Psychodiagnostiek

Factors Influencing BDI-II Scores

• Different factors can influence BDI-II scores, and possible differential diagnoses should be considered.
• For example, a psychiatric setting may require a higher optimal cutoff point in the BDI-II score due to comorbid psychiatric disorders.

Diagnostic Process

• The diagnostic process is based on three elements:
  • Theory formation of problems/complaints and problem behavior
  • Operationalization and subsequent measurement
  • Application of relevant diagnostic methods
• The quality of these elements is based on conceptual and empirical research.

Steps in the Diagnostic Process

• Analysis of the client's request for help and the referrer
• Formulation of questions that arise during the first conversation with the client
• Analysis results in questions, and based on these questions, the diagnostician will construct a diagnostic theory
• To test this theory, five diagnostic measures are needed:
  • Conversion of the preliminary theory into concrete hypotheses
  • Selection of a specific set of research instruments that can support or reject the formulated hypotheses
  • Making predictions about the results or outcomes of these instruments
  • Administration and processing of instruments
  • Based on the obtained results, with a statement of reasons why the hypotheses were accepted or rejected

Five Basic Questions in Clinical Psychodiagnosis

• There are five basic questions that form the basis for most questions asked by clients, referrers, and diagnosticians:
  • Recognition: What are the problems, what works, and what doesn't?
  • Explanation: Why do certain problems exist, and what maintains them?
  • Prediction: How will the client's problems develop in the future?
  • Indication: How can the problems be solved?
  • Evaluation: Are the problems adequately solved as a result of the intervention?

Herkenning (Recognition)

• Recognition involves identifying the client's problems and adequate behavior
• It involves:
  • Inventory and description
  • Organization and categorization into dysfunctional behavioral clusters or disorders
  • Research into the severity of problem behavior

Toelichting (Explanation)

• Explanation provides an answer to the question of why a problem or behavioral problem exists
• It involves:
  • The main problem or problem component
  • The circumstances that explain the occurrence of the problem
  • The causal relationship between the two points above

Voorspelling (Prediction)

• Prediction involves making a statement about the client's problem behavior in the future
• It involves:
  • A relationship between a predictor and a criterion
  • The predictor is the current behavior, and the criterion is the future behavior

Aanwijzing (Indication)

• Indication involves searching for the most suitable treatment and therapist for the client's specific problem and preferences
• It involves:
  • Knowledge of treatments and therapists
  • Knowledge of the relative utility of treatments
  • Knowledge of the client's acceptance of the indication

Evaluatie (Evaluation)

• Evaluation involves assessing the claims made about the diagnosis and/or intervention
• It involves:
  • Checking if the therapy took into account the diagnosis and treatment plan
  • Assessing whether the therapy process and treatment have brought about changes in the client's behavior and experience

The Diagnostic Cycle

• The diagnostic cycle is a way to regulate and discipline the diagnostic process
• It involves:
  • Observation: collecting and classifying empirical material
  • Induction: formulating theories and hypotheses
  • Deduction: deriving testable predictions from these hypotheses
  • Testing: using new materials to determine if the predictions are correct or not
  • Evaluation

The Diagnostic Process: From Request to Report

• The diagnostic process begins with the analysis of the referral request, which provides information about the referrer and the client.
• It is essential to understand the referrer's frame of reference, which is influenced by their training, experience, and profession.
• The analysis of the request clarifies the relationship between the diagnostician and the referrer, distinguishing between the referrer in name and the actual referrer.
• Referrers differ in the nature and extent of their authority, such as psychiatrists versus intake workers.

Referral Request Analysis

• The referral request can be open-ended or closed, with the latter involving the referrer formulating hypotheses about the problem.
• The content of the request is partially linked to the institution from which it originates.
• Requests can be categorized based on the five basic questions: what, why, how, when, and where.

Diagnostical Scenario

• The diagnostician orders all questions from the referrer and the client, including those that have arisen during the request phase, and their knowledge of the problem.
• Based on this information, the diagnostician formulates a provisional theory about the client's problematic behavior.

Hypothesis Formulation

• A hypothesis is an assumption about a correlation in reality that can be formulated to derive concrete, verifiable predictions.
• In the context of the recognition question, hypotheses focus on the presence of psychopathology or differential diagnosis.
• In the context of the explanatory question, hypotheses require a list of explanatory factors and their predisposing or maintaining role.

Selection of Research Instruments

• The hypotheses lead to testable statements about an individual's behavior or experience.
• The selection of examination instruments is linked to the nature of the question, the psychometric quality of the instruments, and efficiency considerations such as the duration of the examination and scoring ease.

Answering the Recognition Question

• Objective instruments are used to answer the recognition question, which can simultaneously detect multiple disorders or specific psychopathological profiles.
• Observations, anamnestic data, and information from informants can also be used as research instruments.

Argumentation

• The administration and scoring results are fed back to the hypotheses and predictions.
• If the results match the predictions, the hypothesis is not rejected.
• If they do not clearly agree, the hypothesis can be maintained, and new hypotheses can emerge.

Report

• The report contains the results of the diagnostic investigation and is intended for the referrer.
• The report's structure follows the five steps in the diagnostic process.
• The report and oral explanation form the diagnostician's masterpiece, which will be evaluated by colleagues and referrers.

Diagnosis and Treatment Combinations (DTCs)

• DTCs involve referring patients to specific departments based on their diagnosis, and the treatment protocol for the corresponding condition is then applied.
• There are nine departments: ADHD, anxiety disorders, depression, eating disorders and obesity, personality problems, somatics and psyche, relationships and psyche, psychotrauma, and sexology.

Critical Comments

• Many patients have multiple complaints/problems, making it difficult to choose a department.
• Some clients have no clearly defined complaints/problems.
• Within departments that address specific complaints/problems, there is a strong focus on the reported complaints/problems, which may lead to overlooking other important existing conditions.
• DTCs assume an interaction between a specific diagnosis and a type of treatment.
• When working with DTCs, there is often insufficient time for an extensive diagnostic investigation into the causes of the complaints/problems.

