Clinical AssessmentTHE BASIC ELEMENTS IN ASSESSMENTThe Relationship between Assessment and

DiagnosisTaking a Social or Behavioral HistoryThe Influence of Professional OrientationTrust and Rapport between the Clinician

and the Client

ASSESSMENT OF THE PHYSICAL ORGANISMThe General Physical ExaminationThe Neurological ExaminationThe Neuropsychological Examination

PSYCHOSOCIAL ASSESSMENTAssessment Interviews

The Clinical Observation of BehaviorPsychological TestsAdvantages and Limitations of Objective

Personality TestsA Psychological Case Study: Esteban

THE INTEGRATION OF ASSESSMENT DATAEthical Issues in Assessment

CLASSIFYING ABNORMAL BEHAVIORReliability and ValidityDiffering Models of ClassificationFormal Diagnostic Classification of Mental

Disorders

e will focus in this chapter on the initial clinical assessment and on arriving ata clinical diagnosis according to DSM-IV-TR. Psychological assessment refers toa procedure by which clinicians, using psychological tests, observation, andinterviews, develop a summary of the client's symptoms and problems. Clinicaldiagnosis is the process through which a clinician arrives at a general "summaryclassification" of the patient's symptoms by following a clearly defined systemsuch as DSM-IV-TR or ICD-l0 (International Classification of Diseases) publishedby the World Health Organization.

Assessment is an ongoing process and may be important at other points dur-ing treatment-for example, to evaluate outcome. In the initial clinical assess-ment, an attempt is made to identify the main dimensions of a client's problemand to predict the probable course of events under various conditions. It is atthis initial stage that crucial decisions have to be made-such as what (if any)treatment approach is to be offered, whether the problem will require hospital-ization, to what extent family members will need to be included as co-clients,and so on. Sometimes these decisions must be made quickly, as in emergencyconditions, and without critical information. As will be seen, various psychologi-cal measurement instruments are employed to maximize assessment efficiency inthis type of pretreatment examination process (Beutler & Harwood, 2002).

A less obvious but equally important function of pretreatment assessmentis establishing baselines for various psychological functions so that the effectsof treatment can be measured. Criteria based on these measurements may beestablished as part of the treatment plan such that the therapy is consideredsuccessful and is terminated only when the client's behavior meets these pre-determined criteria. Also, as we will see in later chapters, comparison of post-treatment with pretreatment assessment results is an essential feature of manyresearch projects designed to evaluate the effectiveness of various therapies.

In this chapter, we will review some of the more com-monly used assessment procedures and show how thedata obtained can be integrated into a coherent clinicalpicture for making decisions about referral and treat-ment. Our survey will include a discussion of neurologi-cal and neuropsychological assessment, the clinicalinterview, behavioral observation, and personalityassessment through the use of projective and objectivepsychological tests. Later in this chapter we will examinethe process of arriving at a clinical diagnosis usingDSM-IV-TR.

Let us look first at what, exactly, a clinician is trying tolearn during the psychological assessment of a client.

THE BASIC ELEMENTS INASSESSMENTWhat does a clinician need to know? First, of course, thepresenting problem, or major symptoms and behavior,must be identified. Is it a situational problem precipitatedby some environmental stressor such as divorce or unem-

ployment, a manifestation of a more pervasive and long-term disorder, or some combination of the two? Is thereany evidence of recent deterioration in cognitive function-ing? What is the duration of the current complaint andhow is the person dealing with the problem? What, if any,prior help has been sought? Are there indications of self-defeating behavior and personality deterioration, or is theindividual using available personal and environmentalresources in a good effort to cope? How pervasively has theproblem affected the person's performance of importantsocial roles? Does the individual's symptomatic behaviorfit any of the diagnostic patterns in the DSM-IV-TR?

The Relationship betweenAssessment and DiagnosisIt is important to have an adequate classification of thepresenting problem for a number of reasons. In manycases, a formal diagnosis is necessary before insuranceclaims can be filed. Clinically, knowledge of a person's typeof disorder can help in planning and managing the appro-priate treatment. Administratively, it is essential to knowthe range of diagnostic problems that are represented

among the patient or client population and for whichtreatment facilities need to be available. If most patients ata facility have been diagnosed as having personality disor-ders, for example, then the staffing, physical environment,and treatment facilities should be arranged accordingly.Thus the nature of the difficulty needs to be understood asclearly as possible, including a diagnostic categorization ifappropriate (see the section "Classifying Abnormal Behav-ior" at the end of this chapter).

Taking a Social or Behavioral HistoryFor most clinical purposes, assigning a formal diagnosticclassification per se is much less important than having aclear understanding of the individual's behavioral history,intellectual functioning, personality characteristics, andenvironmental pressures and resources. That is, an ade-quate assessment includes much more than the diagnosticlabel. For example, it should include an objective descrip-tion of the person's behavior. How does the person charac-teristically respond to other people? Are there excesses inbehavior present, such as eating or drinking too much? Arethere notable deficits, for example, in social skills? Howappropriate is the person's behavior? Is the person mani-festing behavior that is plainly unresponsive or uncooper-ative? Excesses, deficits, and appropriateness are keydimensions to be noted if the clinician is to understand theparticular disorder that has brought the individual to theclinic or hospital.

