Clinical Assessment Research Paper

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Clinical assessment involves the clarification of presenting problems and related factors including identification of outcomes that will be focused on. It should offer guidelines for selection of intervention methods.

Outline

I. Introduction

II. The Guiding Role of Practice Theories

III. Sign and Sample Approaches

A. Some Important Distinctions

B. Past History

C. What about Psychiatric Labels?

IV. Sources of Influence

A. Other People/The Nature of the Client’s Social Relationship

B. The Physical Environment

C. Tasks and Activities

D. Biophysiological Factors

E. Cognitive–Intellectual Characteristics

F. Feelings

G. Cultural Differences

H. Developmental Considerations

I. Reviewing Resources and Obstacles

V. Sources of Information

VI. Assessing the Value of Data

VII. The Social Context of Assessment

VIII. Common Assessment Errors and Their Sources

IX. Ethical Issues and Future Directions

I. Introduction

Goals of clinical assessment include describing clients, their problems and desired outcomes as well as their life situations, understanding why problems occur (inferring causes), deciding on what methods are most likely to achieve desired outcomes, and obtaining a base from which to evaluate progress. Assessment requires the search for and integration of data that are useful in deciding how to remove complaints. It involves (1) detecting client characteristics and environmental factors related to problems; (2) integrating and interpreting data collected; and (3) selecting outcomes to focus on. It should indicate what situational, biological, or psychological factors influence options, create demands, or cause discomfort. Decisions must be made about what data to collect, how to gather this, and how to organize it. Assessment should indicate the specific outcomes related to complaints, what would have to be done to achieve these outcomes, how these could most effectively be pursued, and the potential of attaining them.

The assessment methods that are used differ because of differences in theoretical perspectives which influence the kind of data collected as well as the uses and functions of these data. Clinical inferences vary in how closely they are tied to concrete evidence. Carrying out an assessment is like unraveling a puzzle or locating the pieces of the puzzle. Certain pieces of the puzzle are sought rather than others depending on the clinician’s theoretical orientation and knowledge, and puzzle completion may be declared at diverse points. Issues of practicality also arise. The aim of all methods is to yield data that are useful, reliable, and valid. Specialized knowledge may be required and critical thinking skills are needed to weigh the value of evidence and examine the soundness of assumptions. Although decisions must typically be made on the basis of incomplete data, without a sound assessment framework, opportunities to gather useful data may be lost and ineffective or harmful plans may be suggested. Data should be gathered that are of value in helping clients. Collecting irrelevant data wastes time and money and increases the likelihood of incorrect decisions. Assessment should offer clients more helpful views of problems and a more helpful vocabulary for describing problems and options.

There is general agreement that an individualized assessment should be conducted which considers cultural differences. This does not mean that this is indeed done and practice perspectives differ in what is focused on. Individualized assessment avoids the patient uniformity myth in which clients (or families, or groups) are mistakenly assumed to be similar. Behavior consists of different response systems, which may or may not be related depending on the unique history of each individual: (1) overt behavior (for example, avoidance of crowds) and verbal reports (verbal descriptions of anxiety); (2) cognitions (thoughts about crowds); (3) physiological reactions (for example, increased heart rate when in crowds). Each person may have a different pattern of responses in a situation. Only through an individualized assessment can these unique patterns and related situations be discovered. Suicidal potential should be assessed as relevant. Recognizing the signs of pathology is important anytime this would be helpful in understanding what can be accomplished and how it can be accomplished. A clear agreement between clinicians and clients about the focus of helping efforts increases the likelihood that intervention will focus on outcomes that are of concern to clients.