Narcissism and Narcissistic Personality Disorder

• Narcissism is not a self-confidence test, but rather a measure of narcissistic personality.
• Kohut's self-psychological approach views narcissism as a result of parental failure to empathize with their child in childhood.
• Kernberg's object-relations approach emphasizes aggression and conflict in the psychological development of narcissism.
• Social-critical theory (Wolfe) views narcissism as a defensive response to industrialization and changing economic and social structures.

Narcissistic Personality Disorder (NPD)

• DSM-V criteria for NPD include:
  • Grandiosity and self-importance
  • Fantasies of success, power, beauty, intellectual superiority, or ideal love
  • Sense of superiority and specialness
  • Need for admiration
  • Strong sense of entitlement
  • Manipulation and exploitation of others
  • Lack of empathy
  • Belief that others are jealous of them and being jealous of others
  • Arrogant and haughty attitude and behavior
• At least 5 symptoms are required to establish a diagnosis

Subtypes of Narcissistic Personality Disorder

• Grandiose or overt narcissism (arrogant, pretentious, dominant, self-confident, exhibitionist, or aggressive)
• Vulnerable or covert narcissism (overly sensitive, uncertain, defensive, and anxious, with underlying feelings of shame and inadequacy)

Characteristics of Narcissistic Personality Disorder

• Preoccupation with satisfying one's own needs at the expense of others
• Vulnerability in self-regulation, self-respect, and sense of freedom
• Self-protective reactivity and emotional dysregulation
• Grandiose and egoistic behavior can be seen as a compensation for an underlying fragile sense of self

Prevalence of Narcissistic Personality Disorder

• Higher rates in men than in women
• Higher rates in younger adults
• High comorbidity with substance abuse, mood disorders, anxiety, and other personality disorders (6-7% prevalence)

Development and Manifestation of Narcissistic Personality Disorder

• Dysfunctional parenting is significantly associated with the development of narcissistic personality disorder in adulthood
• Parental coldness and emotional control are more commonly associated with vulnerable narcissism
• Narcissistic individuals often externalize their problems and project them onto others
• Manifestations include social isolation, sexual dysfunction, irritability, and aggression, as well as increased substance abuse and dependence on drugs and/or alcohol to improve mood

Psychological Testing and Assessment

• A psychological test is a standardized measurement of a sample of behavior that establishes norms and uses important test items to discover what the test is meant to uncover about the test-taker.
• Norms are dependent on the number of test-takers and are used to establish what is normal in a group.

Purposes of Psychological Assessment

• Primary goals of psychological assessment:
  • Describe current functioning (e.g., cognitive skills, severity of disturbance, and ability to live independently)
  • Confirm, refute, or modify impressions formed by clinicians through their less structured interactions with patients
  • Identify therapeutic needs, highlight problems that may arise during treatment, and recommend forms of intervention
  • Aid in differential diagnosis of emotional, behavioral, and cognitive disorders
  • Monitor treatment progress over time to evaluate the success of interventions or identify new problems that may require attention
• Other goals:
  • Manage risks, including minimizing potential legal liabilities and identifying unwanted treatment reactions
  • Provide knowledgeable, empathetic assessment feedback as a therapeutic intervention

Differences between Psychological Tests and Psychological Assessment

• Psychological tests: a relatively simple process where a specific scale is used to obtain a score
• Psychological assessment: a more complex process involving a clinician who takes multiple test scores, often obtained from multiple test methods, and considers the data in the context of history, referral information, and observed behavior to understand the person being evaluated

Limitations and Errors in Practice

• Using a single method to obtain information from a patient can lead to an incomplete or biased understanding of the patient
• Patients may be misdiagnosed, mischaracterized, and not optimally treated, which can increase healthcare costs in the long run

Challenges and Implications

• Validity coefficients suggest that psychologists have a limited ability to make rational, individualized judgments based on test scores alone
• Contextual factors play a significant role in determining the final scores achieved on psychological tests, and therefore, must be taken into account
• The practical value of tests used in clinical assessment is likely greater than what is suggested by research into their nomothetic associations

Conclusions

• Formal assessment is an essential element in the professional practice of psychology
• The review has documented the strong and positive evidence that exists for the value of psychological tests and assessment for clinical practice
• The validity of psychological tests is comparable to the validity of medical tests, and differential limits for the reimbursement of psychological and medical tests cannot be justified based on empirical evidence

Validity and Reliability

• Validity refers to measuring what you want to measure, and testing what you are trying to discover.
• Reliability refers to the consistency of the measurement, ensuring that the experiment, test, or measurement procedure yields the same results upon repeated trials.

The Dutch Testing Process for Evaluating Psychological Tests - Evers

• In 1959, the Dutch Institute of Psychologists (NIP) established the Committee on Test Affairs (COTAN) to promote better use of psychological tests.
• COTAN published a book with evaluations of the quality of psychological tests, which has been updated five times, with the last update in 2009.
• In 1969, a significant improvement was introduced: quality assessments for each test, with ratings from A (excellent) to F (insufficient).

Theoretical Basis of the Test

• The theoretical basis of the test is evaluated based on three items:
  • Whether the test manual clarifies the construct being measured, the intended groups, and the application of the test (1.1).
  • Whether the test is based on an existing psychological theory or new ideas that have led to changes in the theory (1.2).
  • Whether the test operationalizes the construct and provides information on the content validity of the test (1.3).

Quality of the Test Materials

• The new evaluation system separates sets of items for paper tests and computer tests.
• Both sets contain 8 items, with 3 key items:
  • Standardization of test content (2.1).
  • Objectivity of the scoring system (2.2).
  • Absence of unnecessary culturally bound words or content that may be offensive to specific groups (2.3).

Completeness of the Manual

• The completeness of the manual is evaluated based on 7 items, including:
  • Whether a manual is provided (3.1).
  • Completeness of instructions for successful administration (3.2).
  • Information on limitations for successful test administration (3.3).
  • Availability of a summary of research results with the test (3.4).
  • Inclusion of case descriptions (3.5).
  • Availability of interpretations for test scores (3.6).
  • Information on the qualifications of the users (3.7).

