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Abstract

Clinical assessment is a procedure in which various forms of information drawn from interviews, behavioral observations, standardized tests, collateral reports, and historical documents are integrated to facilitate decisions about diagnosis and treatment planning.

Outline

Nature and Purpose of Clinical Assessment
Sources of Information in Clinical Assessment
Issues in Clinical Assessment
Future Directions

1. Nature And Purpose Of Clinical Assessment

Clinical assessment consists of collecting various kinds of information about the nature of people to facilitate arriving at certain kinds of decisions intended to promote the welfare of persons being assessed. These decisions most commonly address interrelated issues of differential diagnosis and treatment planning, and they typically are reached in consultation with persons who have been assessed concerning what would be in their best interest.

1.1. Differential Diagnosis

Treatment of persons with physical or psychological problems proceeds best when the nature and origins of these problems can be identified with reasonable certainty. Adequate differential diagnosis includes both nomothetic and idiographic components. The nomothetic component consists of categorizing the type of disorder a person has and noting the kinds of characteristics the person shares in common with other people who have the same disorder. The idiographic component consists of specifying the particular life experiences that have given rise to the disorder in this individual case and identifying current circumstances that appear to be perpetuating the disorder.

1.2. Treatment Planning

Differential diagnostic information derived from clinical assessments guides treatment planning in four key respects. First, the category of disorder with which a person is diagnosed calls attention to modes of treatment that have been shown to be effective in treating people with the same or a similar category of disorder. Second, the diagnosed severity of a person’s disorder indicates whether treatment can be provided adequately on an outpatient basis or instead requires a hospital or other residential setting. Third, diagnostic information about past and present events in a person’s life often points to topics and goals on which the treatment sessions should focus. Fourth, in addition to identifying critical treatment topics and goals, diagnostic information can alert therapists to patient characteristics that might slow progress in the treatment, at least until these potential obstacles to progress have been minimized or overcome.

2. Sources Of Information In Clinical Assessment

Clinical assessment is a multifaceted process in which information is drawn from diverse sources. These sources of information include interviews, behavioral observations, standardized tests, collateral reports, and historical documents. The data obtained from these sources sometimes converge, and in such cases the confirmatory information they provide broadens the base of the assessment process and lends certainty to inferences drawn from it.

In other instances, diverse sources of information may diverge, for example, when a man being interviewed describes himself as a laid back person who is easy to live with, whereas his wife (a collateral informant) describes him as an irritable and demanding person who is nearly impossible to live with. Instances of divergent data from different sources often help clinical assessors to sharpen their decision making by identifying why these divergences have occurred and determining which sources have yielded the most reliable and useful information. Ordinarily, prior to collecting assessment data, it is difficult to anticipate which sources of information will converge (and thus be redundant) and which will diverge (and thus deepen understanding of the person being assessed).

2.1. Interviews

Mental health specialists who conduct clinical assessment interviews ask patients questions and invite them to talk about their symptoms and problems, any previous treatment they have received, their family backgrounds, and their developmental, educational, occupational, and social histories. Depending on the preferences of the clinician and the capacities of the respondent, these interviews may be relatively structured or relatively unstructured. Relatively structured assessment interviews are based primarily on a preset schedule of specific questions (e.g., ‘‘How many brothers and sisters do you have?,’’ ‘‘Do you have trouble sleeping at night?’’). Relatively unstructured interviews, in contrast, consist primarily of open-ended inquiries and comments (e.g., ‘‘What was growing up like for you?,’’ ‘‘You seem a little anxious right now’’). In actual practice, most clinical assessment interviewers combine some open-ended inquiries with various specific questions intended to clarify items of information.

2.2. Behavioral Observations

Clinical assessors learn a great deal about people from observing how they sit, stand, walk, gesture, show their feelings, and express themselves in words. These observations are made mostly while conducting assessment interviews, but clinicians sometimes have opportunities to observe people in other contexts as well, for example, as patients in a residential treatment setting or as inmates in a correctional facility.

Regardless of their context, behavioral observations can take a variety of forms. For example, clinicians working with families may take note of how family members talk to each other during a family group interview or how they interact during a home visit, each of which is a sample of fairly natural behavior. Alternatively, clinicians may watch and listen to how family members collaborate when they are given some task to do or are asked to decide on a single set of answers to a questionnaire, each of which is an artificially contrived situation.