PERSONALITY FACTORS Assessment should include adescription of any relevant long-term personality charac-teristics. Has the person typically responded in deviantways to particular kinds of situations-for example, thoserequiring submission to legitimate authority? Are therepersonality traits or behavior patterns that predispose theindividual to behave in maladaptive ways? Does the persontend to become enmeshed with others to the point of los-ing his or her identity, or is he or she so self-absorbed thatintimate relationships are not possible? Is the person ableto accept help from others? Is the person capable of gen-uine affection and of accepting appropriate responsibilityfor the welfare of others? Such questions are at the heart ofmany assessment efforts.

THE SOCIAL CONTEXT It is also important to assess thesocial context in which the individual operates. What kindsof environmental demands are typically placed on the per-son, and what supports or special stressors exist in his orher life situation? For example, being the primary care-taker for a spouse suffering from Alzheimer's disease is sochallenging that relatively few people can manage the taskwithout significant psychological impairment, especiallywhere outside supports are lacking.

The diverse and often conflicting bits of informationabout the individual's personality traits, behavior patterns,environmental demands, and so on, must then be inte-

Some patients with cognitive deterioration are difficult to evaluateand to provide health care, often requiring special facilities.

grated into a consistent and meaningful picture. Someclinicians refer to this picture as a "dynamic formulation;'because it not only describes the current situation but alsoincludes hypotheses about what is driving the person tobehave in maladaptive ways. At this point in the assess-ment, the clinician should have a plausible explanation forwhy a normally passive and mild-mannered man suddenlyflew into a rage and started breaking up furniture, forexample. The formulation should allow the clinician todevelop hypotheses about the client's future behavior aswell. What is the likelihood of improvement or deteriora-tion if the person's problems are left untreated? Whichbehaviors should be the initial focus of change, and whattreatment methods are likely to be most efficient in pro-ducing this change? How much change might be expectedfrom a particular type of treatment?

Where feasible, decisions about treatment are madecollaboratively with the consent and approval of the indi-vidual. In cases of severe disorder, however, they may haveto be made without the patient's participation or, in rareinstances, even without consulting responsible familymembers. As has already been indicated, knowledge of thepatient's strengths and resources is important; in short,what qualities does the patient bring to treatment that canenhance the chances of improvement?

Because a wide range of factors can play importantroles in causing and maintaining maladaptive behavior,assessment may involve the coordinated use of physical,psychological, and environmental assessment procedures.As we have indicated, however, the nature and comprehen-siveness of clinical assessments vary with the problem andthe treatment agency's facilities. Assessment by phone in asuicide prevention center (Stolberg & Bongar, 2002), for

example, is quite different from assessment aimed at devel-oping a treatment plan for a person who has come to aclinic for help (Perry, Miller, & Klump, 2006).

The Influence of ProfessionalOrientationHow clinicians go about the assessment process oftendepends on their basic treatment orientations. For exam-ple, a biologically oriented clinician-typically a psychia-trist or other medical practitioner-is likely to focus onbiological assessment methods aimed at determining anyunderlying organic malfunctioning that may be causingthe maladaptive behavior. A psychodynamic or psychoan-alytically oriented clinician may choose unstructured per-sonality assessment techniques, such as the Rorschachinkblots or the Thematic Apperception Test (TAT), toidentify intrapsychic conflicts or may simply proceed withtherapy, expecting these conflicts to emerge naturally aspart of the treatment process. A behaviorally oriented clin-ician, in an effort to determine the functional relationshipsbetween environmental events or reinforcements and theabnormal behavior, will rely on such techniques as behav-ioral observation and self-monitoring to identify learnedmaladaptive patterns; for a cognitively oriented behavior-ist, the focus would shift to the dysfunctional thoughtssupposedly mediating those patterns. A humanisticallyoriented clinician might use interview techniques touncover blocked or distorted personal growth, and aninterpersonally oriented clinician might use such tech-niques as personal confrontations and behavioral observa-tions to pinpoint difficulties in interpersonal relationships.

The preceding examples represent general trends andare in no way meant to imply that clinicians of a particularorientation limit themselves to a particular assessmentmethod or that each assessment technique is limited to aparticular theoretical orientation. Such trends are instead amatter of emphasis and point to the fact that certain typesof assessments are more conducive than others to uncover-ing particular causal factors, or for eliciting informationabout symptomatic behavior central to understanding andtreating a disorder within a given conceptual framework.

As you will see in what follows, both physical and psy-chosocial data can be extremely important to understand-ing the patient. In the sections below we will examine insome detail an actual psychological study that has drawnon a variety of assessment data.

Trust and Rapport between theClinician and the ClientIn order for psychological assessment to proceed effec-tively and to provide a clear understanding of behavior andsymptoms, the client being evaluated must feel comfort-able with the clinician. In a clinical assessment situation,this means that a client must feel that the testing will help

the practitioner gain a clear understanding of her or hisproblems and must understand how the tests will be usedand how the psychologist will incorporate them into theclinical evaluation. The clinician should explain what willhappen during assessment and how the information gath-ered will help provide a clearer picture of the problems theclient is facing.

Clients need to be assured that the feelings, beliefs,attitudes, and personal history that they are disclosing willbe used appropriately, will be kept in strict confidence, andwill be made available only to therapists or others involvedin the case. An important aspect of confidentiality is thatthe test results are released to a third party only if the clientsigns an appropriate release form. In cases in which theperson is being tested for a third party such as the courtsystem, the client in effect is the referring source-thejudge ordering the evaluation-not the individual beingtested. In these cases the testing relationship is likely to bestrained, and rapport is likely to be difficult. Of course, in acourt-ordered evaluation, the person's test-taking behav-ior is likely to be very different from what it would be oth-erwise, and interpretation of the test needs to reflect thisdifferent motivational set created by the client's possibleunwillingness to cooperate.

