6013 Week 1 Assessment in Mental Health Professions PDF

**6013 Week 1** **Assessment in Mental Health Professions** **By the end of this week, you should be able to:** - Explore and differentiate observational and questioning techniques used in affective assessment. - Examine the applicability and limitations of observational and question...

**6013 Week 1** **Assessment in Mental Health Professions** **By the end of this week, you should be able to:** - Explore and differentiate observational and questioning techniques used in affective assessment. - Examine the applicability and limitations of observational and questioning techniques in behavioural assessment. - Outline: - The range and purposes of interviews in psychological assessment - The history of interviewing in psychology - The phases, structure, and specific content of a comprehensive or clinical assessment interview **Why do we need psychological assessment?** **Aim:** The aim of psychological assessment is to answer questions about human behaviour and to help make decisions.  While this is a simple definition it is what is at the **core of psychological assessment** -- and why psychological assessment is at the core of any psychological practice.  This broad definition suggests that we don't carry out assessment just for the sake of curiosity or to use a fancy test -- **we do so in order to help make decisions.** In this chapter, we will provide you with an overview of assessment. Before we begin, keep in mind that:  - Psychological testing is a field characterised by the use of samples of behaviour in order to assess psychological constructs (e.g., cognitive and emotional functioning) about a given individual (e.g., the Client). - [A psychological test] is one of the sources of data used within the process of [assessment]; usually more than one test is used. Many psychologists do some level of testing when providing services to clients, and may use simple checklists to assess some traits or symptoms. [But, psychological assessment is a more complex, detailed, and in-depth process]. **The Why, What and How of Assessment** **What is Assessment?** **Case Study** **From Goldfinger and Pomerantz (2014),p.2:** \- Psychologists along with other health professions routinely conduct assessments to understand behaviour, help us make decisions about people, manage risk and develop treatment plans **Testing VS Assessment** **TESTING DOES NOT = ASSESSMENT** **Psychological Testing** - Involves administering, scoring, and interpreting results of tests that measure one or more psychological functions, such as emotional states, cognitive abilities, or personality traits. - The only **relevant data are the psychometric properties** of the test (e.g., its validity or reliability) and the score on the test, which is interpreted within the test's parameters according to its developers. This information, taken in isolation, is insufficient for understanding the complexities of a client's problem or the development of treatment plans. **Example:** Conducting one memory test in Margaret's case would not be sufficient to determine the problem. Thus, it was necessary for the practitioner to conduct interviews with the client and her son. The psychologists also asked the client to complete a self-report of depression as depression and/or anxiety which may affect the results. \- The interviews add depth and ecological validity to the findings, and allow the psychologist to provide useful and meaningful recommendations to the client and Dr Shaw. -The self-report of depression also help to rule out any other potential diagnoses or causes for Margaret's issues with memory. **From Meyer et al.(2001),p.153:** "**A psychological test** is a dumb tool, and the worth of the tool cannot be separated from the sophistication of the clinician who draws inferences from it and then communicates with patients and other professionals." In contrast, **psychological assessment** involves taking the data obtained through testing (usually from multiple tests) and considers this in the context of: - Client history, obtained through referral information and interviews - Observed behaviour during evaluation - Ongoing informal assessment throughout the helping process **Formal VS Informal Assessment** There are two ways information can be gathered about a client during assessment: formal and informal assessment. **Formal Assessment** - Includes administering and interpreting psychological tests, **conducting structured interviews, and considering referral information.** - This takes place at **one specific time** during the helping process. **Informal Assessment** - Includes **observing and questioning** throughout the helping process. - This is an **ongoing** form of assessment that continues beyond the formal assessment timepoint. **Where does it fit?** - An **in-depth formal assessment** should take place at the **second stage** of the helping process - The collection of demographic information, initial observation of behaviour, and introduction to the client's story should take place before this in the **relationship building stage. This is part of informal assessment.** - The in-depth formal assessment may take more than one session. - Informal assessment will continue throughout the helping process. **Road Map of Helping Process** **(Young 2017)** **A Model for Psychological Assessment** From Goldfinger and Pomerantz (2014), p.5:  **3 Phases** 1. **Preparing Phase** Refers to the tasks carried out prior to any new data being collected with the client \- receiving referral \- analysing context \- establishing referral questions \- assessing data needs 2. **Gathering and Drawing Conclusions** Gathering, Scoring and Interpreting Data from a range of instruments and tools in multiple areas This may include interviews and tests assessing \- intelligence \- personality \- psychopathology \- memory \- and other neuropsychological domains The phase also **involves drawing conclusions from the data** 3. **Communication of Findings** **The Importance of Assessment** - Superficial assessments lead to poor outcomes for a client. - Placing inordinate reliance on testing at the expense of gathering background information from multiple sources and conducting ongoing informal assessment can not only result in an **incorrect diagnosis but inappropriate treatment being offered.** **There are several reasons to spend time in the assessment stage:** 1. **Determining whether the client will benefit from the help you can provide.** \- There are many forms of support and therapy available depending on an individual's needs, and a practitioner needs to be sure that the therapy they can offer will be the best for that particular client. 2. **Gaining adequate information to plan useful/realistic goals for the client.** \- Assessment must have appropriate breadth to ensure that no essential information for establishing useful and realistic goals is missed, along with the depth to identify crucial information (e.g., suicide risk, etc). 3. **Helping the client identify previously unrecognised aspects to the problem.** \- The client may not be aware of all possible facets of a problem that are crucial for overcoming the problem. Assessment can help to identify these. 4. **Identifying environmental impacts on a client's mental health.** \- Situational factors such as living environment may be contributing to whatever problem an individual is facing. 5. **Recognising an individual's unique case and circumstances.** \- Thorough assessment allows us to avoid making assumptions based on stereotypes or generalisations. 6. **Uncovering the potential for violence.** \- It isn't always possible to predict violent behaviour, but thorough assessment can identify risk factors and allow precautions to be taken. 7. **Revealing critical historical data.** \- By creating a thorough historical time line for a client, it can be possible to identify the aetiology of a condition or understand the client's worldview. 8. **Identifying strengths, not just weaknesses or pathology.** \- Instead of just focusing on pathology, strength-based assessment helps clients build self-esteem and allows time to be employed more effectively during the helping process. 9. **Helping clients gain awareness of problems.** \- Clients may not be consciously aware of problems until assessment brings them to the surface (e.g., substance abuse). 10. **Selecting which techniques to use as part of the helping process.** \- Only through having a thorough understanding of the client's history and problem can the most appropriate techniques can be employed. **Approach to Assessment** **History** The earliest psychological test was developed in the **mid-to-late-19th century with Galton's whistle**, a method to evaluate high tone hearing. The work of **Binet, Cattell, and Munsterberg** followed over the remainder of the century, focusing primarily on individual differences. To appreciate modern applications of assessment, it can be helpful to gain an understanding of how assessment developed over the 20th and 21st centuries. Here, we will be overviewing the **four major turning points in psychological assessment to allow modern assessment approaches to be considered in their proper context.** **Intelligence and Achievement Testing** The first major form of psychological assessment was intelligence testing **for children in school.** This continued to be developed over the next 50 years. - The Binet-Simon Intelligence Test was introduced in 1905 - The Stanford-Binet Intelligence Scales was developed in 1916 - Currently up to its 5th edition **Military**\ - **Army Alpha and Beta Tests** were developed as group intelligence tests for military personnel in World War I\ - Replaced in World War II by the **Army General Classification Test** In the 1940s, Wechsler extended intelligence testing to adults, and IQ was changed to deviation IQ based on **population-based norms** Alongside test development, research into the construct of intelligence developed throughout the 20th century (e.g., determining whether intelligence is a **general ability \[g\] or a series of abilities**), and the utilization of IQ testing in clinical settings also developed significantly. **IQ Testing** - In addition to achievement testing, **IQ testing is used to identify intellectual disability** in educational settings and is part of cognitive assessments in clinical settings. - Nonetheless, **raw IQ scores are no longer of primary interest**. - Intelligence testing is used in conjunction with other assessment tools to examine **cognitive processes and abnormal thought processes**, along with **language and non-verbal abilities** in neuropsychological contexts. **Personality Assessment** After intelligence testing, the personality assessment became the primary domain of clinicians. To accomplish this, three broad assessment methods emerged: the interview and the projective and objective tests. **The Unstructured Interview** - Historically, the interview was an unstructured conversation between the - Its goals were to obtain the patient's history, assess personality structure and dynamics, and establish a diagnosis. - This form of interview was subjective, unreliable, and could not be validated. As a result, the interview fell out of favour for a time. **The Structured Interview** In response, structured interviews with specific content and items were developed for which reliability could be established and many have now been adapted for both clinical and research purposes. - The structured interview is now so well-established in psychopathology diagnosis that it is rare for research not to use them. - Many psychologists and psychiatrists prefer the structured interview and observation to objective or projective psychological tests given that they are viewed as the 'ultimate validating criterion.' - They now meet psychometric standards of reliability and validity. **Examples** **The Structured Interview** Frequently used comprehensive examples include: The Schedule for Affective Disorders and Schizophrenia (SADS) The Renard Diagnostic Interview The Structured Clinical Interview (SCID), now updated for DSM-5 The Diagnostic Interview Schedule (DIS) Briefer, more specific interviews include: The Hamilton Depression Scale The Young Mania Rating Scale The Mini-Mental Status Examination **Projective Personality Tests** - As the structured interview rose as the preferred diagnostic method in psychopathology, the use of projective personality tests popular in the **1940s and 50s such as the Rorschach technique and the Thematic Apperception Test (TAT) fell.