2.3. Standardized Tests

Standardized tests are formal measuring instruments that consist of a specific set of stimuli and instructions and that are always presented to respondents in the same way. The systematized materials and procedures that characterize standardized tests make it possible to collect normative reference data concerning how certain groups of people (e.g., men, women, children, Americans, Japanese) are likely to respond to these tests on average. The standardized tests commonly used in clinical assessments are categorized as being either self-report inventories or performance-based measures. Self-report inventories sample how people describe themselves when asked to indicate whether, or to what extent, various statements apply to them (e.g., ‘‘I worry quite a bit over possible misfortunes,’’ ‘‘In school, I was sometimes sent to the principal for bad behavior’’). Performance based measures sample how people respond when given a task to do (e.g., putting blocks together to make various designs, describing what a series of inkblots look like). Conjoint use of self-report inventories (what people say about themselves) and performance-based measures (how people go about doing assigned tasks) typically maximizes the scope and utility of the assessment data obtained with standardized testing.

2.4. Collateral Reports

In addition to interviewing, observing, and testing people being evaluated, clinical assessors may obtain collateral information from other individuals who know them or have observed them. Collateral informants are most commonly family members, but they may also include friends, teachers, and employers. Collateral reports usually enhance the scope and reliability of clinical assessments, especially when the people being assessed are unable or reluctant to talk freely or to cooperate fully with testing procedures.

At times, however, mistaken impressions on the part of collateral informants may detract from the accuracy of their reports, which turn out to be less dependable than what the people being assessed have to say. Informants’ reports may also be of questionable reliability if personal issues they have with the people being assessed bias their perspectives. Clinical assessors may also confront instances in which people being evaluated exercise their rights to confidentiality by denying access to informants other than themselves or to historical documents.

2.5. Historical Documents

Historical documents provide real accounts of events in people’s lives for which their own recollections may be vague or distorted. School, medical, military, and criminal records (when available) enhance the dependability of clinical assessments by documenting life experiences that people may be reluctant to talk about or unable to remember clearly. In addition, when there is concern that people being assessed have suffered some decline in mental or emotional capacity from previously higher levels of functioning, historical documents can provide a valuable baseline for comparison. This is especially the case when the past records include clinical assessments.

3. Issues In Clinical Assessment

Contemporary clinical assessments must typically take account of four issues, especially with respect to collecting and using standardized test data. First, are the test results reliable and valid? Second, could the test results reflect malingering or deception on the part of the respondent? Third, are the test findings applicable in light of the respondent’s cultural context? Fourth, can one make appropriate use of computer-based test interpretations?

3.1. Reliability and Validity

The reliability and validity of test results refer to whether the results are dependable, that is, whether they provide an accurate measurement of whatever they are measuring. The reliability of tests is most commonly estimated by examining the internal consistency of their items or by determining the retest stability of the scores they generate. The validity of tests refers to how much is known about what they do in fact measure, as determined by the extent to which their scores correlate with other phenomena such as a diagnosed condition and a favorable response to a particular form of treatment.

Currently available clinical assessment instruments vary in their demonstrated reliability and validity, and examiners must be cautious about relying on measures that are limited in these respects. On balance, however, research findings indicate that most of the tests commonly used in clinical assessment, when administered and interpreted properly, meet the criteria for acceptable reliability and validity.

3.2. Malingering and Deception

Malingering among persons being assessed consists of a conscious and deliberate attempt to appear more disturbed and less capable than is actually the case. Malingering, also known as ‘‘faking bad,’’ commonly emerges as an effort to minimize being held responsible for some misconduct (e.g., being found not guilty of a crime) or to maximize being held deserving of receiving some type of recompense (e.g., being awarded damages for an alleged injury).

Deception, in contrast, consists of attempting to appear less disturbed and more capable than is actually the case. Deception, also known as ‘‘faking good,’’ usually arises as an attempt to gain some benefit (e.g., being employed in a position of responsibility) or to avoid losing some privilege (e.g., being deprived of child custody or visitation rights).

Clinical assessors can draw on various guidelines for identifying malingering and deception on the basis of interview behavior and responses to standardized tests. Based on criteria related to consistency versus inconsistency, these guidelines include specific kinds of interview questions, validity scales on standardized tests, and certain standardized tests designed specifically to reveal efforts to fake bad or fake good. Used in conjunction with data from observational, collateral, and historical sources, these interview and test measures are usually effective in detecting malingering and deception. Nevertheless, research findings indicate that resourceful and motivated respondents, especially when they have been coached with respect to what they should say and how they should conduct themselves, can succeed in misleading even experienced examiners.