Clients being tested in a clinical situation are usuallyhighly motivated to be evaluated and like to know theresults of the testing. They generally are eager for some def-inition of their discomfort. Moreover, providing test feed-back in a clinical setting can be an important element inthe treatment process (Beutler & Harwood, 2002). Inter-estingly, when patients are given appropriate feedback ontest results, they tend to improve-just from gaining a per-spective on their problems from the testing. The test feed-back process itself can be a powerful clinical intervention(Finn & Kamphuis, 2006; Finn & Tonsager, 1997). Whenpersons who were not provided psychological test feed-back were compared with those who were provided withfeedback, the latter group showed a significant decline inreported symptoms and an increase in measured self-esteem as a result of having a clearer understanding oftheir own resources.

In ReVIew~ What is the difference between diagnosis and

clinical assessment? What components mustbe integrated into a dynamic formulation?

~ Describe the important elements in a socialhistory.

~ What is the impact of professionalorientation on the structure and form of apsychological evaluation?

ASSESSMENT OF THEPHYSICAL ORGANISMIn some situations and with certain psychological prob-lems, a medical evaluation is necessary to rule out the pos-sibility that physical abnormalities may be causing orcontributing to the problem. The medical evaluation mayinclude both a general physical examination and specialexaminations aimed at assessing the structural (anatomi-cal) and functional (physiological) integrity of the brainas a behaviorally significant physical system (Rozensky,Sweet, & Tovian, 1997).

The General Physical ExaminationIn cases in which physical symptoms are part of the pre-senting clinical picture, a referral for a medical evaluationis recommended. A physical examination consists of thekinds of procedures most of us have experienced in get-ting a "medical checkup." Typically, a medical history isobtained, and the major systems of the body are checked(LeBlond, DeGowin, & Brown, 2004). This part of theassessment procedure is of obvious importance for disor-ders that entail physical problems, such as somatoform,addictive, and organic brain syndromes. In addition, a vari-ety of organic conditions, including various hormonalirregularities, can produce behavioral symptoms that closelymimic those of mental disorders usually considered to havepredominantly psychosocial origins. Although some long-lasting pain can be related to actual organic conditions,other such pain can result from strictly emotional factors. Acase in point is chronic back pain, in which psychologicalfactors may sometimes play an important part (Arbisi &Butcher, 2004). A diagnostic error in this type of situationcould result in costly and ineffective surgery; hence, inequivocal cases, most clinicians insist on a medical clearancebefore initiating psychosocially based interventions.

The Neurological ExaminationBecause brain pathology is sometimes involved in somemental disorders (e.g., unusual memory deficits or motorimpairments), a specialized neurological examination canbe administered in addition to the general medicalexamination. This may involve the client's getting anelectroencephalogram (EEG) to assess brain wave pat-terns in awake and sleeping states. An EEG is a graphicalrecord of the brain's electrical activity. It is obtained byplacing electrodes on the scalp and amplifying the minutebrain wave impulses from various brain areas; these ampli-fied impulses drive oscillating pens whose deviations aretraced on a strip of paper moving at a constant speed.Much is known about the normal pattern of brainimpulses in waking and sleeping states and under variousconditions of sensory stimulation. Significant divergences

An EEG is a graphical record of the brain's electrical activity.Electrodes are placed on the scalp and brain wave impulses areamplified. The amplified impulses drive oscillating pens whosedeviations are traced on a strip of paper moving at a constantspeed. Significant differences from the normal pattern can reflectabnormalities of brain function.

from the normal pattern can thus reflect abnormalities ofbrain function such as might be caused by a brain tumor orother lesion. When an EEG reveals a dysrhythmia (irregu-lar pattern) in the brain's electrical activity (for example,that adult males with ADHD or adult hyperactivity disor-der show abnormal brain activity; see Hermens, Williams,Lazzaro, et aI., 2004), other specialized techniques may beused in an attempt to arrive at a more precise diagnosis ofthe problem.

ANATOMICAL BRAIN SCANS Radiological technology,such as computerized axial tomography, known in briefas the CAT scan, is one of these specialized techniques.Through the use of X rays, a CAT scan reveals images ofparts of the brain that might be diseased. This procedurehas aided neurological study in recent years by providingrapid access, without surgery, to accurate informationabout the localization and extent of anomalies in thebrain's structural characteristics. The procedure involvesthe use of computer analysis applied to X-ray beams acrosssections of a patient's brain to produce images that a neu-rologist can then interpret.

CAT scans have been increasingly replaced by mag-netic resonance imaging (MRI). The images of the inte-rior of the brain are frequently sharper with MRI becauseof its superior ability to differentiate subtle variations insoft tissue. In addition, the MRI procedure is normally farless complicated to administer, and it does not subject thepatient to ionizing radiation.