** A projective test is a personality test in which subjects are shown ambiguous images and asked to interpret them. The subjects are to project their own emotions, attitudes, and impulses onto the image; and then use these projections to explain an image, tell a story, or finish a sentence. \- Asked to respond to ambiguous stimuli **There are several reasons projective tests declined in use:** 1. These instruments generally lack the psychometric rigor of more sophisticated tests and structured interviews. 2. The development of objective tests such as the Minnesota Multiphasic Personality Inventory (MMPI) allowed similar information to be gathered more efficiently and less expensively. 3. Projective tests are closely aligned with psychoanalytic theory rather than cognitive, behavioural, or biological approaches. **Objective Personality Tests** - Historically, three major objective personality tests have survived into contemporary use: the MMPI and MMPI-2, a series of tests by Guilford and colleagues, and a similar series by Cattell and colleagues. - The Guilford and Cattell tests are trait-oriented and based on factor analysis. - The MMPI and MMPI-2 relate to psychiatric classification. Objective tests involve standardized test questions that are scored and analysed.  **Their use depends on the purpose of testing:** - For individuals expected to function **within the normal range** (e.g., in an organisational or research context), the **Cattell 16PF** can be used. - For individuals expected **not to fall within the normal range** (e.g., in a healthcare setting), the far more extensive **MMPI and MMPI-2** can be used for screening, diagnostic evaluation, and as a research tool. **Neuropsychological Assessment** Neuropsychological assessment developed out of behavioural neurology and psychometrics. Historically, pre-existing psychological tests were used when assessing patients with suspected brain damage, but standardised test batteries were eventually developed for this type of specialist assessment instead. **Halstead-Reitan Neuropsychological Battery** Consists of five core subtests and five optional subtests designed to measure cognitive functions (i.e., language, attention, motor skills, sensory-motor integration, abstract thinking, and memory). **Luria-Nebraska Neuropsychological Battery** Available in two versions and consists of eleven scales designed to assess different cognitive and motor functions (i.e., speech, writing, reading, arithmetic, memory, rhythm, visual and tactile functions, etc). - Numerous other tests can be used as part of neuropsychological assessment, including the revised Wechsler Memory Scale (WMS-III and WMS-IV), California Learning Test, White and Stern's (2003) Neuropsychological Assessment Battery, and Meyers Neuropsychological system. - Discussions regarding how clinicians should approach neuropsychological assessment are also continuing to the present day. For example, should these large, fixed batteries of tests be administered to all patients or should referral question and patient characteristics determine which tests are given? What approaches to test interpretation should be taken? **Behavioural Assessment** In response to the rise of behaviour therapy and the unreliability of aspects of DSM diagnostic schemes and projective assessment methods, **behavioural assessment that favours direct measurement was developed.** - Though still evolving, behavioural assessment emphasises **motoric, physiological, and self-report systems** rather than indirect measurement. - It involves **observation of individuals in naturalistic conditions** (or analogous conditions) where possible, along with self-report as independent criteria. - It is used widely in numerous settings ranging from educational, rehabilitation, community, medical and psychiatric, to clinical. - Several comprehensive assessment schemes have been developed. **Overview of Interviewing** **Introduction to Assessment** \- **Prerequisite** for any helping progression \- Typically, **first source of information** gathering for psychologists and **foundation** for all subsequent actions and interventions to help the client \- Provides the **data** and **frame of reference** that can direct the use of other **assessment methods** \- Where the collaboration between the psychologist and clients begins and lays foundation for **meaningful change.** **Types of Interviews** 1. **Intake Interview** Gain understanding of current issues to determine whether to "intake" the individual to the agency for further assessment and/or treatment 2. **Mental State Examination** Briefly and accurately provide a description of the individuals'; current level of functioning across range of domain 3. **Diagnostic Interview** Structured interview to determine and assign appropriate diagnosis/diagnoses to the individual 4. **Crisis Interview** Assess and offer immediate intervention, either in-person or by phone, for individuals needing urgent attention (e.g., suicide, harm to self or others) 5. **Specialised Interview** For special purpose (e.g., assess used for psychiatric hospitalisation, ability to stand trial) 6. **Assessment Interview (clinical interview)** Broad purpose is to gather relevant information to include as part of a comprehensive assessment (and may also include one or more of the above purposes) and may be a precursor to further assessment and techniques **History of Assessment Interviewing** \- Word interview found in dictionaries as far back as 1514 \- Initially modelled on question and answer medical format **Early 1900s psychoanalytic influences** \- more open, free flowing format **1940s and 1950s** \- research began to focus on questions of content vs process and degree of directedness **1960s** \- Carl Rogers led research that emphasised qualities of clinician (warmth, accurate empathy, unconditional positive regard, genuineness) \- Behaviourists emphasised systematic reflection of information via structured interview **1970s** \- idea of structured diagnostic interviews emerged \- led to development of structured approaches to child assessment from both parents and child **1980s** \- structured interviews developed in line with DSM revisions \- comprehensive cognitive behavioural psychosocial interview (e.g., BASICID) **1990s** \- increased appreciation of implications of culture and gender on the assessment process **2000s** \- increased managed care meant less emphasis on structured approach due to costs and greater reference on unstructured assessment interviews with testing or structured approach as an adjunct \- level of structure increases and at the level of psychopathology in the client **Phases of Assessment Interviews** **What is it?** \- Thoughtful, well planned, deliberate dialogue \- To acquire important information that enables the psychologist to develop a working hypothesis of the problem(s) to answer referral question/s Additional purposes: \- Problem identification and/or diagnosis \- Explore hypotheses about individuals' problem \- Understanding problem's historical sequence \- Observe the client \- To inform the client \- To inform further assessment decisions and data sources \- Informs the later interpretations of other testing **The 'assessment interview"** \- In reality, the assessment interview is typically characterised as **neither purely structured or unstructured** but draws on both \- A **'phased' approach** to assessment interviewing is the **most common** psychological practice and assessment \- According to such models, although the interview format remains unstructured (in as much as the questions and wording are not planned prior to the session) the interviewer typically retains a general idea of the **sequence** and **flow** of the interview. **Shea's (1988) 5 phase Model** 1. The introduction 2. The opening 3. The body 4. The closing 5. The termination 1. **The Introduction** Initiating a helping relationship Providing an introduction to the process and assembling the necessary information to guide the process Put client at ease to facilitate open discussions of a wide range of personal information \- Starts with receiving and greeting the client \- Establishing rapport \- Being sensitive to common fears \- Putting client at ease \- Setting the frame and structure \- Evaluating client expectations \- Educating clients **Examples** Introduction to process, facilitate a discussion, setting us phrase \- warm, setting clear expectations of relations, trust and security \- present, smiling, knowing clients name \- setting frame and structure, confidentiality and limits, informed consent, privacy, providing an overview of what is happening in the interview \- may say about what you're going to do, we're going to ask a lots of questions, there are no right or wrong answer 2. **The Opening** Begins with interviewer's first questions about current concerns Ends when the focus if the interview becomes clear and specific questions are asked about specific topics Non-directive and meant to encourage disclosure \- Starts with an opening statement \- Consider the client's opening response **Example** Usually starts with an opening statement of "Tell me what has brought you hear today?" This informs the client that what they have to say is important, they are responsible for the telling, and that they decide what areas of life they want to talk about. 3. **The Body** Where depth of information is gathered, and rapport is maintained Is the heart of the interview **Asking questions** \- Open, focusing, clarifying questions \- Avoid too many closed or leading questions **Keeping the information flowing** \- Attending, empathy, paraphrasing, summarising, non-judgemental attitude **Content** **Example** Can you give me an example of that? No right or wrong answer Paraphrasing -- shows we understand Summarising 4. **Closing** Closing the interview should be done with some forethought and adequate time \- Reassuring the client \- Summarising \- Instilling hope \- Saving time for any questions from the client \- Discuss any follow up or further arrangements 5. **Termination** The interview needs a clear ending \- Acknowledge by both parties the interview is over \- Be mindful of 'doorknob' statements \- Gesture or statement \- Our time is up for today \- I'll see you next time \- Take care **Considerations** **Important considerations in clinical assessment interviews** \- Consider not only that what is said, but how people report their history for clues to their interpersonal style \- Observe the individual's verbal and non-verbal behaviours \- Pay attention to your emotional responses to client -- countertransference \- Be curious! \- The history will inevitably be choppy and disjointed -- just follow along and guide them when needed \- Don't expect to receive the whole story initially **Review and Reflect** 1. What have you learnt through your counselling skills training that could contribute to gathering useful information during the middle phase of an interview?  \- Asking questions \- Keep information flowing \- Content \- Paraphrasing \- Summarising 2. What do you think some of the key skills or strategies may be?  \- Emphasise that there are no right or wrong answers **Informal Assessment Methods** Informal assessment techniques are an important skill for people in helping profession \- The helper will be able to observe the client over a period of time and make notes of change \- The helper will question the client to determine if the client's needs fit with the helper's abilities 1. **Observation** \- It a conscious process \- With experience you will detect patterns in your clients What to observe? \- Speech \- Clothing, grooming \- Posture, build, gait \- Facial expressions \- How you feel being around the client 2. **Questioning** Necessary to obtain information from the client \- Taking their history \- Significant timeline of events \- Orienting client \- Creating a genogram \- How you are the question \- What questions you choose **Review and Reflect** 1. What is observation? Why is it important that we observe in helping professions? \- how we detect patterns in clients \- conscious process \- it is important as the information may be useful in helping the client 2. How do we know if a question is necessary?  \- First ask ourself whether question if necessary \- only ask if the question if you feel it will clarify your understanding or be helpful to the client as way to deepen the understanding of themselves 3\. Given the examples of challenging questions in the Textbook -** **Young, Ch 9, pg.199, reflect on how you might communicate these when trying to help a client dig deeper. Would you change your tone, rate of speech, something else? \- make tone softer \- slow rate of speech \- make them reflect \- left them know there are no right or wrong answers **Readings** **Young, M. E. (2020). Excerpt from, \[Chapter 9\], \[Assessment and goal setting\], \[Why assessment? - Two informal methods of assessment that every helper uses : Observation and questioning\]. *Learning the art of helping : Building blocks and techniques* (7th ed., pp. 190--199). Pearson Higher Education. ** **Why Assessment? (190- 196)** - Assessment means gathering and organizing information about a client and the client's problems. - Helpers collect information in a variety of ways, beginning with the first contact as the helper studies the client's behaviour and listens to the story. - **Formal assessment methods:** include testing and filling out questionnaires and forms. - **Informal assessment:** encompasses all the other ways a helper learns about a client, including observing and questioning. - Formal assessment may occur at a specific time in the helping relationship, but informal assessment is an ongoing process because a client's progress and the temperature of the therapeutic relationship must be tested throughout. - In this book, I recommend that the helper set aside time for an initial assessment during the second stage of the helping process (Figure 9.1). **Stages of Assessment** **1. Relationship building:** - Because each client's situation is unique, it is impossible to predict how much time to give to each stage of the helping process. - Still, a rule of thumb is to spend one session primarily in relationship building, with the only assessment activities being the collection of basic demographics, observation of the client's behaviour, and whatever else you can glean from the client's story. **2. Goal Setting and Testing** - The second and possibly a third session are spent in a more in-depth assessment before moving on to a goal-setting phase, which might include testing. - Therefore, if a client is seen for 10 sessions, about 10% of the time may be devoted to assessment. **Beginning relationship with formal assessment is not appropriate** - Beginning a relationship with a formal assessment can be a mistake because the initial moments of any human encounter are so important. - Imagine how you would feel if you went for a doctor's appointment and were asked only to fill out forms, contribute blood samples, and answer questions but were not allowed to talk about the reason for your visit. - When clients have been invited to tell their stories, they give much more information during the formal assessment period that follows. - They leave the first session believing that they have made a start on solving problems, instead of feeling dissected by tests and probing questions. - Key data need to be collected at the first interview, but there are several ways to handle this. - For clients who can read and write, asking them to come in early to fill out paperwork can be an effective way of collecting information about their background and current functioning. **Assessment Is a Critical Part of Helping** - Sometimes you will hear that gathering a lot of historical information about a client is not worthwhile. - Certain theories emphasize the present and the future rather than the past, and so they ignore history and personality data. - It is true that some helpers do spend an inordinate amount of time gathering background information and administering tests. - On the other hand, by failing to collect critical data, you take the chance of making a serious mistake. - You must know your customer thoroughly **Superficial assessments** - Conducting superficial assessments, however, does not always lead to such spectacular embarrassment. - It is very common, though, for helpers to accept the client's story without a critical thought. - Even the most astute helper can make drastic mistakes. - It is important to listen to what clients leave out and where they minimize or deny. - Also, it is easy to forget to ask specific questions, so using a structured form for assessment is advised. - Just because a client is well groomed and comes from a prominent family does not mean that you should not ask about drug abuse, intimate partner violence, or suicidal thoughts. - Our prejudices and worldview colour our definition of pathology. Even the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, the diagnostic bible, recognizes that misdiagnosis can occur when the helper is not familiar with a client's cultural background and interprets symptoms within his or her own cultural context. - The next section indicates how assessment can provide the helper with critical information about the client that charts the course of treatment. **Reasons to Spend Time in the Assessment Stage** **Assessment Helps You Determine Whether the Client is a Good Candidate for the Help You Can Provide** - Counselling or psychotherapy from a trained professional is not the best treatment for everyone. - The client must have the capacity to form a relationship, motivated to change, and able to attend sessions and understand what is going on - There may be better avenues of help for the client than "talk therapy." There are educational, online learning, occupational, chemotherapy, and support group alternatives. - When a client arrives for treatment, the first thought should be: Is this the right place for this client? For example, in our university clinic, counsellors are only available one day each week. Thus, we need to assess clients to make sure that they are stable enough to get along on their own between sessions. We refer those who are not to a more intensive treatment center. **Assessment Gives Crucial Information to Plan Useful and Realistic Goals** - The **main purpose of assessment is to gather information that will be useful in planning the goals that will guide the helper and the client.** - Assessment must have both breadth and depth. - As far as breadth is concerned, the helper must throw the net broadly enough to make sure nothing crucial escapes. - That is why many treatment facilities use a standardized assessment or psychosocial intake form that requires details about the client's medical, psychological, and social history as well as current functioning. - Depth refers to getting detailed information on specific issues such as suicide, the existence of mental disorders, and the "presenting problem" or specific issue that acted as a catalyst for the client's decision to seek help. **Assessment Helps Clients Discover Other Factors Related to the Problem** A woman came to a community clinic asking for help in dealing with problems at work. She recognized that her job was stressful, but she found that she was unusually irritable with her co-workers and wanted to work on that problem. After some reflection and homework by the client, we discovered that her angry outbursts all happened between 1:00 p.m. and 2:00 p.m. on days when she had not eaten lunch. The client knew that she became grumpy when she was hungry, but she had never connected this with her behaviour on the job. A physician helped the client to deal with a problem of low blood sugar, and her extreme irritability diminished, which in turn helped in her relationships and her work. - We might easily have treated the problem as anger without ruling out physical causes. In another case, we found that a client's anxiety was at least partially due to drinking eight cups of coffee per day. **Assessment Helps us Understand the Psychological Impact of the Client's Environment** For example, is the client living with family, in a shelter, or alone? Does the client suffer isolation from not speaking the dominant language or belonging to a religious minority? If the client is a child, what is happening at school every day that might be affecting the problem? Is the child bullied, rejected by classmates, or encouraged by a teacher? **Assessment Helps us Recognize the Uniqueness of Individuals** - We all have the tendency to generalize and stereotype. - Unless we ask clients about family and cultural background issues, we may make assumptions about them through our personal cultural lens. The behavior of people from different cultural groups may be judged as being more pathological than of those who share our own background. - A systematic assessment helps us be less manipulated by these strong social influences and more objective because we are recording the answers to standard questions rather than merely relying on our own impressions. Assessment can also be useful in helping clients recognize their own unique personality, values, strengths, and interests **Assessment Uncovers the Potential for Violence** - Assessment can identify individuals who are at risk for violence toward self or others, especially by collecting a thorough history. - Although it is not possible to always accurately predict violent behaviour, a history of self-inflicted injury or harm to others can cue us to examine the client's situation more thoroughly and take precautions. - School counsellors are recognizing the need to identify potential for violent behaviour in the aftermath of school shootings and in the wake of renewed interest in bullying. **Is Path Warm?