Clinical Psychology Assessment
Traditionally, assessment has been one of the most important functions in clinical psychology. Clinical assessment is a procedure by which clinicians, using observation, interviews, and psychological tests, develop a summary of the client’s symptoms and problems in order to develop treatment and other decisions. In clinical assessment, the clinician attempts to identify the main sources and dimensions of a client’s problems and to predict the likely course of events under various conditions. It is at this initial stage that crucial decisions have to be made, such as what, if any, treatment approach is to be offered, whether the problems will require hospitalization, to what extent family members might need to be included in treatment, and so on. Sometimes these decisions might need to be made quickly, as in emergency conditions, and without access to critical information that would probably become available with extended client contact.
Mental health patients may present with behavioral, emotional, or physical discomfort that is often difficult for a clinical practitioner to understand initially. Usually, in mental health settings a clinical psychologist attempts to understand the nature and extent of the patient’s problem by a process of inquiry that is similar to the way a detective might approach a case by collecting evidence and using inductive and deductive logic to focus on the most likely factors. Assessment of mental disorders is usually more difficult, more uncertain, and more protracted than it is for evaluation of many physical diseases. Yet, early assessment of mental health problems is extremely important in clinical practice. No rational, specific treatment plan can be instituted without at least some general notion of what problems need to be addressed.
In order for psychological assessment to proceed effectively, the person being evaluated must feel a sense of rapport with the clinician. The assessor needs to structure the testing situation so that the person feels comfortable. Important components of a good relationship in a clinical assessment situation include the following: Clients need to feel that the testing will help the practitioner gain a clear understanding of their problems and to understand how the tests will be used and how the psychologist will incorporate them in the clinical evaluation.
What does a clinician need to know in psychological assessment? First, of course, the problems must be identified. Are they of a situational nature? That is, have they been precipitated by some environmental stressor, or are the problems more pervasive and long-term? Or is it perhaps some combination of the two? Is there any evidence of recent deterioration in cognitive functioning? How long has the person had the symptoms and how are they dealing with the problem? What, if any, prior help has been sought? Are there indications of self-defeating behavior or low self-esteem, or is the individual using available personal and environmental resources in a good effort to cope? How has the problem affected the person’s performance of important social roles? Does the individual’s symptomatic behavior it any of the diagnostic patterns in the current diagnostic and statistical nomenclature (American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.).
It may be important to have an adequate diagnostic classification of the presenting problem for a number of reasons. Knowing a person’s type of disorder can help in planning and managing the appropriate treatment. However, diagnosis alone is insufficient for most clinical evaluations. Psychological assessment or diagnosis can be an ongoing process that proceeds along with, rather than only preceding, treatment efforts. An important function of pretreatment assessment is that of establishing observational baselines for various psychological functions to be part of the treatment plan. Having a baseline of information about a client’s problems and behaviors allows the clinician to assess changes that might come about in therapy. Several factors that are important to address in clinical assessment are:
- Personal History. It is important to have a basic understanding of the individual’s history and development, family history (whether the person has relatives with a history of mental illness), intellectual functioning, personality characteristics, and environmental pressures and resources. For example, how does the person characteristically respond to other people? Are there excesses in behavior, such as eating or drinking too much? Are there notable deficits, as, for example, in social skills? Does the person show any inappropriate behavior?
- Personality Factors. Assessment needs to include a description of any relevant long-term personality characteristics. Has the person behaved in deviant or bizarre ways in particular situations, for example, circumstances requiring submission to legitimate authority? Do there seem to be personality traits or behavior patterns that predispose the individual to behave in maladaptive ways across a broad range of situations? Does the person tend to become dependent on others to the point of losing his or her identity? Is the person able to accept help from others? Is the person capable of accepting appropriate responsibility for others’ welfare? Such questions are necessarily at the heart of many assessment efforts.
- Social Situations. It is also important to evaluate the social contexts in which the individual functions. What environmental demands do they face? What emotional support or special stressors exist in the person’s life?