Essentially, MRI involves the precise measurement ofvariations in magnetic fields that are caused by the varyingamounts of water content of various organs and parts oforgans. In this manner the anatomical structure of a crosssection at any given plane through an organ such as the

brain can be computed and graphically depicted withastonishing structural differentiation and clarity. MRI thusmakes possible, by noninvasive means, visualization of allbut the most minute abnormalities of brain structure. Ithas been particularly useful in confirming degenerativebrain processes as shown, for example, in enlarged areas ofthe brain. Therefore, MRI studies have considerable poten-tial to illuminate the contribution of brain anomalies to"nonorganic" psychoses such as schizophrenia, and someprogress in this area has already been made (Mathalondolf,Sullivan, Lim, & Pfefferbaum, 2001). The major problemencountered with MRI is that some patients have a claus-trophobic reaction to being placed into the narrow cylin-der of the MRI machine that is necessary to contain themagnetic field and block out external radio signals.

PET SCANS: A METABOLIC PORTRAIT Another scan-ning technique is positron emission tomography, thePET scan. Although a CAT scan is limited to distinguish-ing anatomical features such as the shape of a particularinternal structure, a PET scan allows for an appraisal ofhow an organ is functioning (Mazziotta, 1996). The PETscan provides metabolic portraits by tracking natural com-pounds, such as glucose, as they are metabolized by thebrain or other organs. By revealing areas of differentialmetabolic activity, the PET scan enables a medical special-ist to obtain more clear-cut diagnoses of brain pathologyby, for example, pinpointing sites responsible for epilepticseizures, trauma from head injury or stroke, and braintumors. Thus the PET scan may be able to reveal problemsthat are not immediately apparent anatomically. Moreover,the use of PET scans in research on brain pathology thatoccurs in abnormal conditions such as schizophrenia,depression, and alcoholism may lead to important discov-eries about the organic processes underlying these disor-ders, thus providing clues to more effective treatment(Zametkin & Liotta, 1997). Unfortunately, PET scans havebeen of limited value thus far because of the low-fidelitypictures obtained (Fletcher, 2004; Videbech, Ravnkilde,Kristensen, et aI., 2003).

THE FUNCTIONAL MRI The technique known asfunctional MRI (fMRI) has been used in the study of psy-chopathology for more than a decade. As originally devel-oped and employed, the MRI could reveal brain structurebut not brain activity. For the latter, clinicians and investi-gators remained dependent upon positron emissiontomography (PET) scans, whose principal shortcoming isthe need for a very expensive cyclotron nearby to producethe short-lived radioactive atoms required for the proce-dure. Simply put, in its most common form, fMRI mea-sures changes in local oxygenation (i.e., blood flow) ofspecific areas of brain tissue that in turn depend on neu-ronal activity in those specific regions (Morihisa, 2001).Ongoing psychological activity, such as sensations, images,and thoughts, can thus be "mapped:' at least in principle,revealing the specific areas of the brain that appear to be

The functional MRI (fMRI), like the MRI, allows clinicians to "map"brain structure. However, the exciting breakthrough in fMRItechnology gives clinicians the ability to measure brain activitysuch as sensations, images, and thoughts, revealing the specificareas of the brain that appear to be involved in theirneurophysiological mediation.

involved in their neurophysiological mediation. Becausethe measurement of change in this context is criticallytime-dependent, the emergence of fMRI required thedevelopment of high-speed devices for enhancing therecording process, as well as the computerized analysis ofincoming data. These improvements are now widely avail-able and will likely lead to a marked increase in studies ofdisordered persons using functional imaging.

Optimism about the ultimate value of fMRI in map-ping cognitive processes in mental disorders is still strong.The fMRI is thought by some to hold more promise fordepicting brain abnormalities than currently used proce-dures such as the neuropsychological examination (Mac-Donald & Carter, 2002). A number of published studieshave provided support for this optimism. Research usingfMRI has explored the cortical functioning that underliesvarious psychological processes; for example, one recentstudy showed that psychological factors or environmentalevents can affect brain processes as measured by fMRI.Eisenberger, Lieberman, and Williams (2003) found thatparticipants who were excluded from social participationshowed a similar pattern of brain activation (in the rightventral prefrontal cortex) as participants experiencingphysical pain. (See photo on p. 113.)

Other studies have addressed problems in abnormalbehavior. One study showed that impaired time estimationfound in schizophrenics might result from dysfunction inspecific areas of the brain, thalamus, and prefrontal cortex(Suzuki, Zhou, et aI., 2004; Volz,Nenadic, et aI., 2001); corti-cal functioning in auditory hallucinations in schizophrenia(Shergill, Brammer, et al., 2000); effects of neuroleptic med-ication with schizophrenics (Braus, Ende, et al., 1999); andthe neuroanatomy of depression (Brody, Saxena, et al.,2001). Finally, Whalley et ai. (2004) recently reported thatfMRI technique has the potential of adding to our under-standing of the early development of psychological disorder.

In many instances of known orsuspected organic brain involvement, aclinical neuropsychologist administersa test battery to a patient. The person'sperformance on standardized tasks,particularly perceptual-motor tasks,can give valuable clues about any cogni-tive and intellectual impairment follow-ing brain damage (La Rue & Swanda,1997; Lezak, 1995; Reitan & Wolfson,1985). Such testing can even provideclues to the probable location of thebrain damage, although PET scans,MRIs, and other physical tests may bemore effective in determining the exactlocation of the injury.