** - When you suspect suicide, you should ask the client directly about suicidal thoughts. - Then take it seriously and get immediate help (see Granello, 2010). - IS PATH WARM? (see following) is an acronym that was developed by the American Association of Suicidology (2019) to gauge suicidal risk - It must be remembered that these are guidelines based on risk factors, and there is no foolproof method of determining how likely a client is to commit suicide. - The rule of thumb is to err on the side of caution, and a client who is exhibiting any of these symptoms should be further evaluated. **Ideation:** Does the client think, talk, or write about a desire to self-destruct or to purchase the means to do so? Does the client show an intention to carry out the plan? **Substance Abuse:** Is the client intoxicated or been abusing alcohol or other drugs? **Purposelessness:** Is the client adrift, without a sense of meaning and purpose in life, seeing no reason to keep living? **Anger:** Is the client's mood angry or hostile? Is the client feeling vengeful toward someone? **Trapped:** Does the client feel there is no way out of the present situation and would be better off dead? **Hopelessness:** Does the client have a negative view of the future and feel like a lost cause or beyond help? **Withdrawal:** Has the client withdrawn from family, friends, and other supportive people? **Anxiety:** Is the client experiencing anxiety that interferes with sleep and daily functioning? **Recklessness:** Does the client engage in risky behaviours, such as driving at high speed or taking other chances? **Mood:** Is the client experiencing drastic mood swings? Is the client feeling depressed? **Assessment Reveals Critical Historical Data** Figure 9.2 shows a simple assessment device called a timeline. Rafael was asked to fill in the boxes with critical life events in sequential order. His choice of key interpersonal events gave a glimpse of his worldview and his major concerns. **FIGURE 9.2 Timeline Assessment** **Figure 9.2 Full Alternative Text** **Assessment Can Highlight Strengths, Not Just Weaknesses and Pathology** - More and more helpers are using assessment tools that identify client strengths and competencies - Strength-based assessment instruments such as the Behavioral and Emotional Rating Scale have been developed in response to this need. Strength-based assessment is, in part, a reaction to medical pathology-based models. - It is also being recognized that building on client strengths enhances client self-esteem and helps client and helper use time more effectively - Another emphasis for assessment is wellness. - A wellness philosophy also emphasizes strengths, but its holistic point of view advocates evaluation of clients' interacting physical, mental, emotional, social, cognitive, occupational, and spiritual resources **Assessment Helps Clients Become Aware of Important Problems** - Frequently, painful issues are pushed out of awareness or remain unrecognized until brought to the surface through assessment - A common example of this is substance use. - When clients are asked to list and discuss the problems that alcohol has caused, the results can be surprising. - Many alcohol treatment centres take thorough histories and use motivational interviewing as a beginning step in breaking down the alcoholic's denial system (Miller & Rose, 2009). **Assessment Helps the Helper Choose Which Techniques to Use** - When you think about learning helping techniques, chances are that you have not considered assessment as a critical part of that process. - Yet how do you know which techniques to use? - **The answer is derived from two sources of knowledge:** - **information about your client** - **and information about the client's problems.** - If you know that your client is very religious, for example, you will be able to select techniques that the client will embrace. - If you know when and where your client has panic attacks, you will be better able to identify an effective plan. We have to think about what methods to use with which clients for what particular problem - The next section covers the basic techniques of assessment that are appropriate to use at all stages of treatment to gain knowledge about clients. **Reading** Young, M. E. (2020). Excerpt from, \[Chapter 9\], \[Assessment and goal setting\], \[Why assessment? - Two informal methods of assessment that every helper uses : Observation and questioning\]. *Learning the art of helping : Building blocks and techniques* (7th ed., pp. 190--199). Pearson Higher Education. **Informal Methods of Assessment Chapter 9 (196 -- 199)** **Two Informal Methods of Assessment That Every Helper Uses: Observation and Questioning** - By using the informal assessment techniques of observation and questioning, the helper is able to screen for major problems and determine whether the help offered fits the client's needs. **Observation** - Yogi Berra once said, "You can observe a lot just by watching." - His statement underlines the fact that observation is something of a lost art. - It also emphasizes that observation is not a passive process but a conscious, concerted effort. - Experienced helpers are able to detect patterns in clients from a number of small clues that, on the surface, may seem inconsequential to someone else. **Example** - For example, some helpers can catch signs of alcohol abuse from a client's hand tremors, jaundiced and dry red skin, finger swelling, and changes in the nose. - For example, a registered nurse, Ryan Read, was watching her favourite show, Flip or Flop. Ryan e-mailed the show's host, Tarek El Moussa, after she noticed a lump on his thyroid. It turned out Tarek had thyroid cancer, which has since been successfully treated. - In conjunction with experience and training, observation can be just as crucial in the helping professions. - **Clients often carry the clues to their problems on their faces and in the way they walk and speak.** **Culture Check Assumptions in Assessment** - Our cultural biases, assumptions, worldview, and experiences colour what we observe. - Our family backgrounds and culture shape what we remember and pay attention to. - We see clients through our cultural lenses and judge their behaviour according to our standards. - Freeing ourselves entirely from this conditioning is impossible, but we can become more aware of our own limited cultural vision. - It is enlightening to be a visitor to another culture, but we can also become students of how we react to cultural difference. **Example** - For example, on a trip to Europe, my companions and I met a large group of Japanese tourists taking hundreds of pictures of a Dutch windmill. We found this to be, on the one hand, amusing, and on the other, excessive and annoying. I began talking with the Japanese tour guide about this. The tour guide explained that living on an island means that travel is more restricted, and off-island vacations are relatively rare and brief for most people in Japan. - In addition, pictures are a way of sharing experiences with family and friends back home, who may expect and eagerly await a slide show. Even more important, it is a way for the tourists to relive that moment. When we heard these explanations, my colleagues and I were embarrassed by our cultural encapsulation, and we began to see the behaviour in a completely different light. - Since then, I have tried to take special care in recording and reflecting on my observations when a client is culturally different. - In the following sections, **remember that your impressions come through your own cultural point of view.** When you have the chance to record your observations with real clients, revisit this section and reflect on what you may be bringing to the picture you are painting. **What to Observe** **Speech. ** - Note all aspects of a client's speaking voice. - Does the client's voice annoy or soothe? - Is the client's tone slow and monotonous or excessively labile (variable)? - Does the client have an accent of any kind? - Does the client's voice reflect alcohol abuse or smoking? - Is the client's speech hurried or forced? - Does the client have a speech impediment of any kind? Does the client speak without listening? - Does the client get to the point, or do they go in circles or off on tangents? **Client's Clothing. ** - Does the client wear expensive, stylish, well-coordinated, seductive, old, or outmoded clothing? - Is there anything odd or unusual about it? - Does the client reflect a particular style (artistic, conservative, etc.)? - Is clothing inappropriate for the weather (several layers on a hot day), and is it appropriate to the occasion? - Does the client wear jewellery? A lot of jewellery? - Does the client wear appropriate amounts of makeup? - Does the client wear glasses or a hearing aid? Does the client's clothing suggest a different cultural background? **Grooming. ** - Is the client clean? - Does the client exhibit body odor and a general disregard for personal hygiene? - Even if the client shows concern for cleanliness, is there a disorganized appearance to the hair and clothing, perhaps suggesting disorderliness, depression, or lack of social awareness? - Do cultural differences in grooming account for the client's appearance? - If the client is a child, what does grooming suggest about family environment? **Posture, Build, and Gait. ** - What is the client's posture during the session? What is the position of the shoulders and head? - Does the client sit in a rigid or a slouched position or with head in hands? Does the client's posture reflect the present emotional state, or is the client's posture indicative of a more long-term state of anxiety, tension, or depression? - **Build refers to the body habitus.** - Is the client physically attractive? Is the client obese, muscular, or thin? Are there any unusual physical characteristics, such as excessive acne, physical disabilities, or prostheses? - **Gait means the person's manner of walking**. - Does the client's manner of walking reflect an emotional state, such as depression or anxiety? - Does the client's walk seem to indicate confidence or low self-esteem? Is the client tentative and cautious in finding a seat? **Facial Expressions. ** - Facial expressions include movements of the eyes, lips, forehead, and mouth. Do the client's feelings show, or are the client's expressions flat, devoid of any emotion? - Does the client maintain direct eye contact or avoid it? - Do the eyes fill with tears? Does the client smile or laugh during the session? - Is the brow wrinkled? Could the client's facial expressions be due to cultural injunctions about eye contact or posture in the presence of an authority figure like the helper? **Other Bodily Movements. ** - A client may show anxiety by twisting tissue or by tapping restlessly with fingers, toes, or legs. - One important way in which people express themselves is through their hand movements. - Fritz Perls, the founder of Gestalt therapy, was fond of making clients aware of how bodily movements expressed their inner conflicts and impulses **General Appearance. ** - In recording an assessment of the client, it is sometimes useful to note initial holistic impressions, which may become less noticeable as treatment progresses---for example, "The client appeared much older than his stated age," "The client appeared to be very precise and neat and seemed to carefully consider every statement before speaking," "I had the feeling that the client was a super salesman." - Many of these holistic impressions can be stereotypes, but sometimes they give insight into the impression the client is trying to make. **Feelings of the Helper. ** - Basing his observations on Harry Stack Sullivan's theories, Timothy Leary (1957) (before he took LSD) hypothesized that we **react automatically and unconsciously to the communications of others.