
— Sai che ho fatto un’altra grande scoperta?
La Bice abbassò involontariamente gli occhi. — Quale?
— Che sei diventata proprio bella.... ma proprio.... non è già un
complimento.
— Pazzo che sei! — disse la ragazza imporporandosi in viso. —
Buona notte, buona notte. — El o piantò lì col lume in mano,
incantato a guardarla.

· · · · · · · · · · · · · · · ·

Come si accomodassero le faccende il dì appresso, che

conseguenze avesse nell’avvenire la grande scoperta di Federico, a
che risultato approdasse la visibile simpatia de’ due cugini, son tutte
cose che non si possono saper subito.... Al Natale prossimo.... forse.
 LA ZIA TERESA.

Quella sera, quando s’udì la scampanellata del postino, in casa

dell’avvocato Ettore Gualtieri avevano appena finito di desinare. La
cameriera entrò in salotto portando due giornali pel padrone e una
grossa lettera coperta di francobolli per la signorina Amelia.
La signorina Amelia, una leggiadra giovinetta di forse diciott’anni,
divenne rossa ed esclamò: — È della zia Teresa.
E agitando la lettera con aria trionfale soggiunse: — Scommetto che
qui c’è la fotografia. Era tempo.
Con un oh, oh di curiosità tutti quanti si strinsero intorno all’Amelia.
Erano in quattro, l’avvocato Ettore e la signora Luisa sua moglie, la
Carolina, una ragazza in quell’età critica nella quale è arrischiato
ogni pronostico sulla bellezza femminile, e Amedeo, un fanciullo
sgarbato come sogliono essere i maschi dagli otto ai quindici anni.
— Bada che voglio i francobolli — gridò appunto Amedeo con la sua
voce di pentola fessa.
— E io il monogramma — disse la Carolina.
L’Amelia fece un gesto d’impazienza. — Dio, che noiosi! Avrete i
francobolli, avrete il monogramma, ma non istatemi addosso così.
L’avvocato allontanò col braccio i due importuni e diede alla sua
figliuola maggiore un temperino perch’ell’aprisse la busta senza
stracciarla.
Bisogna notare che, dal signor Ettore in fuori, nessuno dei presenti
aveva conosciuto questa zia Teresa. In primo luogo, dei giovani ella
non era zia ma prozia; aveva cioè sposato molto tempo addietro uno
zio dell’avvocato, un Gualtieri anch’esso, dimorante a Nuova York fin
dal 1849 e arricchitosi colà negli affari. Al momento del matrimonio il
signor Temistocle (l’uomo si chiamava così) aveva
quarantacinqu’anni ed ella ne aveva venti, nè alcuno credette ch’ella
lo prendesse per inclinazione. Comunque sia, questo signore, tanto
più vecchio della moglie, s’era conservato vispo ed arzillo e veniva
ogni due anni in Italia; ella invece tra per le cure da prestarsi al
padre che l’aveva seguita in America, tra per gli acciacchi di cui si
lagnava, non aveva più ripassato l’Oceano.
Erano queste le ragioni ch’ell’adduceva scrivendo all’Amelia, ma il
marito, ne’ suoi viaggi in Europa, affermava che la ragione vera era
la pigrizia, era la paura del mare.
— La salute — egli soleva ripetere — l’ha buonissima, e ingrassa di
giorno in giorno. Anzi, inter nos, questo potrebb’essere un altro dei
motivi pei quali le ripugna di tornare dove c’è tanta gente che se la
ricorda giovine e bella.... Donne, sempre donne.... Già, ne avete la
prova.... ha perfino scrupolo di farsi fare il ritratto per mandarvelo.
Alla lunga, come si vede, lo scrupolo ella lo aveva vinto, e la lettera
giunta quella sera all’Amelia conteneva realmente la sospirata
fotografia.
Bisogna convenire che la prima impressione fu tale da richiamare
alla memoria le parole poco galanti del signor Temistocle. La zia
Teresa aveva l’aspetto d’una donna attempata, più florida del
necessario, senza studio d’eleganza nel vestito ch’era liscio, d’una
sola tinta scura e chiuso fino al collo. Nei capelli spartiti sulle tempie
e ravviati dietro alle orecchie era appuntato un velo nero; la mano