Many neuropsychologists prefer toadminister a highly individualized

array of tests, depending on a patient's case history andother available information. Others administer a standardset of tests that have been preselected to sample, in a sys-tematic and comprehensive manner, a broad range of psy-chological competencies known to be adversely affected byvarious types of brain injury. The use of a constant set oftests has many research and clinical advantages, although itmay compromise flexibility. The components of one suchstandard procedure, the Halstead-Reitan battery, aredescribed in Developments in Practice 4.1.

In summary, the medical and neuropsychological sci-ences are developing many new procedures to assess brainfunctioning and behavioral manifestations of organic dis-order (Snyder & Nussbaum, 1998). Medical procedures toassess organic brain damage include EEGs and CAT, PET,and MRI scans. The new technology holds great promisefor detecting and evaluating organic brain dysfunction andincreasing our understanding of brain function. Neu-ropsychological testing provides a clinician with impor-tant behavioral information on how organic brain damageis affecting a person's present functioning. However, incases where the psychological difficulty is thought to resultfrom nonorganic causes, psychosocial assessment is used.

A pattern of increased activity in the anterior cingulated cortex (ACC) and the right ventralprefrontal cortex (RVPFC) shown here in persans who were excluded from participating in agame are similar to cortical activity of persons experiencing physical pain.

There are some clear methodological limitations thatcan influence fMRI results. For example, both MRI andfMRI are quite sensitive to artifacts as a result of slightmovements of the person being evaluated (Davidson,Thomas, & Casey, 2003). Additionally, the results of fMRIstudies are often difficult to interpret. Even though groupdifferences emerge between a cognitively impaired groupand a control sample, the results usually do not providemuch specific information about the processes studied.Fletcher (2004) provided a somewhat sobering analysis ofthe current status of fMRI in contemporary psychiatry,noting that many professionals who had hoped for intri-cate and unambiguous results might be disappointed withthe overall lack of effective, pragmatic methodology infMRI assessment of cognitive processes.

At this point the fMRI is not considered to be a validor useful diagnostic tool for mental disorders. The primaryvalue of this procedure continues to be research into corti-cal activity and cognitive processes.

The NeuropsychologicalExaminationThe techniques described so far have shown success inidentifying brain abnormalities that are very often accom-panied by gross impairments in behavior and varied psy-chological deficits. However, behavioral and psychologicalimpairments due to organic brain abnormalities maybecome manifest before any organic brain lesion isdetectable by scanning or other means. In these instances,reliable techniques are needed to measure any alterationin behavioral or psychological functioning that hasoccurred because of the organic brain pathology. Thisneed is met by a growing cadre of psychologists specializ-ing in neuropsychological assessment, which involvesthe use of various testing devices to measure a person'scognitive, perceptual, and motor performance as clues tothe extent and location of brain damage (Franzen, 2001;Rohling, Meyers, & Millis, 2003).

In ReVIew~ Compare and contrast five important

neurological procedures. What makes eachone particularly valuable?

~ Describe the use of neuropsychological testsin evaluating the behavioral effects oforganic brain disorders.

~ What is the difference between a PET scanand an fMRI?

4.1 NeuropsychologicalExaminations:Determining Brain-Behavior Relationships

The Halstead-Reitan battery is a neuropsycho-logical examination co.mpose~ of seve:al te:tsand variables from which an "Index of Impair-ment" can be computed (Reitan & Wolfson,1985). In addition, it provides specific infor-

mation about a subject's functioning in several skill areas.Although it typically takes 4 to 6 hours to complete andrequires substantial administrative time, it is being usedincreasingly in neurological evaluations because it yields agreat deal of useful information about an individual's cog-nitive and motor processes (LaRue & Swanda, 1997; Rei-tan & Wolfson, 2000). The Halstead-Reitan battery foradults is made up of the following tests:

1. Halstead Category Test: Measures a subject's abilityto learn and remember material and can provide cluesas to his or her judgment and impulsivity. The subjectis presented with a stimulus (on a screen) that sug-gests a number between 1and 4. The subject pressesa button indicating the number she or he believes wassuggested. A correct choice is followed by the soundof a pleasant doorbell, an incorrect choice by a loudbuzzer. The person is required to determine from thepattern of buzzers and bells what the underlying prin-ciple of the correct choice is.

2. Tactual Performance Test: Measures a subject's motorspeed, response to the unfamiliar, and ability to learnand use tactile and kinesthetic cues. The test surfaceis a board that has spaces for ten blocks of variedshapes. The subject is blindfolded (never actually see-

PSYCHOSOCIALASSESSMENTPsychosocial assessment attempts to provide a realistic pic-ture of an individual in interaction with his or her socialenvironment. This picture includes relevant informationabout the individual's personality makeup and presentlevel of functioning, as well as information about the stres-sors and resources in her or his life situation. For example,early in the process, clinicians may act as puzzle solvers,absorbing as much information about the client as possi-ble-present feelings, attitudes, memories, demographicfacts-and trying to fit the pieces together into a meaning-ful pattern. Clinicians typically formulate hypotheses anddiscard or confirm them as they proceed. Starting with aglobal technique such as a clinical interview, clinicians

ing the board) and asked to place the blocks into thecorrect grooves in the board. Later, the subject isasked to draw the blocks and the board from tactilememory.

3. Rhythm Test: Measures attention and sustained con-centration through an auditory perception task. It is asubtest of Seashore's Test of musical talent andincludes 30 pairs of rhythmic beats that are presentedon a tape recorder. The subject is asked whether thepairs are the same or different.