** - Our reaction, in turn, triggers the other person's next response. - We tend to instinctively react in a positive, friendly manner to individuals we find attractive and friendly. - Similarly, we instinctively respond in a negative way to individuals who are combative or aloof. - They in turn become more abrasive, and the cycle continues. - These interpersonal reflexes occur outside of awareness and are rarely discussed, but they can be very important in the helping relationship and in the client's social world. If the helper is feeling annoyed with the client, is it possible that most of the client's social circle might feel the same way? What would motivate the client to push people away? Is the client even aware of this effect on others? - According to Ernst Beier, **the helper can learn to use personal feelings as an assessment instrument.** - It requires detaching and not reacting to the client's overtures but, instead, thinking about how others in the client's world must feel about the client and making note of this information. **Questioning** - Previously we cautioned helpers not to ask too many questions as it tends to disrupt formation of the relationship and interrupts the client. - In fact, the most common mistake for beginning helpers is relying on questions in the relationship-building stage rather than taking the necessary time to understand the client and provide an atmosphere of openness and trust. - During the assessment stage, however, questions are necessary because they expedite taking personal and sexual histories and drawing the family tree (genogram). It is not that questions are inherently bad; it is just that they are overused by beginning helpers and at the wrong time. **Assessment Questions** - Questioning is an art (Goldberg, 1998). When used artfully, questions can even be therapeutic devices to spur the client's thinking or stimulate action. - Questions can also be used to gain valuable information and to focus the client on the agreed-upon goals. - They serve an "orienting" function in that they tell the client what is important - We call these assessment questions. Following are some assessment questions frequently asked by helpers early in the assessment stage in order to identify important aspects of the client's concerns: "How can I help you?" "Where would you like to begin?" "What prompted you to make today's appointment?" "Has something happened in the last few days or weeks that persuaded you that help was needed?" "What is it that you want to stop doing or do less of?" "What is it that you want to begin to do or do more of?" **Digging Deeper** - Next is a different sort of question that pushes clients to dig deeper and challenges them to act. We call these challenging questions. They differ from assessment questions in that their purpose is not to gather information but to expand the client's thinking. "What effect do you think your depression has on your spouse?" "What would your life be like if the problem were solved?" "What does that do to the relationship between you and your stepmother?" "Where did that idea come from, that you are not capable of being a good father?" **Reading** Goldstein, G., Allen, D. N., & DeLuca, J. (2019). Historical perspectives. G. Goldstein, D. N. Allen, & J. DeLuca (Eds.), *Handbook of Psychological Assessment* (4th ed., pp. 3--27). Academic Press. **Historical Perspectives** **Introduction** - The invention of psychological tests, then known as mental tests, is generally attributed to Galton ([Boring, 1950](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib22)), and occurred during the middle to late 19th century. - Galton's work was largely concerned with differences between individuals, and his approach was essentially in opposition to the approaches of other psychologists of his time. - Perhaps the first psychological test was the **"Galton whistle,"** which evaluated high tone [hearing](https://www.sciencedirect.com/topics/neuroscience/sensation-of-hearing). - Galton also appeared to have believed in the statistical concept that held that errors of measurement in individuals could be cancelled out through the mass effect of large samples. - Obviously, psychologists have come a long way from the simple tests of Galton, Binet, and Munsterberg, and the technology of testing is now in the computer age, with almost science fiction--like extensions, such as testing by satellite and virtual reality applications. - [Psychometrics](https://www.sciencedirect.com/topics/psychology/psychometrics) is now an advanced branch of mathematical and statistical science, and the administration, scoring, and even interpretation of tests has become increasingly objectified and automated. - Testing appears to have become a part of western culture, and there are indeed very few people who enter educational, work, or clinical settings who do not take many tests during their lifetimes. - The presence of testing laboratories equipped with computers in clinical and educational settings is now not uncommon. **Testing and Assessment** - In recent years, there has been a distinction made between testing and assessment, assessment being the broader concept. - Psychologists do not just give tests now; **they perform assessments**. - The term **assessment implies that there are many ways** of evaluating individual differences. - **Testing is one way**, but there are also others, including interviewing, observations of behavior in natural or structured settings, and the recording of various physiological functions. - Certain forms of interviewing and systematic observation of behaviour are now known as behavioral assessments, as opposed to the [psychometric assessment](https://www.sciencedirect.com/topics/psychology/psychometric-assessment) accomplished through the use of formal tests. - Historically, interest in these two forms of assessment has waxed and waned, and in what follows we will briefly try to trace these trends in various areas. **Intelligence and achievement testing** - The testing of intelligence in school children was probably the first major occupation of [clinical psychology](https://www.sciencedirect.com/topics/psychology/clinical-psychology). - However, advocacy efforts to improve the quality of education, such as the **"No Child Left Behind" federal program**, have become associated with substantially increased use of testing of academic abilities. - Tests of reading, writing, and [mathematical abilities](https://www.sciencedirect.com/topics/psychology/mathematical-ability) have become increasingly used over the past several decades. - **The Binet scales and their descendants** continue to be used, along with the IQ concept associated with them. - Later, primarily through the work of David Wechsler and associates, intelligence testing was extended to adults and the IQ concept was changed from the mental age system **(Mental Age/Chronological Age×100) to the notion of a deviation IQ based on established population-based norms**. - While Wechsler was primarily concerned with the individual assessment of intelligence, many group-administered paper-and-pencil tests also emerged during the early years of the 20th century. - These tests were generally designed to allow for the assessment of large groups of individuals in situations where individually administered tests were impractical. - The **old Army Alpha and Beta tests**, developed for the intellectual screening of large groups of inductees into the armed forces during the First World War, were among the first examples of these instruments. - In recent times efficiencies afforded by group testing have been assisted by self-administration of tests using computers. - The English investigators Burt, Pearson, and Spearman and the Americans Thurstone and Guilford are widely known for their work in this area, particularly with factor analysis. - The debate over whether intelligence is a general ability (g) or a series of specific abilities represents one of the classic controversies in psychology. - Factor analysis has provided support for various models describing the structure of intelligence, and has expanded early conceptualizations of intelligence as composed primarily of verbal and nonverbal abilities or fluid and crystallized abilities to the more complex models now used to describe the structure of the Wechsler scales and hierarchies of general, broad, and narrow abilities that typify the Cattell--Horn--Carroll theory. **Clinical Utilisation** - Another highly significant aspect of intelligence testing has to do with its clinical utilization. - The IQ now essentially defines the borders of intellectual ability and disability, formerly called mental retardation, and intelligence tests are widely used to identify disabled children in educational settings \[American Psychiatric Association (APA), [Diagnostic and Statistical Manual of Mental Disorders](https://www.sciencedirect.com/topics/neuroscience/diagnostic-and-statistical-manual-of-mental-disorders), 5th ed., ([DSM-5, 2013](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib138))\]. - However, intelligence testing has gone far beyond the attempt to identify [intellectually disabled](https://www.sciencedirect.com/topics/psychology/intellectual-disability) individuals and has become widely applied in the fields of psychopathology and [neuropsychology](https://www.sciencedirect.com/topics/psychology/neuropsychology). - With regard to psychopathology, under the original impetus of David Rapaport and collaborators ([Rapaport, Gill, & Schafer, 1945](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib101)), the Wechsler scales became clinical instruments used in conjunction with other tests to evaluate patients with such conditions as [schizophrenia](https://www.sciencedirect.com/topics/neuroscience/dementia-praecox) and various stress-related disorders. - In the field of [neuropsychology](https://www.sciencedirect.com/topics/neuroscience/neuropsychology), use of intelligence testing is possibly best described **by [McFie's (1975)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib80) remark, "It is perhaps a matter of luck that many of the Wechsler subtests are neurologically relevant" (p. 14).** - In these applications, the intelligence test was basically used as an instrument by the clinician to examine various [cognitive processes](https://www.sciencedirect.com/topics/psychology/cognitive-process) in order to make inferences about the patient's clinical status. - In summary, the intelligence test has become a widely used assessment instrument in **educational, industrial, military, and clinical settings**. - While in some applications the emphasis remains on the simple obtaining of a numerical IQ value, it is probably fair to say that many, if not most, psychologists now use the intelligence test as a means of examining the individual's [cognitive processes](https://www.sciencedirect.com/topics/neuroscience/cognitive-process); of seeing how he or she goes about solving problems; of identifying those factors that may be interfering with adaptive thinking and behavior; of looking at various language and nonverbal abilities in brain-damaged patients; and of identifying patterns of abnormal thought processes seen in schizophrenia, [autism](https://www.sciencedirect.com/topics/neuroscience/pervasive-developmental-disorder), and other patient groups. - As the theoretical models proposed to understand IQ have become increasingly complex there has been an accompanying increase in the development of various index scores to reflect performance on current versions of intelligence tests. Performance profiles and qualitative characteristics of individual responses to items appear to have become the major foci of interest, rather than the single IQ score. - The recent appearance of the new child and adult versions of the Wechsler intelligence scales reflect the major impacts [cognitive psychology](https://www.sciencedirect.com/topics/psychology/cognitive-psychology) and neuropsychology have had on the way in which intelligence is currently conceptualized and intelligence test results are currently interpreted. **Personality assessment** - Personality assessment has come to rival intelligence testing as a task performed by psychologists. - However, while most psychologists would agree that an intelligence test is generally the best way to measure intelligence, **no such consensus exists for personality evaluation.