II. The Guiding Role of Practice Theories

How problems are structured is a key part of clinical decision-making. Assessment frameworks differ in what is focused on, the kinds of assessment methods used, and how closely assessment is tied to selection of intervention methods. Preferred practice theories influence what clinicians look for and what they notice as well as how they process and organize data collected. Practice theories favored influence beliefs about what can be and is known about behavior and how knowledge can be developed. Dimensions along which theories differ include the following:

• Unit of concern (individual, family, community)
• Goals pursued (e.g., explanation and interpretation alone or understanding based on prediction and influence)
• Clarity of goals pursued
• Criteria used to evaluate the accuracy of explanations (e.g., consensus, authority, scientific)
• Range of problems addressed with success
• Causal importance attributed to feelings, thoughts, and/or environmental factors
• Range of environmental characteristics considered (family, community, society)
• Causal importance attributed to biochemical causes
• Attention devoted to past experiences
• Degree of optimism about how much change is possible
• Degree to which a perspective lends itself to and encourages empirical inquiry (finding out whether it is accurate)
• Degree of empirical support (evidence for and against a theory)
• Attention given to documenting degree of progress
• Ease with which practice guidelines can be developed
• Degree of parsimony

Practice frameworks differ in the value given to observation of interactions in real-life settings, in whether significant others are involved in assessment, and how directive clinicians are. They differ in degree of attention paid to cognitions (thoughts), feelings, environmental characteristics (such as reactions of significant others), genetic causes, and/or physiological causes. Different frameworks are based on different beliefs about the causes of behavior. Beliefs about behavior, thoughts, and feelings, and how they are maintained and can be changed influence what data are gathered and how data are weighted and organized. History shows that beliefs can be misleading. For example, trying to assess people by examining the bumps on their head was not very fruitful. However, for decades many people believed that this method was useful.

Problems can be viewed from a perspective of psychological deficiencies or from a broad view in which both personal and environmental factors are attended to. For example, a key point of feminist counseling is helping clients to understand the effects of the political on the personal, both past and present. Frameworks that focus on psychological characteristics are based on the view that behavior is controlled mainly by characteristics of the individual. In interactional perspectives, attention is given not only to the individual but to people with whom he or she interacts. The unit of analysis is the relationship between environmental events and psychological factors. It is assumed that both personal and environmental factors influence behavior. Interactional views differ in how reciprocal the relationship between the individual and the environment is believed to be and in the range of environmental events considered. In contextual, ecological perspectives, individual, family, community, and societal characteristics are considered as they may relate to problems and possible resolutions. A contextual framework decreases the likelihood of focusing on individual pathology (blaming the victim), and neglecting environmental causes and resources. Practice perspectives that focus on individual causes of personal problems may result in ‘‘psychologizing’’ rather than helping clients. Assessment frameworks differ in the extent to which they take advantage of what is known about behavior, factors related to certain kinds of problems, and the accuracy of different sources of data.

Forming a new conceptualization of presenting problems, one that is shared by both the clinician and the client that will be helpful in resolving problems is an integral aspect of assessment. The kind of conceptualization suggested will depend on the theoretical orientation of the clinician. It is important to arrive at a common view of the problem, as well as agreement as to what will be done to change it. This common view is a motivating factor in that, if clients accept it and if it makes sense to clients, there will be a greater willingness to try out procedures that flow from this account. Mutually agreed-on views are fostered in a variety of ways, including questions asked, assessment procedures used, and rationales offered. Focused summaries help to pull material together within a new framework. Identifying similar themes among seemingly disparate events can be used to suggest alternative views.

III. Sign and Sample Approaches

Traditional assessment is based on a sign approach in which observed behaviors are viewed as indicators of more important underlying (and unobserved) personality dispositions (typically of a pathological nature) or traits. Traits can be defined as a general and personally determined tendency to react in consistent and stable ways. Examples are ‘‘aggression’’ and ‘‘extraversion.’’ Inherent in sign approaches such as psychoanalytic approaches is the assumption that observable behavioral problems are only the outward signs of some underlying process, which must be altered to bring about any lasting change. A focus of change efforts on the behavior itself, according to this model, would not succeed, because no change has supposedly been brought about in underlying causative factors. A clinician may conclude that a child who has difficulty concentrating on his school work and sitting in his seat is hyperactive. The observed behaviors are viewed as a sign of an underlying disorder. The underlying hypothetical constructs are viewed as of major importance in understanding and predicting behavior. Dispositional attributions shift attention away from observing what people do in specific situations to speculating about what they have. Inconsistencies in behavior across situations are not unexpected within this approach because it is assumed that underlying motives, conflicts, wishes may be behaviorally manifested in many different ways.