Norms

• The scoring of a test usually results in a raw score, which is difficult to interpret and unsuitable for practical use.
• To give meaning to a raw score, two ways can be distinguished to scale or categorize raw scores:
  • Norm-referenced interpretation, where a set of scaled scores or norms is derived from the distribution of raw scores of a reference group.
  • Domain-referenced interpretation, where norms are derived from a domain of skills or topics that must be mastered.

Sensitivity and Specificity

• Sensitivity refers to the ability of a test to identify true positives (people with a condition).
• Specificity refers to the ability of a test to identify true negatives (people without a condition).
• The Youden criterion (sensitivity + specificity) is not always correct, as it can produce counter-intuitive results in certain situations.

Conclusion

• The Dutch testing process for evaluating psychological tests emphasizes the importance of validity, reliability, theoretical basis, quality of test materials, completeness of the manual, and norms.
• Sensitivity and specificity are crucial aspects of a test's performance, and the Youden criterion should be used with caution.

Betrouwbaarheid (Reliability)

• Reliability indicates how consistently a method measures something
• When applying the same method to the same sample under the same conditions, you should get the same results; if not, the measurement method may be unreliable

Types of Reliability

Test-Retest Reliability

• Measures the consistency of the same test over time
• Repeat the same test on the same sample at different times
• Calculate the correlation between two sets of results
• Used when measuring something expected to remain constant in the sample (e.g., color blindness)
• High test-retest reliability indicates that the method resists external factors well over time

Inter-Observer (Inter-Rater) Reliability

• Measures the consistency of the same test performed by different people
• Also known as inter-observer reliability
• Measures the degree of agreement between different people observing/evaluating the same thing
• Calculate the correlation between different sets of results
• High inter-observer reliability indicates that the test has good consistency across different observers

Reliability of Parallel Forms

• Measures the consistency of different versions of a test designed to be equivalent
• Calculate the correlation between two equivalent versions of a test
• Make a large set of questions to evaluate the same thing, then randomly divide them into two sets
• High correlation between the two sets of results indicates high reliability of parallel forms

Internal Consistency Reliability

• Measures the consistency of individual items within a test
• Evaluates the correlation between multiple items in a test intended to measure the same construct
• Can be calculated with only one dataset (no repeated testing or multiple observers needed)
• Two commonly used methods to measure internal consistency:
  • Average correlation between items
  • Split-half reliability (split a set of measures into two sets, then calculate the responses)

Test-Retest Method

• Evaluates the consistency of test results when taken at two different times.
• Only valuable if measuring properties that don't change over time.
• Correlation is found between scores of the two administrations.
• Threatened by the overdrift effect, where the first test session influences the scores of the second session.
• Types of overdrift effects:
  • Practice effects: skills improve through practice.
  • Systematic overdrift: everyone's score improves by a certain amount, adding no new variability.
  • Random overdrift effects: affect some, but not all, test-takers.

Time Interval Selection

• Selecting the time interval between test sessions is crucial.
• If the interval is too short, there's a high risk of overdrift and practice effects.
• If the interval is too long, test results may not be comparable.

Article Sampling: Parallel Forms Method

• Compares two equivalent forms of a test measuring the same attribute.
• The two forms use different items, but the rules for selecting items of a certain difficulty level are the same.

Split-Half Method

• Divides a test into halves and scores them separately.
• Correlation is found between the scores of the two halves.
• Can be problematic if the second half is more difficult than the first half.

Correcting for Half-Test Length

• Uses the Spearman-Brown formula to estimate what the correlation between the two halves would be if each half were as long as the full test.
• This formula increases the estimate of reliability.

Conceptualizing Errors

• Psychologists measure complex, invisible, or intangible attributes.
• They must evaluate their measurement instruments to determine how much of the observed score is due to measurement errors.

Classical Test Theory

• Assumes each person has a true score and that measurement errors are random.
• A single observation can deviate significantly from the true score.
• The standard deviation of the distribution of errors for each person tells us about the magnitude of measurement errors.

Domain Sampling Model

• Another key concept in classical test theory.
• It addresses the problems of using a limited number of items to represent a larger, more complex construct.
• Task is to estimate how much error is made by using the score of a shorter test as an estimate of one's true ability.

Reasons to Move Away from Classical Test Theory

• Classical test theory requires that each person receives exactly the same test items.
• Item Response Theory (IRT) uses computers to tailor the difficulty of items to an individual's ability level.
• IRT provides a more reliable estimate of ability with a shorter test and fewer items.

Sources of Error

• Time sampling: test-retest method
• Article sampling: parallel forms method
• Split-half method
• KR20 formula
• Coefficient alpha
• Reliability of difference scores

Variance

• σ2: theoretical values in the population
• S2: actual values obtained from the sample
• If r = 0.4, 40% of the variance will be explained by real differences between people, and 60% will be attributed to chance or random factors.

KR20 Formula

• The KR20 formula is used to calculate the reliability of a test with dichotomous items scored 0 or 1 (usually for correct or incorrect).
• The formula takes into account all possible ways to split the items.
• Ʃpq is the sum of the individual item variances.
• Covariance occurs when the items are correlated with each other.

Coefficient Alpha

• Coefficient alpha (α) is a more general reliability estimate that uses the variance of individual items (i), denoted as ƩSi.
• Si can describe the variance of items, regardless of whether they have a correct-incorrect dichotomy or not.
• Coefficient alpha is the most general method for finding reliability estimates through internal consistency.

Factor Analysis

• Factor analysis is a popular method for dealing with situations where a test appears to measure different traits.
• It can be used to divide items into subgroups, each with internal consistency, but not related to each other.
• Factor analysis is valuable in the test construction process, helping test constructors build tests with submeasures for different traits.

Reliability in Behavioral Observation Studies

• Psychologists with behavioral orientations often prefer direct observation of behavior rather than using psychological tests.
• However, psychologists cannot always continuously monitor behavior and may take samples of behavior at certain time intervals.
• In practice, behavioral observation systems are often unreliable due to discrepancies between actual scores and scores recorded by the observer.