sinistra non si vedeva, la destra, appoggiata sulla spalliera della
poltrona, si protendeva troppo innanzi e appariva di proporzioni
esagerate. Gli occhi ch’erano stati bellissimi, che si capiva dover
essere belli tuttora, erano guastati dalla fotografia mancante
assolutamente di nitidezza e di rilievo.
Vi fu un breve silenzio durante il quale un osservatore attento
avrebbe potuto notare nel volto della signora Luisa un risolino di
trionfo che contrastava con l’aria malsoddisfatta degli altri e
specialmente dell’avvocato. — È questa la zia Teresa? — parevano
domandare i ragazzi. E l’avvocato: — È proprio lei?
Amedeo ruppe il ghiaccio. — Sapete a chi somiglia?... Alla signora
Venosti.
Il babbo gli slanciò uno sguardo fulmineo. — Sciocco!
Anche l’Amelia protestò con gran vivacità.
Ma la signora Luisa venne in aiuto del figliuolo. — Amedeo non ha
tutti i torti. La ricorda....
— No, mamma, no, — rimbeccò l’Amelia che non poteva tollerare
questi paragoni tra una zia dilettissima e una conoscente ridicola da
lei messa in canzonatura infinite volte.
— Si fa presto a dir no, — insistè la signora Luisa. — È un fatto.
Il signor Ettore perdette la pazienza. — Insomma vorrei sapere dove
la si trova questa famosa rassomiglianza....
— Nella bocca, per esempio....
— Oh santo cielo. Nella bocca?... Se la Venosti non ha quasi più
denti....
— E in questo ritratto, con tua licenza, la bocca è chiusa e non
possiamo sapere se i denti ci siano o non ci siano. E poi il taglio
della bocca non ha nulla a che fare coi denti....
— Via, mamma, — ripigliò l’Amelia, — la Venosti ha più di
sessant’anni.
— E credi forse che tua zia sia una bambina?... I suoi cinquanta
deve bene averli....
L’avvocato fece un energico segno negativo col capo. — Nemmen
per sogno.
— O quanti allora?
— È un conto semplice. È nata nel 1843 e siamo nel 1888.
— Da ottantotto a levar quarantatrè rimangono quarantacinque, —
esclamò Amedeo per mostrar la sua perizia nell’aritmetica.
— Precisamente quarantacinque, — ripetè il signor Ettore.
— Più quelli della balia, — soggiunse sghignazzando la moglie.
— È una bella ostinazione, — replicò l’avvocato. — Vuoi un’altra
prova? La Teresa si sposò nell’agosto 1863, venticinque anni fa, nè
più nè meno.... E aveva compiuto i vent’anni in quel mese stesso.
— Sarà, — disse la signora Luisa con quella riluttanza che hanno le
donne a darsi per vinte, soprattutto in certe questioni. — A ogni
modo se non sono che quarantacinqu’anni non gliene faccio le mie
congratulazioni.... Ne mostra molti di più.
Frattanto l’Amelia, che aveva scorso rapidamente la lettera della zia,
ne lesse una mezza pagina ad alta voce: “È la prima volta che vado
dal fotografo dacchè ho lasciato l’Europa. E ci andai per contentarti.
Desidero in compenso di aver le fotografie rinnovate di tutti voi altri.
Ho la tua, quelle di tua sorella e di tuo fratello, ma le ultime
rimontano al 1885 e ritengo che ne avrete di più recenti. Non ho poi
quelle della tua mamma e del tuo babbo, e mi sarebbe così caro di
averle.... Il tuo babbo mi trova molto cambiata, non è vero? Eh, il
tempo passa per tutti, e per noi donne passa più presto che pegli
uomini.„
— Bisogna tornar da Vianelli, — disse l’Amelia ripiegando il foglio.
— Torniamoci addirittura domani. — propose la Carolina.
— Oh, — replicò la madre, — ci andrete voi. Io farò tirar qualche
altra copia dei ritratti del 1885, quelli che ci siam fatti, il babbo ed io,
pochi mesi dopo dei vostri.
E rivolgendosi al marito: — Mi sembra che anche tu potresti
spicciarti allo stesso modo.
L’avvocato sorrise. — No, io voglio esser sincero. Non voglio farmi
passar per più giovine di quello che sono. È giusto che la zia Teresa