The interactions between wishes, the threats anticipated if wishes are expressed, and the processes used to cope with or defend against conflictual situations are of interest in psychodynamic frameworks. Important elements in such processes are believed to be beyond conscious recognition of the individual experiencing them even when they may be recognized or inferred by others. The concepts of ‘‘positions’’ (developmental stages) and ‘‘mechanisms’’ (psychological processes such as defense mechanisms) are central concepts. Defensive aims, processes, and outcomes are of interest. Defense mechanisms include suppression, undoing, repression, role reversal, projection, and regression. The defenses are believed to be heightened under conditions of high emotion, stress, and conflict. Motives include the wish to avoid unpleasant, overwhelming, or out-of-control states. Some unconscious processes anticipate such outcomes. Classification of phenomena is in terms of deflections from volitional consciousness and rationally intended actions: as intrusions and omissions. For example, recurrent dysfunctional alterations in self-esteem and interpersonal behavior (such as those seen in the personality disorders) are viewed as involving both intrusive, inappropriate schemas and omissions of realistic learning of new schemas. It is assumed that the ‘‘dynamic unconscious’’ constantly undergoes symbolic changes which in turn affect feelings and behavior. Other aspects of psychoanalytic approaches include an emphasis on verbal reports concerning early histories and efforts to alter inner processes by verbal means. Compared to behavioral assessment, less attention is devoted to environmental variables that may influence behavior because of the assumed core relevance and stability of underlying dispositions.

There are many different kinds of psychodynamic assessment frameworks. For example, there are variants of object relations theory, each of which may have a somewhat different approach to assessment. The nature of a client’s past interactions with their parents is viewed as central. However, there are differences in what is focused on by clinicians of different psychodynamic persuasions. In object relations theory, the concepts of mirroring and self objects are key ones. Attention is given to internal mental representations of the self and significant others. It is assumed that how we feel about ourselves and act toward others is a reflection of internal relationships based on experience. The term ‘‘object relations’’ refers to the interplay between the images of self and others. This interplay results in wishes, impulses, thoughts, and feelings of power (or its lack). Ego psychology emphasizes identification and support of strengths and working within the ‘‘defenses’’ rather than breaking them down. Proponents consider resistance to change natural and work with and support adaptive strengths. Defense mechanisms, such as rationalization of actions and projection of feelings onto others are identified but not necessarily discussed.

Behavioral assessment involves a sample approach. In a sample approach, direct observation of behavior in real life settings (or, if this is not possible, in situations that resemble these) is valued. A behavioral approach is based on an interactional view in which it is assumed that behavior is a function of both organismic variables (genetic history and physiological states) and the environment. Labels are used as summarizing categories rather than as terms indicating some underlying characteristic (usually a disorder). Unlike in sign approaches where the cause of behavior is assumed to be underlying dispositions, the cause of behavior is assumed to lie largely in environmental differences. Behavioral frameworks differ in the relative amount of attention devoted to thoughts and environmental contingencies. Differences in focus are so marked that they have resulted to the formation of different journals and societies. Differences in emphasis are related to the role attributed to thoughts in influencing behavior. This role varies from a causal to a mediating role. In the former, reflected in cognitive–behavioral frameworks, thoughts are presumed to cause changes in feelings and behavior. In the latter, reflected in applied behavior analysis, thoughts are assumed to influence feelings and behavior in a mediating (not causal) manner. It is assumed that one must look to past and present environmental contingencies to account for both thoughts and feelings.

In cognitive–behavioral methods, attention is devoted to thoughts as well as behaviors. Thoughts of interest include attributions for behavior, feelings, and outcomes, negative and positive self-statements, expectations, and cognitive distortions. Attention is devoted to identifying the particular kinds of thoughts that occur in problem related situations. Cognitive– behavioral approaches differ in their assumptions about the kinds of thoughts that underlie behavior. However, all share certain assumptions such as the belief that individuals respond to cognitive representations of environmental events rather than to the events per se. It is assumed that learning is cognitively mediated and that cognition mediates emotional and behavioral dysfunction.