What to Do with Low Reliability

• Two common approaches to dealing with low reliability are:
  • Increasing the length of the test (number of items)
  • Removing items that decrease reliability
• Two methods to ensure items measure the same trait:
  • Conducting a factor analysis
  • Analyzing the correlation between each item and the total score of the test

Correcting for Attenuation

• Due to low reliability, findings may not be significant, and potential correlations may be weakened or reduced by measurement errors.
• Measurement theory allows for estimating what the correlation between two measures would be if they were not measured with error.
• Correction for attenuation is a method that "corrects" for the weakening of correlations caused by measurement errors.

Validity

• Validity refers to the degree to which a test score or measurement reflects the quality it is supposed to measure.
• Validity can be defined as the answer to the question: "Does the test measure what it is supposed to measure?"

Types of Validity

• Construct Validity: The extent to which a test measures the underlying construct it is supposed to measure.
  • Convergent Validity: The degree to which the test correlates with other measures of the same construct.
  • Discriminant Validity: The degree to which the test does not correlate with measures of different constructs.
• Content Validity: The extent to which the test content represents the entire domain of the construct being measured.
  • Representativeness: The test should cover all relevant aspects of the construct.
  • Coverage: The test should have sufficient items to provide a comprehensive picture of the construct.
• Criterion Validity: The extent to which the test results correlate with an external criterion.
  • Concurrent Validity: The degree to which the test results correlate with currently available criterion data.
  • Predictive Validity: The degree to which the test results predict future outcomes.

Methods to Evaluate Validity

• Construct Validity: Factor analysis, hypothesis testing
• Content Validity: Expert judgment, systematic development processes
• Criterion Validity: Correlation coefficients, regression analysis

Face Validity

• Face Validity: The extent to which a test appears to measure what it is supposed to measure.
• Face validity is not a type of validity, but rather an appearance of validity.
• Face validity can motivate test-takers and improve their performance.

Examples of Validity

• Construct Validity: A new scale for measuring social anxiety, convergent and discriminant validity
• Content Validity: A math test for middle school students, representativeness and coverage
• Criterion Validity: A job application test, concurrent and predictive validity

Self-Other Disagreement

• Self-Other Disagreement: The difference between how an individual perceives themselves and how others perceive them on the same characteristics or behaviors.
• Importance: Provides insights into self-awareness, social perception, and interpersonal relationships.

Examples and Contexts of Self-Other Disagreement

• Personality Assessments: Self-ratings vs. peer ratings of extraversion
• Performance Evaluations: Self-ratings vs. manager ratings of job performance
• Behavioral Ratings: Self-ratings vs. peer ratings of helpfulness and friendliness

Possible Causes of Self-Other Disagreement

• Self-Enhancement and Self-Defense: Individuals tend to rate themselves more positively to protect and enhance their self-image.
• Lack of Self-Insight: Some individuals have difficulty accurately perceiving and rating their own behavior and characteristics.
• Perceptual Differences: The context in which behavior is observed can influence ratings.
• Information Mismatch: Individuals have access to internal thoughts and feelings that others do not see, while others may have more objective behavioral observations.

Implications and Consequences

• Self-Awareness and Development: Self-other disagreement can highlight areas where individuals can improve their self-awareness or performance.
• Interpersonal Relationships: Discrepancies can lead to misunderstandings or conflicts in relationships if individuals do not accurately perceive or understand each other.
• Feedback and Evaluation: Self-other disagreement can be important for providing effective feedback and developing employees in work contexts.

Foundations of Educational and Psychological Tests

• Foundations focus on psychometric basis concepts such as validity and reliability.

Operations of Tests

• Operations involve test design, development, and administration, including scoring and reporting.
• It also evaluates standards for test manuals and documentation.

Application of Tests

• Application addresses a broader range of issues, including training needed to administer and interpret tests.

Validity

• Validity refers to the evidence supporting the intended interpretation of a test score.
• There are three types of evidence:
  • Construct-related evidence
  • Criterion-related evidence
  • Content-related evidence
• Validity is a unitary concept representing all the evidence supporting the intended interpretation of a test score.

Validity Coefficient

• Validity coefficient is a correlation that describes the relationship between a test and a criterion.
• The coefficient indicates how well the test is valid for making predictions about the criterion.
• A validity coefficient between 0.3-0.4 is generally considered sufficient.
• The validity coefficient squared (x) is the percentage of variation in the criterion that can be predicted from the test scores.

Evaluating Validity Coefficients

• Look for changes in the cause of relationships.
• Consider the criterion: criterion-related validity studies are meaningless unless the criterion is valid and reliable.
• Evaluate the population of the validity study: ensure the sample is representative of the group to which inferences will be made.
• Ensure the sample size is sufficient: a small sample size can lead to artificial inflation of the validity coefficient.
• Check for cross-validation: a good validity study should provide evidence for cross-validation.

Validity and Reliability

• Defining the validity of a test is not possible if the test is not reliable.
• Unreliable and valid cannot exist: we can have reliability without validity.
• Relation between reliability and validity: reliability is a necessary condition for validity.

Ensuring Validity

• Consider validity in the early stages of research when deciding how to collect data.
• Choose the right measurement methods: methods should be of high quality and targeted to measure what you want to know.
• Use the right sampling methods to select participants: define the population clearly and ensure sufficient representative participants.
• Interpretation of the validity coefficient: a rule of thumb is that validity can range from 0 to 1.

Clinicians' Judgment

• Romantics are easily impressed and inspired, and tend to accept findings based on clinical validation.
• Empiricists, on the other hand, insist that grand claims be scientifically tested, and are likely to adopt a more skeptical attitude.

Cognitive Biases and Heuristics

• Cognitive heuristics and biases are often used to describe how clinical psychologists and others make judgments.
• Affect heuristic: relying on feelings of affective reactions, which is quick and automatic (e.g., feelings associated with words like "love" or "hate").
• Affect is likely to lead clinical judgment and decision-making, with both positive and negative effects.

