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Psychological Examination and Diagnostics (The Assessment Interview…
Psychological Examination and Diagnostics
Behavioral Assessment
History & Development
Has a long history, dating back to the days of Little Albert.
Mid- to late 60s, it became popular in a clinical settings.
More inferential techniques, such as measuring underlying cognitive structures (schemas) that organize more specific thoughts and behaviors, have become a frequent part of behavioral assessment.
During the 1970s, there was a much greater emphasis on a wider approach.
The 1980s and 1990s saw a proliferation of publications in the field of behavioral assessment, a dramatic reevaluation of some of its most basic assumptions.
Current directions include analog and virtual reality assessment, advances in psychophysiological assessment, utilization of innovative technology, use of ambulatory sensors, assessment of clients in their natural environments, and greater applications for special populations.
Reliability and Validity Issues
Behavioral assessment assumes variability based largely on environmental and contextual factors.
Stresses the importance of individually tailored approaches emphasizing the client’s idiosyncrasies. Thus, normative comparisons are frequently seen as both irrelevant and inappropriate.
In general, few validity studies have been performed on behavioral interviews and naturalistic observations, whereas much more has been done on behavioral questionnaires.
Assets & Limitations
Main asset: Its practitioners have continually paid attention to its relevance toward treatment.
Particularly useful for persons using a hypothesis-testing approach and for those who wish to have clear accountability that behavioral change has actually taken place.
Offers a wide range of possible techniques for use in extremelyvaried contexts.
Particularly appropriate when a presenting problem is likely determined primarily by environmental factors.
Important drawback of many behavioral assessment strategies is that they have poor or, at least, untested psychometric properties.
The accuracy of behavioral observation and interviewing can be distorted because of observer bias, halo effects, primacy effects, low inter-observer agreement, confirmatory bias, and so forth.
It often requires extensive resources in terms of time, personnel, and equipment.
Strategies of Behavioral Assessment
Behavioral interviewing
Behaviorally oriented interviews generally focus on describing and understanding the relationships between antecedents, behaviors, and consequences (ABC).
Current models of behavioral assessment emphasize taking this wide context into consideration.
Behavioral observation
Some form of actual behavioral observation is often required before, during, and/or after treatment.
Types
Interval recording
Event recording
Narrative recording
Ratings recording
Cognitive-behavioral assessment
Having the person think aloud, listing different thoughts, thought sampling at various intervals, and a wide variety of self-statement inventories.
Internal perspective
Cognitive processes not only change during the course of effective therapy but may be causally related to both the development and the maintenance of different types of disorders.
All material is necessarily derived from the client’s self-report of his or her internal processes and, as such, may be subject to a number of distortions.
Cognitive self-report inventories
Psychometric properties vary greatly.
Strong face validity and are both easy and inexpensive to administer.
Frequently assessed
Eating disorders
Assertiveness
Social phobia
Marital relationships
Self-efficacy
Imagery
Recording cognitions
Articulated thoughts
Production methods
Private speech
Endorsement methods
Thinking aloud
Thought listing
Thought sampling
Thought recording
Psychophysiological assessment
Psychophysiological assessments have recently become easier to make because of increased interest and knowledge regarding instrumentation (MRI, electronics, computers), operant conditioning of behaviors that at one time were considered involuntary, physiological and neurochemical aspects of behavior, and behavioral medicine.
The most frequently assessed physiological responses are heart rate, blood pressure, skin temperature, muscle tension, vasodilation, galvanic skin response (GSR), and brain activity as measured by electroencephalograms (EEGs).
A set of specific techniques as well as a way of thinking about behavior disorders and how these disorders can be changed. One of its core assumptions is that behavior can be most effectively understood by focusing on preceding events and resulting consequences.
The behavioral approach stresses that different behavior disorders are typically expressed in a variety of modes. These modes might include overt behaviors, cognitions, changes in physiological states, or patterns of verbal expressions. This approach implies that different assessment strategies should be used for each of these modes.
The Assessment Interview
History & Development
Adolf Meyer developed the more structured and goal-oriented mental status examination in 1902.
During the 1940s and 1950s, researchers and clinicians began conceptualizing and investigating five critical dimensions of interviews
Content vs process
Goal orientation vs expressive elements
Degree of directiveness
Amount of structure
Relative amount of activity expressed by the participants
In the 1960s, C. Rogers emphasized understanding the proper interpersonal ingredients necessary for an optimal therapeutic relationship.
In the 1970s, child assessment became concerned not only with information derived from parents but also with the child’s own experience.
In the 1990s and into the millennium, interview strategies for special populations and the development of new technologies were important.
Reliability and Validity Issues
Evaluating the psychometric properties of interviews is important because interviews can introduce numerous sources of bias, particularly if the interviews are relatively unstructured.
When interviewers were given narrow areas to assess and were trained in interviewer strategies, interrater agreement increased.
Confirmatory bias might occur when an interviewer makes an inference about a client and then directs the interview to elicit information that confirms the original inference.
Validity increases as the structure of the interview format increases.
Assets & Limitations
The flexibility inherent in unstructured and semi-structured interviews is frequently their strongest advantage over standardized tests.