The diverse information about the individual’s personality traits, behavior patterns, and environmental demands need to be integrated into a consistent and meaningful picture often referred to as a dynamic formulation, because it describes the current situation and provides hypotheses about what is driving the person to behave in maladaptive ways. For example, the clinician should try to arrive at a plausible explanation for why a normally passive and mild-mannered man suddenly flew into a rage and became physically abusive toward his wife. The formulation will allow the clinician to develop hypotheses that might explain the client’s future behavior. What is the likelihood that the person would get worse if the problems are left untreated? Which behaviors should be the initial focus of change, and what treatment methods are likely to be most efficient in producing this change? What changes might reasonably be expected if the person were provided a particular type of therapy?
Clients who are being assessed in a clinical situation are usually highly motivated to be evaluated and usually like to know the results of the testing. They usually are eager to give some definition to their discomfort. In many situations, it is important to incorporate information from a medical evaluation in the psychological assessment in order to rule out physical abnormalities that may be causing or contributing to the problem.
Clinical assessment attempts to provide a comprehensive picture of an individual’s psychological functioning and the stressors and resources in his or her life situation. In the early stages of the process, the assessment psychologist attempts to obtain as much information about the client as possible—including present feelings, attitudes, memories, demographic facts, important formative life events—and tries to fit the diverse pieces together into a meaningful pattern. Starting with a global technique, such as a clinical interview, clinicians may later select more specific assessment tasks or tests. The following procedures are some of the methods that may be used to obtain the necessary data.
Assessment Interview
The assessment interview is usually the initial and often the central information source in the assessment process. This is usually a face-to-face interaction in which information about various aspects of a patient’s situation, behavior, past history characteristics, and personality is acquired. The initial interview may be relatively open in format, with an interviewer deciding about his or her next question based on the client’s answers to other ones, or it may be more structured so that a planned set of questions is followed. In structured interviewing, the clinician may choose from a number of possible interview formats whose reliability has been established in research. The structured interviewing approach is likely to be more reliable but may be less spontaneous than the free-response interview.
Clinical interviews can be subject to error because they rely upon human judgment to choose the questions and process the information. The assessment interview can be made more reliable by the use of rating scales that serve to focus inquiry and quantify the interview data. For example, the person may be rated on a 3-, 5-, or 7-point scale with respect to suicide potential, violence potential, or other personality characteristics, depending upon the goals of the assessment.
Clinical Observation
One of the most useful assessment techniques that a clinician has for gaining patient-relevant information is direct observation. Observation can enable the clinician to learn more about the person’s psychological functioning, for example, personal hygiene, emotional responses, and pertinent behaviors including depression, anxiety, aggression, hallucinations, or delusions. Clinical observation is probably more effective if conducted in the natural environment (such as classroom or home). However, it is more likely to take place upon admission or in the clinic or hospital ward.
Rating Scales
Clinical observation can provide more valuable information in the clinical situation if it is objectively structured, for example, by using structured rating scales. The most useful rating scales are those that enable a rater to indicate not only the presence or absence of a particular behavior but also its prominence. Standard rating scales can provide a quantifiable format for rating clinical symptoms. For example, the Hamilton Anxiety Rating Scale (M. Hamilton, “The assessment of anxiety states by rating,” British Journal of Medical Psychology, 1959, 32, 50-55) specifically addresses behavior related to the experience of intense anxiety and has become almost the standard in this respect for assessing anxiety states. Observations made in clinical settings by trained observers can provide behavioral data useful in ongoing clinical management of patients, for example, to focus on specific patient behaviors to be changed.
Psychological Tests
Psychological tests are standardized sets of procedures or tasks for obtaining samples of behavior. A client’s responses to the standardized stimuli are compared with those of other people having comparable demographic characteristics, usually through established test norms or test score distributions. Psychological tests are useful diagnostic tools for clinical psychologists in much the same way that blood tests or X-ray films are useful to physicians in diagnosing physical problems. In all these procedures, problems may be revealed in people that would otherwise not be observed. The data from tests allow a clinician to draw inferences about how much the person’s psychological qualities differ from those of a reference norm group, typically a sample of “normal” persons. Psychological tests have been developed to measure many psychological attributes in which people vary. Tests have been devised to measure such characteristics as coping patterns, motive patterns, personality factors, role behaviors, values, levels of depression or anxiety, and intellectual functioning.