In applied behavior analysis, environmental contingencies are focused on. A contingency analysis requires identification of the environmental events that occasion and maintain behavior. There is an interest in describing the relationships between behavior and what happens right before and after as well as ‘‘metacontingencies’’— the relationships between cultural practices and the outcomes of these practices. There is an emphasis on current contingencies. Attention is directed toward the change of ‘‘deviant’’ environments rather than the change of ‘‘deviant’’ client behaviors. There is an interest in identifying functional relationships. A behavioral analysis includes a description of behaviors of concern as well as evidence that specific antecedents and consequences influence these behaviors; it requires a functional as well as a descriptive analysis.

Although there are differences, all behavioral approaches share many characteristics that distinguish them from sign approaches. Assessment is an ongoing process in behavioral assessment. This contrasts with some traditional assessment approaches in which assessment is used to ‘‘diagnose’’ a client in order to decide on treatment methods. What a person does is of interest in behavioral approaches rather than what she has. Behavior is of great interest, especially the behaviors of individuals in real-life contexts. Identifying variables that influence the frequency of behaviors of interest is a key assessment goal. Behavior is assumed to vary in different contexts because of different learning histories and different current contingencies as well as different levels of deprivation and fatigue. There is an emphasis on clear description of assessment methods as well as clear description of problems and outcomes. It is assumed that only if complaints are clearly described can they be translated into specific changes that would result in their removal. The emphasis on behavior and the influence of environmental contingencies call for the translation of problems into observable behaviors and the discovery of ways in which the environment can be rearranged. Clients are encouraged to recognize and alter the role they play in maintaining problems. For example, teachers and parents often reinforce behaviors they complain about. Assessment is individualized; each person, group, family, organization or community is viewed as unique. Data about group differences do not offer precise information about what an individual does in specific situations and what cues and consequences influence their behavior.

The focus on behavior has a number of implications for assessment. One is the importance of observing people in real-life contexts whenever feasible, ethical, and necessary to acquire helpful data. A range of assessment methods is used including observation in real-life settings as well as role plays. Multiple assessment methods are also called for because of the lack of synchrony in overt behavior, physiological reactions, cognitions (thoughts), and feelings. Assessment and treatment are closely related in a behavioral model. It is assumed that assessment should have treatment utility. There is an emphasis on the use of validated assessment methods. The principles of behavior are relied on to guide assessment and intervention. There is a preference for limited inference and a focus on constructing repertoires (on helping clients to acquire additional knowledge and skills that will increase opportunities for reinforcement). Clients are viewed in terms of their assets rather than their deficiencies. The preference for enhancement of knowledge and skills requires a focus on behaviors that are effective in real-life contexts. In a task analysis, the specific behaviors that are required to achieve an outcome are identified. For each step, performance is clearly described as well as the conditions in which it is expected to occur.

A. Some Important Distinctions

The form of a behavior (its topography) does not necessarily indicate its function (why the behavior occurs). Identical forms of behavior may be maintained by very different contingencies. Just as the same behavior may have different functions, different behaviors may have identical functions. The distinction between motivational and behavioral deficits is also important. If a desired behavior does not occur, this may indicate either that the behavior exists but is not reinforced on an effective schedule or is punished (a motivational deficit) or that the behavior is not present in the client’s repertoire (a behavior deficit). Motivational deficits are often mistaken for behavioral deficits. Motivational and behavioral deficits can be distinguished by arranging conditions for performance of a behavior. For example, clients could be requested to role play behaviors and asked whether similar or identical behaviors occur in other situations. Behavior surfeits are often related to behavior deficits. For example, aggression on the part of a child may be related to a lack of friendship skills. It is also important to distinguish response inhibitions from behavior deficits. Emotional reactions such as anxiety may interfere with desired behavior.

B. Past History

Although the past is viewed as important in influencing current behavior in just about all perspectives, assessment frameworks differ in how much attention is devoted to the past and what is focused on. Past experiences are a major focus in psychodynamic assessment frameworks. Knowledge about past circumstances may be of value when it is difficult to identify current maintaining factors and may be helpful in preventing future problems. Information about a person’s past may provide valuable information about unusual social histories related to problems. An understanding of how problems began can be useful in clarifying the origins of what seem to be puzzling reactions. New ways of viewing past events may be helpful to clients. Information about the past can be useful in encouraging clients to alter present behaviors and may help clients understand the source of current reactions. Demographic indicators about a client’s past behavior in certain contexts may be better predictors of future behavior than personality tests or clinical judgments.