The greatest difficulty with unstructured interviews is interviewer bias from perceptual and interactional processes such as the halo effect, confirmatory bias, and the primacy effect.
Because structured interviews have more psychometric precision, the results enable comparability between one case and the next (or the population).
The standardized presentation allows for the development of reliable ratings, reduces information variance, and uses consistent diagnostic criteria.
Structured interviews tend to overlook the idiosyncrasies and richness of the person.
The Assessment Interview and Case History
Interview Tactics
Preliminaries
Directive vs. non-directive interviews
Sequence of interview tactics
Comprehensiveness
Avoidance of "Why" questions
Nonverbal behaviors
Concluding the interview
The goal of a diagnostic interview is to develop a specific diagnosis, which usually was formerly based on the DSM-5 model.
Many practitioners do not believe in the value of formal diagnosis and, accordingly, do not pursue a formal DSM-5 diagnosis. Even those who do value formal diagnosis may believe that the purpose of the clinical interview is to understand context, history, and interviewee’s perspective, and the full assessment can work toward determining a formal diagnosis.
Mental Status Evaluation
The mental status exam reviews the major systems of psychiatric functioning (appearance, cognitive function, insight, etc.). A brief mental status examination might be appropriate before assessment to determine the appropriateness of more formal psychological testing.
One of the most popular has been the Mini Mental State Examination.
Typical areas covered
General appearance, behavior, relatedness
Speech and language
Feeling
Perception and thinking
Orientation
Memory, attention, concentration
Insight and judgement
Thought content
Interpreting Interview Data
Involves clinical judgement
Structured Interviews
SCID (Structured Clinical Interview for DSM-5)
Most common structured interview
SADS (Schedule for Affective Disorders and Schizophrenia)
Clinician-administered, extensive, semistructured interview that has been one of the most widely used structured interviews for clinical research purposes.
Its primary strength lies in obtaining fine detail regarding different subtypes of affective disorders and schizophrenia.
DIS (Diagnostic Interview Schedule)
Economical to administer
Questions are directed toward obtaining information regarding the client’s life, and information is also requested regarding more current symptoms based on the past 2 weeks, past month, past 6 months, and past year. Specific probe questions distinguish whether a symptom is clinically significant.
DICA (Diagnostic Interview for Children and Adolescents)
Semistructured and primarily organized around different themes, such as behavior at home, behavior at school, and interpersonal relationships with peers.
"The single most important means of data collection to provide context for psychological evaluation"
The Role of Assessment in Evidence-Based Practice
EBPP requires the psychologist to integrate systematically collected data, clinical expertise and client preferences when planning and providing psychological services. These 3 elements of EBP must be examined and considered not just at the start of treatment but throughout the duration of services delivered to clients. EBPP is predicated on the assumption that psychologists continually monitor the impact of their services, actively collaborate with their clients throughout the course of treatment and critically appraise their clinical decisions to optimally match treatment parameters to client needs and resources. Framed in this manner, it is obvious that assessment is a key component of EBPP and furthermore that for the services to be truly EB the assessment data informing the services must be EB.
Context of Clinical Assessment
Types of referral settings
Psychiatric setting
Assess defense mechanisms, diagnosis, cognition and psychosocial history.
Assessment both by psychologist and psychiatrist.
General medical setting
2/3 of all patients with a doctor have psychosocial difficulties.
Between 25-50 % of those with a medical diagnosis also has a psychological disorder, but many of them are never diagnosed.
Legal context
Ex: Assessing the reliability of a witness.
Typically used in criminal cases, parental conflict, or in potentially false witness testimony.
Academic context
Assess children who have learning difficulties.
Psychological clinic
Mostly those who refer themselves for mild/moderate problems.
"A referral source sometimes is unable to adequately formulate the referral question. In fact, the referral question is usually neither clear nor concise. It is the evaluator’s responsibility to
look beyond the referral question
and determine the basis for the referral in its widest scope".
Ethical practice
Developing a professional relationship
Informed Consent
Should contain the process, reasoning, and use of information obtained.
Confidentiality
Labeling and restriction of freedom
Self-fulfilling prophecy
A diagnosis can restrict freedom
Competent use of assessment instruments
Interpretation and use of test results
Communicating test results
Maintenance of test security and release of test data
Assessing diverse groups
Language skills
Cultural competency
Cultural/racial identity
Test equivalence
Linguistic
Metric
Conceptual
Diagnostic issues
Must be considered in a cultural context.
Interpretation guidelines
It's almost impossible to prove equivalence due to all the differences one has to account for. Therefore, the clinician has to be flexible and sensitive.
Selecting psychological tests
Consider the test most useful to answer the referral question
Another important factor in test selection is a particular practitioner’s training, experience, personal preferences, and familiarity with relevant literature.
The assessment instrument should have good psychometric properties.
Malingering (“inconsistent effort”) is becoming
an increasingly important issue, especially in forensic settings, where personal gain may result in presenting “fake bad” results.
Computer-assisted assessment
Mainly used in neuropsychology
Can reduce costs and bias
Can improve reliability and validity
Can not replace, but rather support the clinical assessment.