Limitations of Informal Observations

• Cognitive processes of clinicians are prone to error.
• Accurate feedback on the validity of judgments is not available.
• It is difficult to learn from informal observations.

Need for Empiricism

• Psychologists should be less reliant on informal observations and clinical validation when:
  • Choosing a assessment instrument or treatment intervention.
  • Reviewing diagnostic criteria.
  • Making clinical judgments or test interpretations.

New Approaches to Evaluating Validity

• Two new approaches to evaluate the validity of descriptions of personality and psychopathology:
  • Daily self-reporting by patients to indicate whether they exhibited specific behaviors that day.
  • Improved research design and statistical analysis, collecting information from ≥1 source (e.g., parents, teachers, peers, etc.).

Bias in Diagnostic Outcome

• Bias refers to something that influences the outcome of diagnostic assessments.
• There are 12 types of biases that can affect diagnostic outcomes, including:

Role Bias

• Role bias occurs when clinical and forensic roles are mixed, leading to conflicts of interest.
• A clinician may want to help in the legal process but must also remain objective and unbiased.
• Prevention: take on separate roles and avoid dual agent conflicts.

Financial/Billing Bias

• Financial/billing bias occurs when judgments or scores are influenced by financial rewards or impulses.
• Different payment systems can influence judgments, such as:
  • Unforeseen payment systems that depend on legal outcomes.
  • Liens (letters of protection) that promise payment for services regardless of legal outcomes.
  • Payment for services provided, regardless of legal outcomes.
  • Capped payment systems that may lead to decreased productivity.
• Prevention: be cautious when receiving payment and make clear what you are being paid for.

Referral Source Bias (Anchor Bias)

• Referral source bias occurs when there is a tendency to favor one side over the other.
• The 50/50 myth: believing that working 50% for both sides eliminates bias, but this is not true because one always has a preference.
• Prevention: be critical when forming a professional opinion, and avoid saying something just because you always handle defense cases.

Bias in Self-Reporting

• Bias in self-reporting occurs when there is a discrepancy between self-reported and actual values of the same measurement.
• Prevention: use additional information to support anamnesis or supplementing data to form opinions.

Underutilization of Base Rates

• Base rates refer to the frequency or prevalence of a diagnosis, condition, symptom, or sign within a specific population.
• Examples of base rates include:
  • Bipolar disorder: 1%
  • NPD: 7%
  • Depression: 3.8-8.4%
• Importance of base rates: helps inform decision-making, calculate probability of positive outcomes, and evaluate the importance of test findings.
• Prevention: know the prevalence of conditions.

Ignoring Normal Variability in Test Scores

• Ignoring normal variability in test scores occurs when all factors are attributed to a condition, without considering factors that are not related to the condition.
• Prevention: know when test scores are abnormal; use evidence that supports or contradicts two scenarios, and consider both.

Confirmation Bias (Anchoring)

• Confirmation bias occurs when there is a tendency to seek information that supports existing hypotheses or information, while neglecting contradictory information.
• Prevention: always consider two simultaneous hypotheses and seek evidence that confirms or contradicts them.

Personal and Political Bias

• Personal and political bias occurs when a psychologist's personal experiences, beliefs, and (political) preferences influence attitudes and contribute to unconscious stereotyping.
• Prevention: be aware of personal and political biases.

Group Attribution Error

• Group attribution error occurs when a characteristic of one individual is assumed to be representative of the entire group.
• Prevention: analyze interviews to see if there are no symptoms being missed because someone presents themselves in a certain way.

Diagnostic Momentum Bias

• Diagnostic momentum bias occurs when the initial diagnosis is accepted without considering alternative diagnoses.
• Prevention: consider alternative diagnoses and perform own research if possible.

Good Old Days Bias

• Good old days bias occurs when individuals perceive themselves as healthier or more functional in the past, or underestimate symptoms prior to an injury.
• Prevention: involve multiple informants (family members or friends), use complete data from the past, and have a good overview of capacities before the injury.

Overestimation of Abilities

• Overestimation of abilities occurs when one overestimates their diagnostic capabilities, leading to diagnostic errors due to the inability to consider alternative hypotheses.
• Prevention: use two simultaneous hypotheses.

Diagnosing Errors

• System 1 thinking: fast, automatic, and unconscious, often leading to quick decisions and potential errors
• System 2 thinking: slow, analytical, and deliberate, helping to prevent errors
• Heuristics ( Mental shortcuts) with biases as possible consequences
• Experienced clinicians can recognize atypical presentations, whereas junior clinicians may not

The Influence of Referral Letters

• The diagnosis in a referral letter can influence the diagnostic decision of moderately experienced clinicians
• Experienced clinicians are less affected by the suggested diagnosis in a referral letter and have higher diagnostic accuracy
• Intermediate clinicians (2-10 years of experience) perform worse on psychodiagnostic classification but better on remembering clinical case information

Factors Influencing Diagnosis

• Patient characteristics (e.g., race)
• Context in which the subject is observed
• Task characteristics (e.g., dynamic stimuli that are not predictable, measurement error)
• The clinician's perspective (e.g., characteristics of the clinician that influence the assessment)

Anchoring

• The tendency to prematurely fixate on specific features of a presentation and base the probability of an event on information available at the beginning
• Related to premature closure and confirmation bias

Bayes' Rule

• A mathematical formula used to determine the conditional probability of events
• Helps calculate the posterior probability of a person's condition (disease/disorder) from three elements:
  • Prevalence (prior probability) of the individual population
  • Test outcome
  • Psychometric characteristics of the test (sensitivity and specificity)
• Importance of knowing the prevalence of a condition in a population, as it can lead to incorrect conclusions if overlooked

Interpreting Test Results

• 5 steps to follow:
  1. Determine the population and setting of the individual
  2. Find the prevalence of the condition in that population and setting
  3. Find the sensitivity and specificity of the test
  4. Enter the numbers into a flowchart or contingency table
  5. Calculate the probability of the presence or absence of the condition based on the test result

Examples of Bayes' Rule

• Positive predictive value (probability of presence) = true positives / total positives = 0.34 (34%)
• A positive test result does not necessarily mean it is true, additional testing is needed
• Negative predictive value (probability of absence) = true negatives / total negatives = 0.97 (97.4%)
• A negative test result can rule out depression, given the high predictability of 97%

Relative Risk

• Two times the probability does not mean the risk is greater if the probability is low
• Example: risk of thrombosis without a pill is 0.01%, and with a pill is 0.038%, still very low

Conclusion

• Neglecting Bayes' rule can lead to over- or underdiagnosis of a condition, especially if it is rare
• This can be easily understood by looking at the flowchart: with a low prevalence, the "no disorder" group is very large, and the post-test probability will remain low, even with high specificity.