4. Speech Sounds Perception Test: Determineswhether an individual can identify spoken words.Nonsense words are presented on a tape recorder,and the subject is asked to identify the presentedword from a list of four printed words. This task mea-sures the subject's concentration, attention, andcomprehension.

5. Finger Oscillation Task: Measures the speed at whichan individual can depress a lever with the index finger.Several trials are given with each hand.

In addition to the Halstead-Reitan battery, other tests,referred to as "allied procedures," may be used in a neu-ropsychology laboratory. For example, Boll (1980) recom-mends use of the modified Halstead-Wepman AphasiaScreening Test for obtaining information about a subject'slanguage ability and about her or his abilities to identifynumbers and body parts, to follow directions, to spell, andto pantomime simple actions.

may later select more specific assessment tasks or tests.The following are some of the psychosocial proceduresthat may be used.

An assessment interview, often considered the central ele-ment of the assessment process, usually involves a face-to-face interaction in which a clinician obtains informationabout various aspects of a patient's situation, behavior, andpersonality (Barbour & Davison, 2004; Craig, 2004). Theinterview may vary from a simple set of questions orprompts to a more extended and detailed format (Kici &Westhoff, 2004). It may be relatively open in character,with an interviewer making moment-to-moment deci-sions about his or her next question on the basis ofresponses to previous ones, or it may be more tightly con-trolled and structured so as to ensure that a particular set

STRUCTURED AND UNSTRUCTUREDINTERVIEWS Although many clini-cians prefer the freedom to explore asthey feel responses merit, the researchdata show that the more controlled andstructured type of assessment inter-views yields far more reliable resultsthan the flexible format. There appearsto be widespread overconfidence amongclinicians in the accuracy of their ownmethods and judgments (Taylor &Meux, 1997). Every rule has exceptions,but in most instances, an assessor is wise to conduct aninterview that is carefully structured in terms of goals,comprehensive symptom review, other content to beexplored, and the type of relationship the interviewerattempts to establish with the person. See Figure 4.1 for adescription of the differences between structured andunstructured interviews.

The reliability of the assessment interview may also beenhanced by the use of rating scales that help focus inquiry

and quantify the interview data. Forexample, the person may be rated on a3-, 5-, or 7-point scale with respect toself-esteem, anxiety, and various othercharacteristics. Such a structured andpreselected format is particularly effec-tive in giving a comprehensive impres-sion, or "profile," of the subject and hisor her life situation and in revealing spe-cific problems or crises-such as maritaldifficulties, drug dependence, or suici-dal fantasies-that may require imme-diate therapeutic intervention.

Clinical interviews can be subject toerror because they rely on human judg-

ment to choose the questions and process the information.Evidence of this unreliability includes the fact that differ-ent clinicians have often arrived at different formal diag-noses on the basis of the interview data they elicited from aparticular patient. It is chiefly for this reason that recentversions of the DSM (that is, III, III -R, IV, and IV-TR) haveemphasized an "operational" assessment approach, one

of questions is covered. In the latter case, the interviewermay choose from a number of highly structured, standard-ized interview formats whose reliabilityhas been established in prior research.

As used here, reliability meanssimply that two or moreinterviewers assessing the sameclient will generate highly similarconclusions about the client, atype of consensus that researchshows can by no means be takenfor granted.

Unstructured InterviewsUnstructured assessment interviews are typically subjective and do not follow apredetermined set of questions. The beginning statements in the interview are usuallygeneral, and follow-up questions are tailored for each client. The content of theinterview questions is influenced by the habits or theoretical views of the interviewer.The interviewer does not ask the same questions of all clients; rather, he or shesubjectively decides what to ask based on the client's response to previous questions.Because the questions are asked in an unplanned way, important criteria needed for aDSM -IV diagnosis might be skipped. Interview responses based on unstructuredprocedures are difficult to quantify or compare with responses of clients from otherinterviews. Thus, uses of unstructured interviews in mental health research are limited.

On the positive side, unstructured interviews can be viewed by clients as beingmore sensitive to their needs or problems than more structured procedures.Moreover, the spontaneous follow-up questions that emerge in an interview can, attimes, provide valuable information that would not emerge in a structured interview.

Structured InterviewsStructured interviews follow a predetermined set of questions throughout theinterview. The beginning statements or introduction to the interview follow setprocedures. The themes and questions are predetermined to obtain particularresponses for all items. The interviewer cannot deviate from the question lists andprocedures. All questions are asked of each client in a preset way. Each question isstructured in a manner so as to allow responses to be quantified or clearly determined.

On the negative side, structured interviews typically take longer to administerthan unstructured interviews and may include some seemingly tangential questions.Patients can sometimes be frustrated by the overly detailed questions in areas that areof no concern to them. Differences between

Unstructured andStructured Interviews

During an assessment interview, a clinician obtains informationabout various aspects of a patient's situation, behavior, andpersonality makeup. The interview is usually conducted face-to-face and may have a relatively open structure or be more tightlycontrolled depending on the goals and style of the clinician_

that specifies observable criteria for diagnosis and providesspecific guidelines for making diagnostic judgments."Winging it" has limited use in this type of assessmentprocess. The operational approach leads to more reliablepsychiatric diagnoses, perhaps at some cost in reducedinterviewer flexibility. For further discussion and illustra-tion of the differences between structured and unstruc-tured diagnostic interviewing see Figure 4.1 on page 115 .