** - From a long-term perspective, it would appear that two major philosophies and perhaps three assessment methods have emerged. - The two philosophies can be traced back to [Allport's (1937)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib3) distinction between **nomothetic versus idiographic methodologies** and [Meehl's (1954)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib83) distinction between clinical and statistical or actuarial prediction. - In essence, some psychologists feel that personality assessments are best accomplished when they are highly individualized, while others have a preference for quantitative procedures based on group norms. - The phrase **"seer versus sign"** coined in a paper by [Lindzey (1965)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib75) has been used to epitomize the dispute regarding whether the **judgment of clinicians (seer) or actuarial statistical approaches (sign)** provide superior predictive efficiency. - The three methods referred to are the **interview and the projective and objective tests.** **The interview** - Obviously, the initial way that psychologists and their predecessors found out about people was to talk to them, giving the interview historical precedence. - Following a period wherein the use of the interview was eschewed by many psychologists, it now has made a return. It would appear that the field is in a historical spiral, with various methods leaving and returning at different levels. - The interview began as a relatively unstructured conversation with the patient and perhaps an informant, with varying goals including obtaining a history, assessing personality structure and dynamics, establishing a diagnosis, and many other matters. - Numerous publications have been written about interviewing (e.g., [Menninger, 1952](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib84)), but in general they provided outlines and general guidelines as to what should be accomplished by the interview. - However, model interviews were not provided. With or without this guidance, the interview was viewed by many as a subjective, unreliable procedure that could not be sufficiently validated. - For example, the unreliability of psychiatric diagnosis based on studies of multiple interviewers had been well established ([Zubin, 1967](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib134)). In reaction to unreliability of clinical interviews at the time, several structured psychiatric interviews appeared in which the specific content, if not specific items, is presented, and for which very adequate reliability has been established. - There are now several such interviews available, including the Schedule for Affective Disorders and [Schizophrenia](https://www.sciencedirect.com/topics/neuroscience/dementia-praecox) (SADS) ([Spitzer & Endicott, 1977](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib111)), the Renard Diagnostic Interview ([Helzer, Robins, Croughan, & Welner, 1981](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib50)), and the Structured Clinical Interview for DSM-III, DSM-III-R, or DSM-IV (SCID or SCID-R) ([Spitzer & Williams, 1983](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib113)) (now updated for DSM-5). - These interviews have been established in conjunction with objective diagnostic criteria included in the DSMs, the Research Diagnostic Criteria ([Spitzer, Endicott, & Robins, 1977](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib112)), and the Feighner Criteria ([Feighner et al., 1972](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib37)). - Some have been adapted for application in both research and clinical settings. - These procedures have apparently ushered in a "comeback" of the interview, and many psychiatrists and psychologists now prefer to use these procedures when making psychiatric diagnoses rather than either the objective or projective-type psychological test. Those advocating use of structured interviews point to the fact that in [psychiatry](https://www.sciencedirect.com/topics/neuroscience/psychiatry), at least, tests must ultimately be validated against diagnostic judgments made by psychiatrists. - These judgments are generally based on interviews and observation, since there really are no specific biological or other objective markers of most forms of psychopathology. If that is indeed the case, there seems little point in administering elaborate and often lengthy tests when one can just as well use the criterion measure itself, that is, the interview, rather than the test. Put another way, there is no way that a test can be more valid than an interview if an interview is the ultimate validating criterion. **Structured Interviews** - Structured interviews have made a major impact on the scientific literature in psychopathology, and it is rare to find a recently written research report in which the diagnoses were not established by one of them. - It would appear that we have come full cycle regarding this matter, and until objective and specific markers of various forms of psychopathology are discovered, we will continue to rely primarily on the structured interviews for diagnostic assessments. - Interviews such as the SCID or the Diagnostic Interview Schedule (DIS) type are relatively lengthy and comprehensive, but there are also several briefer, more specific interview or interview-like procedures that allow for diagnosis of specific conditions, as well as procedures that allow clinicians to make severity ratings of specific symptoms based on an interview with the client. - Within psychiatry, perhaps the most well-known procedure is the Brief Psychiatric Rating Scale (BPRS) ([Overall & Gorham, 1962](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib99)). In the area of affective disorders, the [Hamilton Depression Scale](https://www.sciencedirect.com/topics/neuroscience/hamilton-rating-scale-for-depression) ([Hamilton, 1960](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib46)) and Young [Mania Rating Scale](https://www.sciencedirect.com/topics/psychology/mania-rating-scale) ([Young, Biggs, Ziegler, & Meyer, 1978](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib133)) have played similar roles historically. A wide range of specific interview procedures are also available for examination of psychotic symptoms including the positive and negative symptom scales developed by [Andreasen (1984)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib9) as well as newer second generation measures developed to assess negative symptoms based on more recent theoretical models ([Kirkpatrick et al., 2011](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib69), [Kring et al., 2013](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib71)). - Many other interview based procedures are available as well. Unlike the SCID and similar measures, interview procedures like the BPRS are often not tied directly to DSM or other diagnostic criteria. - However, they do allow for examination of presence and severity of symptoms consistent with specific diagnoses, and when repeated, reflect a standardized way to examine change in patient symptoms, usually as a function of taking some form of [psychotropic](https://www.sciencedirect.com/topics/neuroscience/psychoactive-drug) medication or in response to behavioral interventions. **Dementia Specific Interviews** - There are also several widely used interviews for patients with dementia, which generally combine a brief [mental status examination](https://www.sciencedirect.com/topics/neuroscience/mental-status-examination) and some form of functional assessment, with particular reference to activities of daily living. Historically, the most popular of these scales are the Mini-Mental Status Examination of [Folstein, Folstein, and McHugh (1975)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib38), and the Dementia Scale of [Blessed, Tomlinson, and Roth (1968)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib21). - Extensive validation studies have been conducted with these instruments, perhaps the most well-known study having to do with the correlation between scores on the Blessed, Tomlinson, and Roth scale used in patients while they are living and the [senile plaque](https://www.sciencedirect.com/topics/neuroscience/senile-plaque) count determined on autopsy in patients with dementia. - The obtained correlation of 0.7 quite impressively suggested that the scale was a valid one for detection of dementia. Since the publication of the last edition, the [Montreal Cognitive Assessment](https://www.sciencedirect.com/topics/psychology/montreal-cognitive-assessment) has become one of the most commonly used interviews for patients with dementia ([Ozer, Young, Champ, & Burke, 2016](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib100)). **Psychiatric** - In addition to these interviews and rating scales, numerous methods have been developed by nurses and psychiatric aids for assessment of psychopathology based on direct observation of ward behavior ([Raskin, 1982](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib102)). - Historically, the most widely used of these rating scales are the Nurses' Observation Scale for Inpatient Evaluation (NOSIE-30) ([Honigfeld & Klett, 1965](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib63)) and the Ward Behavior Inventory - These scales assess such behaviors as cooperativeness, appearance, communication, aggressive episodes, and related behaviors, and are based on direct observation rather than reference to medical records or the reports of others. - Scales of this type supplement the interview with information concerning social competence and the capacity to carry out functional activities of daily living. In recent years a new procedure called motivational interviewing has appeared, originally for use with problem drinkers; but it is really more of a counselling method than an assessment procedure used to help clients explore and resolve ambivalence about addressing their psychological concerns and motivating them for treatment. **Comeback of Interviews -- how they are different** - Again taking a long-term historical view, it is our impression that after many years of neglect by the field, the interview has made a successful return to the arena of psychological assessment, but the interviews now used are quite different from the loosely organized, "freewheeling," conversation-like interviews of the past ([Hersen & Van Hassett, 1998](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib60)). - **First, their organization tends to be structured, and the interviewer is required to obtain certain items of information.