The Importance of Diagnosis in Mental Health Care

• The diagnosis of mental health disorders has 4 main goals:
  • Identifying problems
  • Recognizing factors that contribute to and maintain the identified problems
  • Selecting the most suitable treatment approach
  • Adapting treatment to the client's needs

The Role of Cultural Validity in Diagnosis

• Cultural validity is essential in the evaluation and clinical diagnosis of mental health disorders
• The ethnic validity model refers to the recognition, acceptance, and respect for the presence of differences and similarities in psychosocial development and experiences between people from different ethnic or cultural backgrounds
• Cultural validity involves the exploration of inaccuracies in evaluation and diagnosis due to differences in race, ethnicity, nationality, or culture

Threats to Cultural Validity

• Bedreigingen voor culturele validiteit (threats to cultural validity) include:
  • Pathoplasticity of psychological disorders (variability in symptoms, course, and distribution of mental health disorders between different cultural groups)
  • Cultural factors influencing symptom expression
  • Therapist bias in clinical judgment
  • Language barriers
  • Inappropriate use of clinical and personality tests

Pathoplasticity of Psychological Disorders

• Pathoplasticity of psychological disorders refers to the variability in symptoms, course, and distribution of mental health disorders between different cultural groups
• This can lead to inaccurate diagnosis and ineffective treatment of culturally diverse populations

Cultural Factors Influencing Symptom Expression

• Cultural factors can influence symptom expression and manifestation
• Examples include:
  • Hospitalization rates
  • Somatization
  • Inappropriateness of and stigma associated with expressing mental health symptoms
  • Psychologization of depression (Western cultures place too much emphasis on the affective or psychological aspects of depression)

Therapist Bias in Clinical Judgment

• Therapist bias can be conceptualized as culturally-based countertransference
• Racial and ethnic differences can influence clinical judgment and assessment
• Therapists may overpathologize culturally diverse clients

Language Barriers

• Language barriers can hinder effective therapeutic communication
• Examples include:
  • Inhibiting the exchange of information
  • Stimulating bias in the therapist's evaluation
  • Use of interpreters (can lead to distortions that negatively impact diagnostic evaluations)

Inappropriate Use of Clinical and Personality Tests

• Clinical and personality tests may not be suitable for culturally diverse populations
• Examples include:
  • Generalization of test results from one cultural group to another
  • Tests may not be translated into the client's language
  • The predictive validity of tests may not be established for other ethnic and cultural groups

Conclusion

• Cultural factors are essential in the clinical diagnosis and assessment of mental health disorders
• Recommendations to reduce threats to cultural validity include:
  • Culturally relevant interventions
  • Awareness of communication and language differences
  • Avoiding misinterpretation of cultural effects
  • Utilizing informal support systems (e.g., churches, ethnic clubs, family organizations, and community leaders)
  • Ensuring measurement equivalence of assessment instruments
  • Recognizing differences within and between groups

Bias and Equivalence

• Bias occurs when score differences on indicators of a construct (e.g., percentage of students who know Warsaw is the capital of Poland) do not correspond to differences in the underlying trait or ability (e.g., geographic knowledge).
• Equivalence is the opposite of bias, referring to the absence of bias.

Types of Bias

• Construct bias: occurs when the measured construct is not identical across cultural groups (e.g., intelligence may be geared towards reasoning or social factors).
• Method bias: caused by the method of measurement (e.g., mode of test administration).
  • Subtypes:
    • Sample bias: occurs due to differences in sample characteristics other than the target variable (e.g., educational background).
    • Instrument bias: problems arising from the characteristics of the instrument (e.g., stimulus familiarity).
    • Administration bias: communication problems between interviewers and respondents (e.g., language barriers, cultural differences).
• Item bias: bias caused by the content of individual items (e.g., differential item functioning).
  • Item bias refers to distortions at the item level, as opposed to construct and method bias.
  • Items can have different psychological meanings across cultures, leading to invalid comparisons.

Consequences of Bias

• Conclusions based on biased scores are invalid and may not generalize to other instruments measuring the same underlying trait.
• Statements about bias always refer to the application of an instrument in a specific intercultural comparison (e.g., comparing German and Japanese individuals).

Detection and Solution

• Mental-Haenszel-statistic can be used to detect item bias.
• Specifying the theoretical conceptualization underlying the measure can help address construct bias.
• Restricting the comparison to a subset of the Western construct, acknowledging the incompleteness of the measurement for non-Western groups, can also address construct bias.

Translation in Multilingual Studies

• A suitable translation requires a balanced approach to psychological, linguistic, and cultural considerations.
• Two commonly used procedures for developing a translation:
  • Translation-Back-Translation procedure: a text is translated from the source language to the target language, and then back-translated to the source language to evaluate the accuracy of the translation.
  • Committee approach: a group of people with different expertise (e.g., cultural, linguistic, and psychological) work together to develop a translation.

Instrument Development

• Types of instrument development:
  • Simultaneous development: a new instrument is developed for each language group.
  • Successive development: an existing instrument is translated and adapted for use in a different language group.
• Approaches to translation:
  • Literal translation: direct translation of an instrument into the target language.
  • Adaptation: translation of part of the items and/or modifications to other items to ensure that the underlying constructs are adequately measured in each language.
  • Assemblage: a new instrument is assembled by combining items from different sources.