Two types of psychological tests are typically incorporated in psychological assessments in clinical practice: intelligence tests and personality tests.
Intelligence Tests
In many cases, it is important to have an evaluation of the person’s level of intellectual functioning. The clinician can assess intellectual ability with a wide range of intelligence tests. For example, if the patient is: a child, the Wechsler Intelligence Scale for Children-Revised or WISC-III (Psychological Corporation. Wechsler Intelligence Scale for Children [WISC-III] manual. San Antonio. Texas. 1992) and the current edition of the Stanford-Binet Intelligence Scale (Terman. L. M. The Stanford-Binet [4th Ed.]. Standard-Binet Intelligence Scale: Manual for the 4th Ed.. Boston. 1997) might be used for measuring the child’s intellectual abilities. For measuring adult intelligence, the Wechsler Adult Intelligence Scale-Revised or WAIS-III (Psychological Corporation. WAIS-III manual. San Antonio, Texas. 1997) is the most frequently used measure, individually administered intelligence tests—such as the WISC-R, the WAIS-III, and the Stanford-Binet—are labor intensive and typically require 2 to 3 hours to administer, score, and interpret. The information obtained about the cognitive functioning of patients, however, can provide useful hypotheses about the person’s intellectual resources and capability of dealing with problems.
Personality Tests
The clinician would likely employ several tests designed to measure personal characteristics. Personality tests are of two general types: projective and objective.
Projective Techniques. Projective techniques are unstructured tasks, for example, ambiguous stimuli such as incomplete sentences, which the person is asked to complete. The individual’s responses to these ambiguous materials are thought to reveal a great deal about their personal problems, conflicts, motives, coping techniques, and personality traits. One important assumption underlying the use of projective techniques is that individuals (in trying to make sense out of vague. unstructured stimuli) tend to “project” their own problems, motives, and wishes into the situation, because they have little else on which to rely in formulating their responses to these materials. Projective tests are considered to be valuable in providing clues as to an individual’s past learning and personality. The three most frequently used projective tests are the Sentence Completion Test, the Thematic Apperception Test (TAT), and the Rorschach. Due to space considerations we will examine in detail only the Rorschach and the TAT.
The Rorschach test was developed by the Swiss psychiatrist Hermann Rorschach in 1911. The test uses ten inkblot pictures the person is instructed to look at and respond to in terms of “what it looks like or reminds you of.” After the initial responses to all the cards are recorded, the examiner then goes back through the responses to determine “what about the inkblot made it look the way it did.” Once the responses are obtained, the clinician must then interpret what they mean. This normally involves scoring the protocol according to a standard method in order to determine what the responses mean. The most widely used and reliable scoring system is the Exner Comprehensive System (Exner & Weiner. 1993). The indexes resulting from the scoring summary are then employed to explore the literature to determine the meaning of the responses. Experience with the instrument is extremely important in arriving at useful hypotheses about clients.
The Thematic Apperception Test (TAT) was introduced in 1935 by C. D. Morgan and H. A. Murray (“A method for investigating fantasies.” Archives of Neurology and Psychiatry, 1935. 34. 289-306) as a means of studying personality traits. The TAT uses a series of pictures about which a subject is instructed to make up stories. The content of the pictures is highly ambiguous as to actions and motives, so that people tend to project or attribute their own conflicts and worries into their stories. Interpretation of the stories is impressionistic. The interpreter reads the constructions and rationally determines what potential motives as behavioral tendencies the respondent might have in “seeing” the pictures in the ways they did. The content of the TAT stories is thought to reflect the person’s underlying traits, motives, and preoccupations.
Projective tests, like the Rorschach and TAT, can be valuable in many clinical assessment situations, particularly in cases where the task involves obtaining a comprehensive picture of a person’s personality makeup. The great strengths of projective techniques are their unstructured nature and their focus on the unique aspects of personality. However, this is also a weakness because their interpretation is subjective, unreliable, and difficult to validate. In addition, projective tests typically require a great deal of time to administer and advanced skill to interpret. The clinician also needs to employ more objective tasks in order to put the client’s symptoms and behavior in an appropriate perspective.
