ch09.ppt

CHAPTER 9 – ASSESSMENT: INTEGRATION AND CLINICAL DECISION MAKING COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTEGRATION AND CLINICAL DECISION MAKING Psychologists are responsible for making optimal judgments about client problems, course of treatment, and future behavi...

CHAPTER 9 – ASSESSMENT: INTEGRATION AND CLINICAL DECISION MAKING COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTEGRATION AND CLINICAL DECISION MAKING Psychologists are responsible for making optimal judgments about client problems, course of treatment, and future behavior among several other decisions. Clinicians must integrate a huge variety of clinical data while facing conflicting pressures to decrease diagnostic uncertainty, risks to patients, and costs. Deciding what information to gather, which tests to order, how to interpret and integrate this information to draw diagnostic conclusions, and which treatments to give is known as clinical decision making. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTEGRATION AND CLINICAL DECISION MAKING All assessments are designed to address a question Psychologist determines the most appropriate type of assessment based on this question As the assessment progresses different tests or assessments may be added COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTEGRATING ASSESSMENT DATA Descriptive account of the client’s level of functioning Importance of understanding client in his/her social and interpersonal environment Often different assessments/tests provide conflicting results  Importance of multiple informants especially with children COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL CASE FORMULATİON Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors. https://healthskills.wordpress.com/2008/09/25/an-introduction-to-case-formulation/ COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. https://www.slideshare.net/actsconz/assessment-and- formulation-for-advanced-practice-using-a-case-study- approach COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  CASE FORMULATION Case Formulation: A clear hypothesis that relates to how a problem developed and how it is maintained A clinical formulation, also known as case formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  CASE FORMULATION Case Formulation: In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and psychiatrists and is deemed to be a core component of these professions. Mental health nurses and social workers also use formulations COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  CASE FORMULATION Case Formulation:  There are many different frameworks for case formulation, but several key elements are usually present: 1.a description of the presenting issues; 2.the factors that act to create vulnerability or precipitate the problems developing; 3.factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally, 4.factors that can help the person cope or act as resources. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  CASE FORMULATION Case Formulation:  To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (ie. what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognisable features that are present.  Suggestions are then made – e.g., psychological services, additional assessment, or planning of other services for the client  Often helps guide treatment & specific interventions COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. CASE FORMULATION Some Benefits of a case formulation:  Provides connections between various problems  Provides guidance on the type of treatment  Predicts the patient’s functioning with and without treatment  Provides options if difficulties are encountered in treatment  Indicates options, outside of psychological services COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  CASE FORMULATION Components of a case formulation:  Description of problems & symptoms  Events or stressors that led to the symptoms or problems  Predisposing life events/ vulnerabilities  A hypothesized mechanism that links the problems to the person’s current functioning COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. CASE FORMULATION Steps of a case formulation:  1. Develop a comprehensive problem list  2. Determine the origin, precipitants, and consequences of the problems  3. Identify patterns among the problems  4. Develop working hypotheses to explain the problems  5. Evaluate and refine the hypotheses  6. In treatment, the hypotheses should be reconsidered, re- evaluated, and revised THREATS TO THE VALIDITY OF CASE FORMULATIONS Client Factors:  Clients may try and under-pathologize themselves  Problems clearly recalling a problem behavior or memories from their past (retrospective recall)  Can’t assume clients are accurately perceiving/portraying reality COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  THREATS TO THE VALIDITY OF CASE FORMULATIONS Clinician Factors:  Self-serving attributional bias: Bias to make internal, stable and global attributions for positive events (can seriously affect how clinicians evaluate their effectiveness)  Overuse of heuristics (mental short cuts)  Biases (gender, ethnic, socioeconomic, etc.)  Several common decision making biases (see text table 9.3) COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  IMPROVING THE ACCURACY OF CLINICAL JUDGMENT Some Important strategies:  Use directly relevant psychometrically sound tests  Check for scoring errors  Use normative data and base rate information  Use DSM criteria when making diagnosis  Use decision trees or clinical guidelines.  In unstructured interviews be as systematic as possible  Be aware of relevant research  Be aware of personal biases and preconceptions.  Search for alternative explanations for hypotheses  Seek consultation  Don’t rely on memory and don’t rush to a conclusion  IMPORTANT CONCEPTS IN ASSESSMENT REPORTS Important to remember the ‘audience’ of the report Privacy is important – avoiding stigmatizing labels, using multiple sources Exercising caution with computer-based interpretations (CBI’s) – problematic to include this in a testing report http://www.veterans.gc.ca/public/pages/publications/system-pdfs/ psy_assesesment_e.pdf COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  IMPORTANT CONCEPTS IN ASSESSMENT REPORTS Contents of a typical assessment report  Identifying patient/client information  Reason for referral  Background information (including, developmental history, educational & employment history, family & relationship history, medical history, etc.)  Assessment methods (including tests administered)  Interview data and behavioral observations  Test results (including interpretation of test scores)  Diagnostic impressions  Summary  Recommendations COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  IMPORTANT CONCEPTS IN ASSESSMENT REPORTS Purpose of giving feedback on an assessment report  Verify the general accuracy of the assessment results  Refine the interpretation of the results  Put the individual’s symptoms, in the context of his/her life history and current life circumstances  Provide some psychological relief for the individual by presenting an integrated picture  Provide concrete information about steps to address personal difficulties  Help the individual identify potentially stressful situations  Collaborate to design goals that build on personal strengths  Collaborate: işbirliği yapmak COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.