Sources of Bias

• Types of bias:
  • Construct bias: differences in the definition and measurement of a construct across cultures.
  • Method bias: differences in the administration and scoring of a test across cultures.
  • Item bias: differences in the functioning of individual items across cultures.
• Sources of bias:
  • Construct bias:
    • Incomplete or inadequate definition of the construct.
    • Differential allocation of behaviors related to the construct.
    • Incomplete coverage of all relevant aspects/facets of the construct.
  • Method bias:
    • Inconsistencies in the sampling procedure.
    • Differences in the administration and scoring of a test across cultures.
  • Item bias:
    • Poor translation of items and/or ambiguous items.
    • Cultural nuances and differences in the connotation of words.

Remedies

• Strategies to address bias:
  • Construct bias:
    • Decentering: developing an instrument simultaneously in multiple cultures.
    • Convergent approach: developing instruments independently in each culture and then comparing them.
  • Method bias:
    • Use of informants with knowledge of the local culture and language.
    • Use of local surveys (e.g., content analysis of open-ended questions).
    • Non-standard administration of the instrument (e.g., "think-aloud" protocols).
  • Item bias:
    • Linguistic and psychological analysis to detect item bias.
    • Psychometric methods to detect item bias (e.g., Differential Item Functioning analysis).
    • Analysis of errors or distractors.

Conclusion

• Score differences observed in intercultural comparisons may have a different meaning than those in intracultural comparisons, which is referred to as bias.
• The likelihood of a particular type of bias depends on the type of research question and the type of equivalence aimed for.
• The cultural distance between groups encompasses all aspects in which the groups differ and which are relevant to the target variable.

Therapeutic Assessment (TA)

• A semi-structured approach to clinical personality assessment
• Humanistic approach to clients, related to collaborative assessment
• Procedures are extensively documented, allowing for easy transfer and empirical testing
• Recent studies have shown that TA before treatment has the potential to improve outcomes in specific psychiatric populations

Characteristics of TA

• Primary assessment goals are formulated in collaboration with the client as questions to be answered by the assessment
• Test selection is guided by the client's and referring doctor's questions
• Administration and scoring are performed according to standardized techniques
• Individualized feedback is an important element, characterized by its question-guided, patient-centered, collaborative nature (test data → daily life context)

Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

• A personality test used in TA
• 4 face-to-face sessions:
  • Session 1: Collecting questions and completing the MMPI-2
  • Session 2: Performance-based tests, including the Rorschach
  • Session 3: Assessment intervention session
  • Session 4: Feedback discussion

Goal-Focused Pre-Treatment Intervention (GPTI)

• Based on a 5-session model, standard for good primary care in Dutch mental healthcare
• Strong protocol-driven comparison condition, based on a widely applied protocol for standard care
• Four face-to-face sessions, with patients receiving a workbook with homework assignments and a written goal for each session
• Session 1: Focus on combating demoralization and promoting hope through psycho-education on the dynamics of maladaptive behavior and their potential for change
• Session 2: Focus on the primary problem to be addressed in treatment
• Session 3: Exploring the dilemma of change
• Session 4: Focus on achieving a shared reassessment of problems, including setting goals for the remaining period before treatment

Conclusions

• Patients in the TA condition (compared to GPTI) had:
  • Higher outcome expectations for their upcoming treatment
  • Were more satisfied with the quality of the intervention
  • Felt more focused on their treatment goals
  • Had higher satisfaction with the received intervention, even compared to a highly credible control condition
• TA exerted medium to large effects on these measures, even compared to a highly credible control condition
• No statically significant differences in symptom and demoralization improvements were observed between interventions

Therapeutic Assessment (TA)

• TA is an evidence-based approach to positive personal change through psychological assessment, aiming to maximize the likelihood of therapeutic change for clients.
• It incorporates knowledge from various psychological fields to produce a semi-structured approach to assessment that is focused on the therapeutic effect.

History of TA

• Historically, people were treated as objects to be measured, predicted, and controlled.
• Fisher (1978) argued that psychologists should recognize that people are goal-directed and that professional insights are not superior to clients' own insights.
• The collaborative/therapeutic assessment movement began in 1992, led by Finn, who developed the therapeutic assessment approach.

Scientific Basis of TA

• Finn and Tonsager (1992): A study of students in two groups (assessment vs. no assessment) found that the assessment group showed significant symptom reduction and increased self-esteem, while the non-assessment group showed no changes in variables.
• Newman and Greenwat (1997): A similar study with refinements found comparable results, but with smaller effect sizes.

Key Ingredients of TA

• Changing the client's self-story: TA changes the narrative clients have about themselves, which can drastically alter their self-perception and life choices.
• Walking the boundary between self-verification and desintegration: A key challenge in therapeutic change is balancing the need for self-verification with the potential for desintegration, which can lead to feelings of emotional distress, disorientation, and anxiety.

Using Psychological Tests as "Empathy Magnifying Glasses"

• Psychological tests can be used to create a unique experience of being deeply seen and understood, which can be therapeutic in itself.
• The tests can help clients feel deeply understood and validated, leading to increased empathy and self-awareness.

Involving the Whole System in Childhood and Family Interventions

• TA is a family system intervention that involves caregivers in every step of the process, helping them understand their child's needs and interact with them more effectively.
• The approach focuses on the most important interpersonal environment of the child to create the conditions for growth and therapeutic change.

Projective Identification in Couples

• A key challenge in couple therapy is uncovering and reducing relationship patterns rooted in childhood experiences that influence expectations, reactions, and behavior in the current relationship.
• TA in couples involves separate assessments of each partner to gain insight into the underlying dynamics that affect the relationship, followed by joint discussions to increase awareness and reality-based interactions.

Therapeutic Assessment Stages

• The assessment process begins with the referring professional and later with the client, usually via a phone call.
• The first phone contact provides valuable information about the client's presentation, concerns, tone of voice, and openness to the assessment.
• A collaborative relationship between the assessor and client is established during the first phone contact by asking the client to think about questions they want to address during the assessment.