** Formulation of specifically worded questions is sometimes viewed as counterproductive but even in cases where this is the interview format, the interviewer, who should be an experienced clinician trained in the reliable use of the procedure, should be able to formulate questions that will elicit the required information. - **Second, the interview procedure must meet psychometric standards of validity and reliability.** - **Finally, while structured interviews tend to be a theoretical in orientation, many are based on contemporary scientific knowledge of psychopathology.** - Thus, for example, the information needed to establish a [differential diagnosis](https://www.sciencedirect.com/topics/neuroscience/differential-diagnosis) within the general classification of mood disorders is derived from current scientific literature on depression and related mood disorders as reflected in the DSM, or negative symptoms of psychosis are evaluated based on current theoretical understandings of symptom organization and structure. **Projective personality tests** - The rise of the interview appears to have occurred in parallel with the decline of projective techniques. - Those of us in a chronological category that may be roughly described as elderly may recall that our graduate training in [clinical psychology](https://www.sciencedirect.com/topics/psychology/clinical-psychology) probably included extensive coursework and practicum experience involving the various projective techniques. - Most clinical psychologists would probably agree that even though projective techniques are still used to some extent, the atmosphere of excitement concerning these procedures that existed during the 1940s and 1950s no longer seems to exist. - Even though the Rorschach technique and [Thematic Apperception Test](https://www.sciencedirect.com/topics/neuroscience/thematic-apperception-test) (TAT) were the major procedures used during that era, a variety of other tests emerged quite rapidly: the projective use of human-figure drawings ([Machover, 1949](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib78)), the Szondi Test ([Szondi, 1952](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib116)), the Make-A-Picture-Story (MAPS) Test ([Shneidman, 1952](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib110)), the Four-Picture Test ([VanLennep, 1951](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib121)), the Sentence Completion Tests (e.g., [Rohde, 1957](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib105)), and the Holtzman Inkblot Test. - The exciting work of Murray and his collaborators reported on in Explorations in Personality had a major impact on the field and stimulated extensive utilization of the TAT. It would probably be fair to say that the sole survivor of this active movement is the [Rorschach test](https://www.sciencedirect.com/topics/neuroscience/rorschach-test). - Some clinicians continue to use the Rorschach test, and the work of Exner and his collaborators has lent it increasing scientific respectability (see Dr. Philip Erdberg's [Chapter 14](https://www.sciencedirect.com/science/article/pii/B9780128022030000146#c0014): The Rorschach in this volume for a modern conceptualization of the Rorschach). Validity evidence now exists for a number of the Rorschach indices, particularly when used in the examination of individuals with [psychotic disorders](https://www.sciencedirect.com/topics/psychology/psychotic-disorder) ([Mihura, Meyer, Dumitrascu, & Bombel, 2013](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib88)). **Decline in projective techniques** - There are undoubtedly many reasons for the decline in utilization of projective techniques, but in our view they can be summarized by the three following points. - **First, increasing scientific sophistication created an atmosphere of scepticism concerning these instruments.** - **Their validity and reliability were called into question by numerous studies**, and a substantial segment of the professional community felt that the claims made for these procedures could not be substantiated. - **Second, developments in alternative procedures, notably the Minnesota Multiphasic Personality Inventory (MMPI) and other objective tests**, convinced many clinicians that the information previously gained from projective tests could be gained more efficiently and less expensively with objective methods. - In particular, the voluminous MMPI research literature demonstrated its usefulness in an extremely wide variety of clinical and research settings. When the MMPI and related objective techniques were pitted against projective techniques during the days of the "seer versus sign" controversy, it was generally demonstrated that sign was as good as or better than seer in most of the studies accomplished ([Meehl, 1954](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib83)). A current review of this research is contained in the chapter by Carolyn Williams, James Butcher, and Jacob Paulsen in this volume. Third, in general, the projective techniques are not atheoretical and, in fact, are generally viewed as being associated with one or another branch of [psychoanalytic theory](https://www.sciencedirect.com/topics/neuroscience/psychoanalytic-theory). - While [psychoanalysis](https://www.sciencedirect.com/topics/psychology/psychoanalysis) remains a movement within psychology, there are numerous alternative theoretical systems at large, notably cognitive, behavioral, and biologically oriented systems. These alternative systems have largely supplanted psychoanalytic approaches and are consistent with the movement toward evidence-based interventions that have been proven effective as preferable to those with less validity evidence. As implied in the section of this chapter covering behavioral assessment, behaviorally oriented psychologists pose theoretical objections to projective techniques and make little use of them in their practices. Similarly, projective techniques tend not to currently receive high levels of acceptance in psychiatry departments which have become increasingly biologically oriented. In effect, then, utilization of projective techniques declined for scientific, practical, and philosophical reasons. However, the Rorschach test in particular continues to be used, often by psychodynamically oriented clinicians. **Objective personality tests** - The early history of objective personality tests has been traced by Cronbach (1949, (https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib32)). - The beginnings apparently go back to Sir Francis Galton, who devised personality questionnaires during the latter part of the 19th century. - We will not repeat that history here, but rather will focus on those procedures that survived into the contemporary era. In our view, there have been three such major survivors: a series of tests developed by Guilford and collaborators ([Guilford & Zimmerman, 1949](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib45)), a similar series developed by Cattell and collaborators, and the MMPI. - In general, but certainly not in all cases, the Guilford and Cattell procedures are used for individuals functioning within the normal range, while the MMPI is more widely used in clinical populations. - Thus, for example, Cattell's 16PF test may be used to screen job applicants, while the MMPI may be more typically used in psychiatric healthcare facilities. Furthermore, the Guilford and Cattell tests are based on factor analysis and are trait-oriented, while the MMPI in its original form did not make use of factor analytically derived scales and is more oriented toward psychiatric classification. - Thus, the Guilford and Cattell scales contain measures of such traits as dominance or sociability, while most of the MMPI scales are named after psychiatric classifications such as paranoia or depression. Currently, most psychologists use one or more of these objective tests rather than interviews or projective tests in screening situations. For example, many thousands of patients admitted to psychiatric facilities operated by the Department of Veterans Affairs (VA) take the MMPI shortly after admission, while applicants for prison guard jobs in the state of Pennsylvania took the Cattell 16PF. **MMPI** - However, the MMPI in particular is commonly used as more than a screening instrument. It is frequently used as a part of an extensive diagnostic evaluation, as a method of evaluating treatment, and in numerous research applications. There is little question that it is the most widely used and extensively studied procedure in the objective personality-test area. - Even though the 566 true-or-false items have remained essentially the same since the initial development of the instrument, the test has been revised and applications in clinical interpretation have evolved dramatically over the years. - We have gone from perhaps an overly naive dependence on single-scale evaluations and overly literal interpretation of the names of the clinical scales (many of which are archaic psychiatric terms) to a sophisticated configural interpretation of profiles, much of which is based on empirical research reviewed in the chapter by Dr. Williams and colleagues, and earlier by [Gilberstadt and Duker (1965)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib40) and [Marks, Seeman, and Hailer (1974)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib79). - Correspondingly, the methods of administering, scoring, and interpreting the MMPI have kept pace with technological and scientific advances in the behavioral sciences. - From beginning with sorting cards into piles, hand scoring, and subjective interpretation, the MMPI has gone to computerized administration and scoring, interpretation based to a great extent on empirical research findings, and computerized interpretation. - As is well known, there are several companies that will provide computerized scoring and interpretations of the MMPI. - The MMPI has been completely revised and re-standardized, and is now known as the MMPI-2. Since the appearance of the third edition of this handbook, use of the MMPI-2 has been widely adopted. Another procedure aside from the MMPI for objective personality assessment is presented in the work of Millon. Millon has produced a series of tests called the Millon Clinical Multiaxial Inventory (Versions I and II), the Millon Adolescent Personality Inventory, and the Millon Behavioral Health Inventory ([Millon, 1982](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib89), [Millon, 1985](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib90)). **Reliability and Validity** - Even though we should anticipate continued spiraling of trends in personality assessment, it would appear that we have passed an era of projective techniques and are now living in a time of objective assessment, with an increasing interest in the structured interview. - There also appears to be increasing concern with the scientific status of our assessment procedures. - There has been particular concern about reliability of diagnosis, especially since distressing findings appeared in the literature suggesting that psychiatric diagnoses were being made quite unreliably ([Zubin, 1967](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib134)). - The issue of validity in personality and psychopathology assessment remains a difficult one for a number of reasons. - First, if by personality assessment we mean prediction or classification of some psychiatric diagnostic category, we have the problem of there being essentially no known objective markers for the major forms