3.3. Cross-Cultural Contexts

Cross-cultural clinical assessment generally proceeds in two phases. The first phase consists of drawing on sources of assessment information to identify the nature of an individual’s psychological characteristics. The second phase consists of determining the implications of these psychological characteristics within the person’s cultural context. With respect to collecting information, some assessment methods are relatively culture free (e.g., copying a design from memory). Other assessment methods, especially those involving language (e.g., interviews, self-report inventories), are relatively culture bound. To obtain reliable results, particularly with culture-bound methods, assessment data should be collected by an examiner or with a test form in a language with which the person being examined is thoroughly familiar.

Following collection of the data in cross-cultural assessment, the process of interpreting these data should be attuned as much as possible to available normative standards within groups to which the person being examined belongs. On the other hand, normative cross-cultural differences in assessment findings, such as scores on some test variable, may indicate an actual difference between cultures in the psychological characteristic measured by that variable rather than a need to adjust standards for interpreting the variable. In the case of standardized tests, in fact, many variables identify psychological characteristics in the same way regardless of the person’s cultural context.

The main challenge in doing adequate cross-cultural assessment arises during the second phase of the process, that is, when clinicians must estimate the implications of a person’s identified psychological characteristics for how the person is likely to function in his or her daily life. In some instances, psychological characteristics are likely to have universal implications. For example, being out of touch with reality will ordinarily interfere with adequate adjustment in any social, cultural, ethnic, or national surroundings. In most instances, however, the implications of psychological characteristics are likely to depend on their sociocultural context. For example, whether being a passive, dependent, group-oriented, and self-sacrificing person promotes effective functioning and a sense of well-being will depend on whether the person is part of a society that values these personality characteristics or that instead is embedded in a family, neighborhood, or societal context that values assertiveness, self-reliance, and ambitious striving for personal self-fulfillment.

3.4. Computer-Based Test Interpretation

Computer software programs are available for most standardized and widely used clinical assessment instruments. The data entry for these programs consists of the score for each test item or response, and the output typically includes (a) a list of these scores; (b) a set of indexes, summary scores, and profiles calculated on the basis of the test scores; and (c) a narrative report concerning the interpretive significance of these indexes, summary scores, and profiles. This narrative report is the key feature of what is commonly called computer based test interpretation (CBTI).

Self-report inventories also lend themselves to a computerized test administration in which the test items and the alternative responses to them (e.g., ‘‘agree strongly,’’ ‘‘agree,’’ ‘‘disagree,’’ ‘‘disagree strongly’’) appear on the screen. Computerized administration of performance-based measures has not yet been shown to be practicable, however, owing to the fact that the response data are observational, infinite in their variety, and frequently interactive (in the sense that responses may require certain kinds of inquiry to clarify how they should be scored).

Computerized testing programs usually reduce scoring and calculation errors and also save time in recording and arraying the various indexes, summary scores, and profiles that provide the basis for test interpretation. Computerization also facilitates the interpretive process itself by virtue of a computer’s complete scanning and perfect memory. A good CBTI program does not overlook any encoded implications the data are believed to have for psychological characteristics of the person being assessed.

On the other hand, CBTI is limited by its unavoidable nomothetic focus. Computer-generated interpretive statements describe features of a test protocol and present inferences that are applicable to people in general who show the same or similar test features. These statements do not necessarily describe the person being assessed, nor do they identify idiographic ways in which the person differs from most people who show certain similar test scores. Consequently, because of human individuality, CBTI narrative reports nearly always include some statements that do not apply to the respondent or that are inconsistent with other statements.

Accordingly, informed and professionally responsible computerized testing requires thorough knowledge of how and why test scores generate certain interpretive statements. Sophisticated clinical application of computer-generated test interpretation also requires appreciation of what a computer-generated report implies in the context of each respondent’s personal history and current life circumstances. Unfortunately, CBTI programs can be obtained and used by persons with little or no knowledge of the tests on which they are based, especially in the case of self-report software that conducts the test administration, and with little appreciation of how and why to translate the nomothetic statements in computer-generated reports into the idiographic statements that are essential for an adequate clinical report.

4. Future Directions

Research findings have validated a large number and a wide variety of clinical assessment methods as providers of accurate and dependable information about the psychological characteristics of people. This information has, in turn, been shown to be helpful to mental health professionals in making decisions about differential diagnosis and treatment planning. However, little is yet known about the long-term impact of decisions made on the basis of clinical assessment findings. Are people better off as a result of having been assessed than they would have been otherwise? Do assessment-based decisions enhance the quality of life that people are able to enjoy? These questions set an important agenda for further directions in clinical assessment research that should emphasize follow-up studies of the long-term effectiveness of assessment procedures.

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