First Session

• This session sets the framework for the assessment.
• The assessor aims to show authentic warmth, respect, empathy, and curiosity, and involve the client as a collaborator.
• The client is encouraged to discuss their life problems, and the assessor actively listens to identify potential areas of focus.
• The assessor collects relevant background information for each central question.
• It's also useful to inquire about past assessments and any pain they may have caused (without re-traumatizing the client).

Standardized Test Scores

• Testing usually begins in the next session.
• Standardized tests are administered to collect information that will inform the answers to the client's questions.
• The assessor often chooses tests that are more closely related to the client's questions.

Intervention Session

• In this session, the assessor uses the collected information to create an analog of the client's most important problems in vivo.
• The client is invited to experience and observe their problem behavior in the session.
• If successful, the client is encouraged to understand and solve the problem behavior in the session.

Summary/Discussion Session

• This session provides an opportunity for the assessor and client to discuss the assessment findings together.
• The assessor contacts the referring professional to discuss the findings and plan the summary/discussion session.
• The assessor presents the client's questions and provides tentative answers based on the tests and previous conversations.
• The assessor checks in with the client after each point to ensure they understand the findings.

Written Feedback

• After the summary/discussion session, the assessor writes a letter to the client outlining the assessment findings.
• The letter usually takes the form of a personalized report, reiterating each question and summarizing the answer.
• This letter serves as a permanent document of the assessment findings and the client's relationship with the assessor.

Follow-up Session

• This session is typically scheduled 3-6 months after the summary/discussion session.
• It provides an opportunity for the assessor and client to check in and clarify or deepen the assessment results, and explore how they may be influencing recent concerns.
• This can sometimes become an annual follow-up.

NIP and Ethische Code

• Het Nederlands Instituut van Psychologen (NIP) is a national professional organization that protects the interests of all psychologists.
• The NIP operates in a broad range of sectors to strengthen the position of psychologists and psychology.
• The organization controls the quality of 'Code of Ethics', 'Association Law', 'Promotion of Knowledge', and 'Education'.

Ethische Code

• The Ethische Code is an ethical code that contains clear ethical principles, values, and norms to guide the decisions of psychologists and support them in difficult and challenging situations.
• The code provides guidelines for ethical decision-making and serves as a quality instrument for the NIP.
• The code has several goals: it serves as a tool for psychologists to make ethical decisions, clarifies what the public can expect from a psychologist, and serves as a standard for psychologists to account for their actions during a complaint procedure.

4 Basic Principles of Ethische Code

• Verantwoordelijkheid (Responsibility): Psychologists must accept their professional and scientific responsibility towards individuals, their environment, and society.
  • Quality of professional activities
  • Continuity of professional activities
  • Prevention and limitation of damage
  • Prevention of misuse
• Integriteit (Integrity): Psychologists must strive for integrity in the practice of their science, education, and application of psychology.
  • Reliability
  • Honesty
  • Role integrity
• Respect: Psychologists must respect the fundamental rights and dignity of individuals.
  • General respect
  • Autonomy and self-determination
  • Confidentiality
  • Providing information
• Expertise: Psychologists must strive to acquire and maintain a high level of expertise in the exercise of their profession.
  • Ethical awareness
  • Professional competence
  • Boundaries of professional activities

Klachtenprocedure (Complaint Procedure)

• A person involved in professional activities can file a complaint with the Supervisory Committee if they believe a psychologist has acted contrary to the Ethische Code.
• The Supervisory Committee gives the psychologist the opportunity to respond to the complaint.
• If the complaint is justified, the Committee can take measures: warning, reprimand, suspension, or termination of membership.
• An appeal can be filed against a decision of the Committee with the Appeal Board.

De Leidraad Toetsgebruik: A Guide to Responsible use of Psychodiagnostic Instruments

• The De Leidraad Toetsgebruik is a specification of the Ethical Code, providing guidelines for the responsible use of psychodiagnostic instruments in psychology and psychological interventions.

Psychodiagnostic Instruments

• Psychodiagnostic instruments are used to establish a person's characteristics, with the goal of making assessments or recommendations about that person.
• These instruments include tests, questionnaires, and other methods of data collection.

Assessment Procedure

• The assessment procedure involves the following steps:
  • Invitation to the client: the client is invited to participate in the assessment, and is informed about the purpose, methods, and reporting of the assessment.
  • Informed consent: the client gives informed consent, and if under 18, parents or guardians are also involved.
  • Creating a file: a file is created for the client, containing information relevant to the assessment.
  • Test administration: the test is administered, and the psychologist is responsible for ensuring the test is taken correctly.
  • Scoring and interpretation: the test is scored and interpreted, and the results are reported to the client.

Use of Psychodiagnostic Instruments

• Psychodiagnostic instruments should only be used when there is a reasonable expectation that they will improve the quality of the assessment or recommendation.
• The psychologist should consider the following factors when choosing an instrument:
  • Quality of the instrument
  • Relevance to the assessment question
  • Cultural and linguistic background of the client

Protecting the Client's Rights

• The client has the right to:
  • Receive a debriefing about the assessment
  • Inspect the report before it is published
  • Block the report from being shared with others
  • Request corrections or additions to the report
  • Receive a copy of the report
  • Have guided access to the raw test data

Reporting and Documentation

• The psychologist's report should include:
  • The assessment question and method
  • The results of the assessment
  • The conclusions and recommendations
  • The limitations of the assessment
  • The psychologist's qualifications and expertise
• The report should be written in a clear and concise manner, and should be based on the assessment data.

Confidentiality and Security

• The psychologist should ensure that all assessment data and reports are kept confidential and secure.
• The psychologist should use secure methods of communication, such as encrypted email or web portals, to share reports with clients and others.

Special Considerations

• The psychologist should consider the following special considerations:
  • Cultural and linguistic diversity of the client
  • Use of automated reporting tools
  • Use of digital psychodiagnostic instruments
  • Security risks associated with emailing reports