of psychopathology. - Therefore, we were left essentially with psychiatrists' judgments. The more recent DSM systems have greatly improved this situation by providing objective criteria for the various [mental disorders](https://www.sciencedirect.com/topics/neuroscience/mental-disorder), but the capacity of such instruments as the MMPI or Rorschach test to predict DSM diagnoses remains an ongoing research question. - Some scholars, however, have questioned the usefulness of taking that research course rather than developing increasingly reliable and valid structured interviews ([Zubin, 1984](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib135)). - Similarly, there have been many reports of the failure of objective tests to predict such matters as success in an occupation or academic program, trustworthiness with regard to handling a weapon, and other matters. - For example, objective tests are no longer used to screen astronauts, since they were not successful in predicting who would be successful or unsuccessful ([Cordes, 1983](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib31)). There does, in fact, appear to be a movement within the general public and the profession toward discontinuation of the use of personality assessment procedures for decision-making in employment situations. We would also note as another possibly significant trend a movement toward direct observation of behavior in the form of behavioral assessment, as in the case of the development of the [Autism Diagnostic Observation Schedule](https://www.sciencedirect.com/topics/psychology/autism-diagnostic-observation-schedule) (ADOS) ([Lord et al., 1989](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib77)). The zeitgeist definitely is in opposition to procedures in which the [intent](https://www.sciencedirect.com/topics/psychology/intention) is disguised. Some time ago, [Burdock and Zubin (1985)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib25)argued that, "nothing has as yet replaced behavior for evaluation of mental patients," and a similar argument might be made in current times. **Neuropsychological assessment** - Another area that has an interesting historical development is neuropsychological assessment. - The term itself is a relatively new one and probably was made popular through the first edition of [Lezak's (1976)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib73) book of that title. [Neuropsychological assessment](https://www.sciencedirect.com/topics/neuroscience/neuropsychological-assessment) is of particular historical interest because it represents a confluence of two quite separate antecedents: central and eastern European [behavioral neurology](https://www.sciencedirect.com/topics/neuroscience/behavioral-neurology) and American and English psychometrics. - Neurologists, of course, have always been concerned with the behavioral manifestations of structural [brain damage](https://www.sciencedirect.com/topics/neuroscience/brain-injury) and the relationship between brain function and behavior. - Broca's discovery of a speech center in the left frontal zone of the brain is often cited as the first scientific neuropsychological discovery because it delineated a relatively specific relationship between a behavioral function---that is, speech---and a correspondingly specific region of the brain (the third frontal convolution of the left hemisphere). - Clinical psychologists developed an interest in this area when they were called upon to assess patients with known or suspected brain damage. The first approach to this diagnostic area involved utilization of the already-existing psychological tests, and the old literature deals primarily with how tests such as the Wechsler scales, the [Rorschach test](https://www.sciencedirect.com/topics/neuroscience/rorschach-test), or the Bender--Gestalt test could be used to diagnose brain damage. - More recently, special tests were devised specifically for assessment work with patients having known or suspected brain damage. The merger between clinical psychology and behavioral neurology can be said to have occurred when the sophistication of neurologists working in the areas of brain function and brain disease was combined with the psychometric sophistication of clinical psychology. The wedding occurred when reliable, valid, and well-standardized measurement instruments began to be used to answer complex questions in neurological and differential neuropsychiatric diagnosis. Thus, clinicians who ultimately identified themselves as clinical neuropsychologists tended to be individuals who knew their psychometrics, but who also had extensive training and experience in neurological settings. - Just as many clinical psychologists worked with psychiatrists, many clinical neuropsychologists worked with neurologists and neurosurgeons. This relationship culminated in the development of standard [neuropsychological test](https://www.sciencedirect.com/topics/neuroscience/neuropsychological-test) batteries, notably the Halstead--Reitan ([Reitan & Wolfson, 1993](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib103)) and Luria--Nebraska batteries ([Golden et al., 1980](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib41), [Golden et al., 1985](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib42)), as well as in the capacity of many trained psychologists to perform individualized neuropsychological assessments of adults and children. - Thus, within the history of psychological assessment, clinical neuropsychological evaluation has recently emerged as an independent discipline to be distinguished from general clinical psychology on the basis of the specific expertise that members of that discipline have in the areas of brain--behavior relationships and diseases of the [nervous system](https://www.sciencedirect.com/topics/psychology/nervous-system). **Expansion of neuropsychology tests** - There have been expansions of both the standard batteries and the individual neuropsychological tests. An alternate form ([Golden, et al., 1985](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib42)) as well as a children's version ([Golden, 1981](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib43)) of the Luria--Nebraska Neuropsychological Battery are now available. - Also prominent are the series of tests described in detail by Arthur Benton and collaborators in Contributions to Neuropsychological Assessment ([Benton, Hamsher, Vamey, & Spreen, 1983](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib19)), the [California Verbal Learning Test](https://www.sciencedirect.com/topics/neuroscience/california-verbal-learning-test) ([Delis, Kramer, Kaplan, & Ober, 1987](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib33)), and the recently revised and thoroughly reworked [Wechsler Memory Scale](https://www.sciencedirect.com/topics/neuroscience/wechsler-memory-scale) (WMS-III and WMS-IV). - General distinctions have also developed between the approach to assessment, that is, whether one should use a fixed battery of tests that are administered to all patients regardless of diagnosis or referral question, or whether tests should be selected in an individualized manner based on the unique characteristics of the patient, or whether a balance should be struck between these two approaches so that a group of tests are administered to all patients to assess major domains of cognitive function with additional tests given based on the unique patient characteristics and referral question. - Active discussions regarding the value or summative scores and actuarial approaches to test interpretation versus the process patients use to complete test items are also ongoing. Since the publication of the last edition of this handbook, many new neuropsychological tests have been developed, and two new comprehensive batteries have appeared, the Neuropsychological Assessment Battery and the Meyers Neuropsychological system that are now in common use. These procedures are described in the chapter on neuropsychological assessment batteries by Goldstein, Allen, and DeLuca. **Behavioral assessment** - Behavioral assessment has been one of the major developments to emerge in the field of [psychological evaluation](https://www.sciencedirect.com/topics/psychology/psychological-evaluation) ([Bellack and Hersen, 1988a](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib14), [Bellack and Hersen, 1998b](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib15)). - Although its seeds were planted long before behavior therapy became a popular therapeutic movement, it is with the advent of behavior therapy that the strategies of behavioral assessment began to flourish (cf. [Hersen and Bellack, 1976](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib55), [Hersen and Bellack, 1981](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib56)). - Behavioral assessment can be conceptualized as a reaction to a number of factors ([Barlow and Hersen, 1984](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib12), [Hersen and Barlow, 1976](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib54), [Hersen and Bellack, 1976](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib55)). Among these were problems with unreliability and invalidity of aspects of the DSM-I and DSM-II diagnostic schemes and concerns over the indirect relationship between what was evaluated in traditional testing (e.g., the projective tests) and how it subsequently was used in treatment planning and application. - Increasing acceptance of behavior therapy by the professional community as a viable series of therapeutic modalities, and parallel developments in the field of diagnosis in general, involving greater precision and accountability (e.g., the problem-oriented record (POR)) also fueled the movement toward behavioral assessment. **Unreliability and invalidity of aspects of the DSM-I and DSM-II diagnostic schemes** - Among factors contributing to development of behavioral assessment, unreliability and invalidity of aspects of the DSM-I and DSM-II diagnostic schemes made early DSMs targets of considerable criticism from psychiatrists ([Hines & Williams, 1975](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib61)) and psychologists alike ([Begelman, 1975](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib13)). - Indeed, [Begelman (1975)](https://www.sciencedirect.com/science/article/pii/B9780128022030000018?via%3Dihub#bib13), in a more humorous vein, referred to the two systems as "twice-told tales" in the sense that neither resulted in highly reliable classification schemes when patients were independently evaluated by separate psychiatric interviewers - Problems were especially evident when attempts to obtain interrater reliability were made for the more minor diagnostic groupings of the DSM schemes. Frequently, clinical psychologists would be consulted to carry out their testing procedures to confirm or disconfirm psychiatrists' diagnostic impressions based on DSM-I and DSM-II. But in so doing, such psychologists, operating very much as X-ray technicians, used procedures (objective and projective tests) that only had a tangential relationship to the psychiatric descriptors for each of the nosological groups of interest. Thus, over time, the futility of this kind of assessment strategy became increasingly apparent. **External validity of the systems** - Moreover, not only were there problems with diagnostic reliability for the DSM-I and DSM-II, but empirical studies also documented considerable problems with regard to external validity of the systems -