Objective Personality Scales: The MMPI-2. Objective tests are structured in that they use questions or items that are carefully phrased. In giving alternative responses as choices, they provide a more quantifiable format than projective instruments and. Thus, are more objective. This provides greater response, which in turn enhances the reliability of test outcomes. The most widely used of the major structured inventories for personality assessment is the Minnesota Multiphasic Personality Inventory (MMPI), now the MMPI-2 after a revision in 1989 (J. N. Butcher. W. G. Dahlstrom. J. R. Graham. A. Tellegen. & B. Kaemmer. Minnesota Multiphasic Personality lnventory-2 (MMPI-2): Manual for administration and scoring, Minneapolis. 1989). It is described here because in many ways it is the most successful test in this class of instruments and because it is the most widely studied test.
The MMPI was introduced for general use in 1943 by S. R. Hathaway and J. C. McKinley; it is today the most widely used personality test for both clinical assessment and psychopathologic research in the United States and is the assessment instrument most frequently taught in graduate clinical psychology programs. Moreover, translated versions of the MMPI-2 are widely used internationally (J. N. Butcher. International adaptations of the MMPI-2. Minneapolis. 1996). The MMPI-2 consists of 567 items covering topics ranging from physical symptoms and psychological problems and social attitudes. Normally, subjects are encouraged to answer all of the items either true or false.
The MMPI-2 is interpreted by scoring scales that have been devised to measure clinical problems. The MMPI clinical scales were originally developed by an empirical item selection method. The pool of items for the inventory was administered to a large group of normal and several quite homogeneous groups of clinical patients who had been carefully diagnosed. Answers to the items were then analyzed to see which ones differentiated the various groups. On the basis of the findings, the clinical scales were constructed, each consisting of the items that were answered by one of the patient groups in the direction opposite to the predominant response of the normal group. This method of item selection, known as empirical keying, produced scales that were valid in predicting symptoms and behavior. If a person’s pattern of true/false responses closely approximates that of a particular group, such as depressed patients. it is a reasonable inference that he or she shares other psychiatrically significant characteristics with the group, and may, in fact, be functioning “psychologically” like others in that group.
Each of these “clinical” scales measures tendencies to respond in psychologically deviant ways. Raw scores of a client are compared with the scores of the normal population, many of whom did (and do) answer a few items in the critical direction, and the results are plotted on the standard MMPI-2 profile form. By drawing a line connecting the scores for the different scales, a clinician can construct a profile that shows how far from normal a patient’s performance is on each of the scales. The schizophrenia scale, for example, is made up of the items that schizophrenic patients consistently answered in a way that differentiated them from normal individuals. People who score high (relative to norms) on this scale, though not necessarily schizophrenic, often show characteristics typical of the schizophrenic population. For instance, high scorers on this scale may be socially withdrawn, have peculiar thought processes, may have diminished contact with reality, and in severe cases may have delusions and hallucinations.
One extremely useful feature of the MMPI-2 is that it contains a number of scales to evaluate test-taking attitudes. It includes a number of validity scales to detect whether a patient has answered the questions in a straightforward, honest manner. For example, there is one scale that detects lying or claiming extreme virtue, and several scales to detect faking or malingering. Extreme endorsement of the items on any of these measures may invalidate the test.
The MMPI-2 is used in several ways to evaluate a patient’s personality characteristics and clinical problems. The traditional use of the MMPI-2 is as a diagnostic standard. The individual’s profile pattern is compared with profiles of known patient groups. If the client’s profile matches a particular group, information about patients in this group can suggest a broad descriptive diagnosis for the patient under study. A second approach to MMPI interpretation is referred to as content interpretation. This approach is used to supplement the empirical interpretation by focusing on the content themes in a person’s response to the inventory. For example, if an individual endorses an unusually large number of items about depression. a clinician might well conclude that the subject is preoccupied with low mood.
Applications of Clinical Assessment
Psychological assessment methods have found applicability in a broad range of settings. Three diverse applications will be highlighted to illustrate their use.
Assessment in Mental Health Settings
Most clinical assessment is undertaken in medical. psychiatric, or prison settings to evaluate the mental health status of people undergoing problems. The practitioner would administer, score, and interpret the battery of tests, usually at the beginning of the clinical contact. and develop an integrated report. The report would likely focus on such tasks as developing mental health treatment plans (L, E. Beutler & M. R. Berran, Integrative Assessment of Adult Personality. 1995).