One of the traditional and most useful assessment toolsthat a clinician has available is direct observation of apatient's characteristic behavior (Hartmann, Barrios, &Wood, 2004). The main purpose of direct observation is tolearn more about the person's psychological functioningthrough the objective description of appearance andbehavior in various contexts. Clinical observation is theclinician's objective description of the person's appearanceand behavior-his or her personal hygiene and emotionalresponses and any depression, anxiety, aggression, halluci-nations, or delusions he or she may manifest. Ideally, clini-cal observation takes place in a natural environment (suchas observing a child's behavior in a classroom or at home),but it is more likely to take place upon admission to a

clinic or hospital (Leichtman, 2002). For example, a briefdescription is usually made of a subject's behavior uponhospital admission, and more detailed observations aremade periodically on the ward.

Some practitioners and researchers use a more con-trolled, rather than a naturalistic, behavioral setting forconducting observations in contrived situations. Theseanalogue situations, which are designed to yield informa-tion about the person's adaptive strategies, might involvesuch tasks as staged role-playing, event reenactment, fam-ily interaction assignments, or think-aloud procedures(Haynes, 2001).

In addition to making their own observations, manyclinicians enlist their patients' help by providing theminstruction in self-monitoring: self-observation andobjective reporting of behavior, thoughts, and feelings asthey occur in various natural settings. This method can bea valuable aid in determining the kinds of situations inwhich maladaptive behavior is likely to be evoked, andnumerous studies also show it to have therapeutic benefitsin its own right. Alternatively, a patient may be asked to fillout a more or less formal self-report or a checklist con-cerning problematic reactions experienced in various situ-ations. Many instruments have been published in theprofessional literature and are commercially available toclinicians. These approaches recognize that people areexcellent sources of information about themselves. Assum-ing that the right questions are asked and that people arewilling to disclose information about themselves, theresults can have a crucial bearing on treatment planning.

The procedures described above focus on a subject'sovert behavior, omitting the often equally important con-sideration of concurrent mental events-that is, the indi-vidual's ongoing thoughts. In an attempt to samplenaturally occurring thoughts, psychologists are experi-menting with having individuals carry small electronicbeepers that produce a signal, such as a soft tone, at unex-pected intervals. At each signal, the person is to write downor electronically record whatever thoughts the signal inter-rupted. These "thought reports" can then be analyzed invarious ways, and they can be used for some kinds of per-sonality assessment and diagnosis as well as for monitoringprogress in psychological therapy (Klinger & Kroll-Mensing, 1995).

RATING SCALES As in the case of interviews, the use ofrating scales in clinical observation and in self-reportshelps both to organize information and to encourage reli-ability and objectivity (Aiken, 1996). That is, the formalstructure of a scale is likely to keep observer inferences toa minimum. The most useful rating scales are those thatenable a rater to indicate not only the presence or absenceof a trait or behavior but also its prominence or degree.The following item is an example from such a ratingscale; the observer would check the most appropriatedescription.

___ 1. Sexually assaultive: aggressively approachesmales or females with sexual intent.

___ 2. Sexually soliciting: exposes genitals with sexualintent, makes overt sexual advances to otherpatients or staff, masturbates openly.

___ 3. No overt sexual behavior: not preoccupiedwith discussion of sexual matters.

___ 4. Avoids sex topics: made uneasy by discussionof sex, becomes disturbed if approachedsexually by others.

___ 5. Excessive prudishness about sex: considers sexfilthy, condemns sexual behavior in others,becomes panic-stricken if approached sexually.

Ratings like these may be made not only as part of aninitial evaluation but also to check on the course or out-come of treatment.

One of the rating scales most widely used for record-ing observations in clinical practice and in psychiatricresearch is the Brief Psychiatric Rating Scale (BPRS)(Overall & Hollister, 1982; Serper, Goldberg, & Salzinger,2004). The BPRS provides a structured and quantifiableformat for rating clinical symptoms such as somatic con-cern, anxiety, emotional withdrawal, guilt feelings, hostil-ity, suspiciousness, and unusual thought patterns .. Itcontains 18 scales that are scored from ratings made by aclinician following an interview with a patient. The dis-tinct patterns of behavior reflected in the BPRS ratingsenable clinicians to make a standardized comparison oftheir patients' symptoms with the behavior of other psy-chiatric patients. The BPRS has been found to be anextremely useful instrument in clinical research (for exam-ple, see Davidson, Shahar, Stayner, et al., 2004; Lachar, Bail-ley; et al., 2001), especially for the purpose of assigningpatients to treatment groups on the basis of similarity insymptoms. However, it is not widely used for making treat-ment or diagnostic decisions in clinical practice. TheHamilton Rating Scale for Depression (HRSD), a similarbut more specifically targeted instrument, is one of the mostwidely used procedures for selecting clinically depressedresearch subjects and also for assessing the response ofsuch subjects to various treatments (see Beevers & Miller,2004; Santor & Coyne, 2001).