trovi cambiato me come io trovo cambiata lei.
Questa dichiarazione in cui c’era una punta d’ironia crebbe le
disposizioni irascibili della signora Luisa. — Io non sono tenuta ad
aver tanti scrupoli, ella disse con piglio acre. — La zia Teresa non mi
ha conosciuta e non può quindi trovarmi cambiata. Già non crederei
d’esser così cambiata in tre anni.
La signora Luisa, sebben rasentasse la quarantina, aveva ancora le
sue pretese.
Il marito non le diede la soddisfazione di rilevare le sue parole, ma si
mise a sgridare Amedeo che, uscito un momento dalla stanza, vi
rientrava con malagrazia rovesciando una seggiola sul suo
passaggio.
Avvezzo ai rimproveri paterni, il ragazzo si limitò a rialzare la
seggiola e posò un grosso album sulla tavola. — Me li lasci levare
questi francobolli? — egli chiese all’Amelia stendendo la mano verso
la busta.
— Aspetta un momento.... Non scappano mica....
— Giacchè ho qui l’album....
La Carolina ricordò timidamente che doveva avere il monogramma.
— Lo so, lo so, l’ho già sentito.... Son gusti incomprensibili.... Ne
avete non so quanti di questi francobolli di Nuova York, di questi
monogrammi della zia Teresa.... Giurerei che non avete altro nei
vostri splendidissimi album....
— Oh sì! Io ho quarantotto francobolli tutti diversi....
— E io ventitrè monogrammi.... tutti magnifici....
— Figuriamoci....
Mentre i figliuoli si bisticciavano, la signora Luisa s’era rimessa a
guardare la fotografia, e, siccome ell’era di quelle che nelle dispute
non la finirebbero mai, riattaccò il discorso al punto di prima.
— Che col tempo le linee della fisonomia e della persona si
modifichino, è troppo naturale — ella disse riconsegnando il ritratto
all’Amelia; — ma altro è modificarsi, altro è trasformarsi.... E a me
non entrerà in mente che questa donna sia stata bella.
Gualtieri si strinse nelle spalle. — Ce ne furono poche di belle come
lei.
— Basta sentir lo zio Temistocle, — notò l’Amelia.
— Oh, lui, s’intende, — rispose la madre. — Se l’ha sposata senza
un soldo è segno che a lui pareva bella....
— Pareva?... Era bella, era bella.... con o senza il tuo permesso, —
ribattè infastidito l’avvocato.
— Non riscaldarti il sangue.... È evidente che tutti e due, zio e
nipote, la trovavate la Venere dei Medici.... Però una Venere che
preferì chi poteva vestirla di porpora e di velluto.
La signora Luisa non aveva ancora terminata la frase imprudente
ch’ell’era già pentita di essersela lasciata sfuggire. Ma ormai era
troppo tardi.
Una fiamma passò negli occhi di Ettore Gualtieri. Pur si contenne e
con una voce che l’emozione rendeva più penetrante, — Luisa, —
egli disse, — a te non è lecito ignorare per qual ragione la Teresa
Rosnati abbia sposato mio zio che aveva più del doppio della sua
età e ch’ella non amava. Che se tu lo hai dimenticato, stimo
opportuno di ricordartelo, anche perchè i nostri figliuoli, qui presenti,
non giudichino male una zia che non hanno mai vista, che forse non
vedranno mai, ma dalla quale non hanno ricevuto che gentilezze....
Oh non è una storia lunga.... La Teresa era le mille miglia lontana
dall’idea di quel matrimonio quando suo padre, rovinato da cattive
speculazioni, si trovò in procinto di fallire. Il suo maggior creditore
era Temistocle Gualtieri, stabilito da un pezzo in America, ma giunto
allora in Europa per uno de’ suoi viaggi d’affari. Corso a Venezia per
questo minacciato fallimento, egli vide la ragazza, se ne invaghì e ne
chiese la mano. Pur d’ottenerla, non solo egli accondiscendeva ad
annullare il debito che il Rosnati aveva verso di lui e lo aiutava a
liquidar onorevolmente la casa, ma gli offriva un posto lucroso nel
suo banco a Nuova York. D’altra parte, egli diceva chiaro e tondo