Psychological Assessment in Forensic or Legal Cases
One of the fastest-growing applications of psychological tests involves their use in evaluating clients in court cases. Psychological tests have been found to provide valuable information for forensic evaluations, particularly if they contain a means of assessing the person’s test-taking attitudes (such as the MMPI-2, which contains several measures that provide an appraisal of the person’s cooperativeness or frankness in responding to the test items). Many litigants or defendants in criminal cases attempt to present themselves in a particular way (for example, to appear disturbed in the case of an insanity plea or impeccably virtuous when trying to present a false or exaggerated physical injury), and their motivations to “fake good” or “fake bad” tend to result in noncredible test patterns.
Because of their scientific acceptability, well-known psychological tests, such as the WAIS-III and MMPI-2, are widely accepted by courts as appropriate assessment instruments. In order for a test to be allowed into testimony, it must be shown to be an accepted scientific standard. The primary means of assuring that tests are appropriate for court testimony is that they are standardized and are not experimental procedures (J. Ogloff, The legal basis of forensic application of the MMPI-2. In Y. S. Ben-Porath. J. R. Graham, G. C. N. Hall. R. D. Hirschman. & M. S. Zaragoza (Eds.), Forensic applications of the MMPI-2, Thousand Oaks. CA, 1995). Psychological assessments in court cases can provide information about the mental state of felons on trial, to assess the psychological adjustment of litigants in civil court cases and to aid in the determination of child custody in divorce cases.
Use of Psychological Tests in Personnel Screening
Personality tests in testing employment screening have a long tradition. Actually, the first formal use of a standardized personality scale in the United States was implemented to screen out World War I draftees who were psychologically unfit for military service (R. S. Wood-worth, The Personal Data Sheet. Chicago, 1920). Today, personality tests are widely used for personnel screening in occupations that require great public trust. Some occupations such as police officers, airline flight crews, firefighters, nuclear power plant workers, and certain military specialties require greater emotional stability than most other jobs. Maladaptive personality traits or behavior problems in such employees can result in public safety concerns. For example, someone who behaves in an irresponsible manner in a nuclear power plant control room could significantly endanger the operation of the facility and the surrounding community. The potential for problems can be so great in some high-stress occupations that measures need to be taken in the hiring process to evaluate applicants for emotional adjustment.
Personnel screening for emotional stability and potentially irresponsible behavior requires a somewhat different set of assumptions than clinical assessment. One assumption is that personality or emotional problems, such as poor reality contact, impulsivity, or pathological indecisiveness, would adversely affect the way in which a person would function in a critical job. Psychological tests should not be the sole means of determining whether a person is hired. Psychological tests are more appropriately used in the context of an employment interview, a background check, and a careful evaluation of previous work records.
Summary
Psychological assessment is one of the most important and complex activities undertaken by clinical psychologists. The goals of psychological assessment include identifying and describing the individual’s symptoms and possible causes and severity of the problem, as well as exploring the individual’s personal resources, which might be valuable in the decisions to be made.
A broad range of psychological assessment methods is used for gathering relevant psychological information for clinical decisions about people. The most flexible assessment methods are the clinical interview and behavior observation. These methods can provide a wealth of clinical information. Psychological tests are used to measure personality by employing standardized stimuli for collecting behavior samples that can be compared with other individuals through test norms. Two different personality testing methods have been employed: projective tests, such as the Rorschach, in which unstructured stimuli are presented to a subject, who then “projects” meaning or structure onto the stimulus, thereby revealing “hidden” motives, feelings, and so on: and objective tests, or personality inventories, in which a subject is required to read and respond to itemized statements or questions. Objective personality tests usually provide a cost-effective way of collecting personality information. The MMPI-2 provides a number of clinically relevant scales for describing abnormal behavior. Psychological tests are widely used for making clinical decisions in mental health settings, forensic applications, and personnel screening for positions that require emotionally stable employees.
See also:
- Clinical Psychology History
- Clinical Psychology Theories
- Clinical Psychology Interventions
- Clinical Psychology Bibliography