Psychological TestsInterviews and behavioral observation are relatively directattempts to determine a person's beliefs, attitudes, andproblems. Psychological tests are a more indirect means ofassessing psychological characteristics. Scientificallydeveloped psychological tests (as opposed to the recre-ational ones sometimes appearing in magazines or on theInternet) are standardized sets of procedures or tasks forobtaining samples of behavior. A subject's responses to the

standardized stimuli are compared with those of otherpeople who have comparable demographic characteris-tics, usually through established test norms or test scoredistributions. From these comparisons, a clinician canthen draw inferences about how much the person's psy-chological qualities differ from those of a reference group,typically a psychologically normal one. Among the char-acteristics that these tests can measure are coping pat-terns, motive patterns, personality characteristics, rolebehaviors, values, levels of depression or anxiety, andintellectual functioning. Impressive advances in the tech-nology of test development have made it possible to createinstruments of acceptable reliability and validity to mea-sure almost any conceivable psychological characteristicon which people may vary. Moreover, many proceduresare available in a computer-administered and computer-interpreted format (see Developments in Practice 4.2,p. 118).

Although psychological tests are more precise andoften more reliable than interviews or some observationaltechniques, they are far from perfect tools. Their value oftendepends on the competence of the clinician who interpretsthem. In general, they are useful diagnostic tools for psy-chologists in much the same way that blood tests, X-rayfilms, and MRI scans are useful to physicians. In all thesecases, pathology may be revealed in people who appear tobe normal, or a general impression of "something wrong"can be checked against more precise information.

Two general categories of psychological tests for use inclinical practice are intelligence tests and personality tests(projective and objective).

INTELLIGENCE TESTS A clinician can choose from awide range of intelligence tests. The Wechsler IntelligenceScale for Children-Revised (WISC-III) and the current

There are a Wide variety of psychological tests that measure theintellectual abilities of children. The researcher in this photo ismeasuring this child's cognitive development by evaluating howshe classifies and sorts the candy.

Perhaps the most dramatic innovation in clin-ical assessment during the last 40 yearshas been the increasing use of computers inindividual assessment. Computers areeffectively used in assessment both to

gather information directly from an individual and toassemble and evaluate all the information that has beengathered previously through interviews, tests, and otherassessment procedures (Butcher, Perry, & Atlis, 2000). Bycomparing the incoming information with data previouslystored in its memory banks, a computer can perform a widerange of assessment tasks (Garb, 1995). It can supply aprobable diagnosis, indicate the likelihood of certain kindsof behavior, suggest the most appropriate form of treat-ment, predict the outcome, and print out a su'mmary reportconcerning the subject. In many of these functions, a com-puter is actually superior to a clinician because it is moreefficient and accurate in recalling stored material (Epstein& Klinkenberg, 2001; Olson, 2001).

With the increased efficiency and reliability of the useof computers in clinical practice, one might expect a nearlyunanimous welcoming of computers into the clinic. This isnot always the case, however, and some practitioners weknow even resist using such "modern" techniques as e-mail,fax machines, and computerized billing in their practices(McMinn, Buchanan, et aI., 1999). Some clinicians arereluctant to use computer-based test interpretations inspite of their demonstrated utility and low cost. Eventhough many clinics and independent practitioners usemicrocomputers for record keeping and billing purposes, asmaller number incorporate computer-based clinicalassessment procedures into their practice. Possible rea-sons for the underutiliz.ation of computer-based assess-ment procedures include the following:

•. Practitioners trained before the computer age mayfeel uncomfortable with computers or may not havetime to get acquainted with them.

edition of the Stanford-Binet Intelligence Scale (Kam-phaus & Kroncke, 2004) are widely used in clinical settingsfor measuring the intellectual abilities of children (Wasser-man, 2003). Probably the most commonly used test formeasuring adult intelligence is the Wechsler Adult Intelli-gence Scale-Revised (WAIS-III) (Zhu, Weiss, Prifitera, &Coalson. 2004). It includes both verbal and performancematerial and consists of 11 subtests. A brief description oftwo of the sub tests will serve to illustrate the types of func-tions the WAIS-III measures.

The Automated Practice:Use of the Computer inPsychological Testing

•. Many practitioners limit their practice to psychologi-cal treatment and do not do extensive pretreatmentassessments of their cases. Many also have littleinterest in, or time for, the systematic evaluation oftreatment efficacy that periodic formal assessmentsfacilitate.

•. To some clinicians, the impersonal and mechanizedlook of the booklets and answer sheets common tomuch computerized assessment is inconsistent withthe image and style of warm and personal engage-ment they hope to convey to clients.

•. Some clinicians view computer-based assessment asa threat to their own functioning and fear that com-puter-assessment specialists seek to replace humandiagnostic functioning with automated reports(Matarazzo, 1986). Some of these concerns are notunlike those expressed by many people in industrywhen computers and robots come to the workplace.Are human mental health practitioners in danger ofbeing replaced by computers? Not at all. Computershave intrinsic limitations that will always relegatethem to an accessory role in psychological assess-ment. It is the clinician who must play the major orga-nizing role and accept the responsibility for anassessment. An ill-qualified clinician wholly depen-dent on computerized reports would quickly be identi-fied as incompetent by discerning referral sources andprobably by most self-referred clients; a thriving prac-tice would not be a likely outcome. On the other hand,judicious use of computerized assessment can free lip

much time for doing those things that can be accom-plished only by the personal application of high levelsof clinical skill and wisdom.

II> Vocabulary (verbal): This subtest consists of a listof words to define that are presented orally to theindividual. This task is designed to evaluate knowl-edge of vocabulary, which has been shown to behighly related to general intelligence.

It'- Digit Span (performance): In this test of short-term memory, a sequence of numbers is adminis-teredorally. The individual is asked to repeat thedigits in the order administered. Another task in this