Information about the past offers a view of current events in a more comprehensive context. Major areas include medical history, educational and work history, significant relationships, family history and developmental history. Helpful coping skills may be discovered by finding out what clients have tried in the past to resolve problems. Research concerning autobiographical memory suggests that memories change over time, making it difficult to know whether reports are accurate. From a psychodynamic perspective, accuracy would not be an issue. Rather, the client’s memories of events, whether accurate or not, are the substance of import. It is assumed in fact that memories may be distorted by unconscious motives/conflicts and so on. Excessive attention to past troubles may create pessimism about the future and encourage rationalizations and excuses that interfere with change, especially if this is not fruitful in selecting effective plans.

C. What about Psychiatric Labels?

Labels are used in assessment in two main ways. One is as a shorthand term to refer to specific behaviors. The term hyperactive may refer to the fact that a student often gets out of his seat and talks out of turn in class. A counselor may use ‘‘hyperactive’’ as a summary term to refer to these behaviors. Labels are also used as a diagnostic category which is supposed to offer guidelines for knowing what to do about a problem. Here, a label connotes more than a cluster of behaviors. It involves additional assumptions about the person labeled which should be of ‘‘diagnostic’’ value. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association describes hundreds of terms used to describe various disorders.

Methodological and conceptual problems connected with the use of diagnostic categories include lack of agreement about what label to assign clients and lack of association between a diagnosis and indications of what intervention will be effective. Psychiatric labels have been criticized for being imprecise (saying too little about positive attributes, potential for change, and change that does occur, and too much about presumed negative characteristics and limits to change). Both traits and diagnostic labels offer little detail about what people do in specific situations and what specific circumstances influence behavior. There is no evidence that traits have dispositional properties. Little cross-situational consistency has been found in relation to ‘‘personality traits.’’ Some behaviors may appear ‘‘trait-like’’ in that they are similar over time and situations because of similar contingencies of reinforcement. Degree of consistency should be empirically explored for particular classes of clients and behavior rather than assumed. Acceptance of a label may prematurely close off consideration of promising options. The tendency to use a binary classification system (people are labeled as either having or not having something, for example, as being an alcoholic or not), may obscure the varied individual patterns that may be referred to by a term. Critics of the DSM highlight the consensual nature of what is included (reliance on agreement rather than empirical criteria) and the role of economic considerations in its creation. Some argue that psychiatric classification systems encourage blaming victims for their plights rather than altering the social circumstances responsible for problems.

Labels that are instrumental (they point to effective interventions) are helpful. For example, the understanding of anxiety disorders has advanced requiring the differential diagnosis among different categories (simple phobia, generalized anxiety, panic attacks and agoraphobia). Failure to use labels that are indeed informativemay prevent clients from receiving appropriate intervention. Labels can normalize client concerns. Parents who have been struggling to understand why their child is developmentally slow may view themselves as failures. Recognition that their child has a specific kind of developmental disability that accounts for this can be a relief.

IV. Sources of Influence

Influences on behavior include other people’s actions, the physical environment, tasks and materials, physiological changes, thoughts, genetic differences, and developmental factors. Material and community resources and related political, economic, and social conditions influence options. It is important to obtain an overview of the client’s current life as this may relate to problems, including relationships with significant others, employment, physical health, recreational activities, and community and material resources available. Antecedents of behavior, like consequences, have a variety of sources. In addition to proximal antecedents (those that occur right before a behavior), distal antecedents may influence current behavior. Past or future events may be made current by thinking about these. These thoughts may then influence what we do, feel, and think. Setting events are antecedents that are closely associated with a behavior but are not in the situation in which behaviors of concern occur. For example, an unpleasant exchange with a teacher may influence how a child responds to his parents at home. The earlier event alters the likelihood of given reactions in subsequent situations. Preferred practice theories influence the attention given to various sources. Problems vary in the complexity of related factors. Problems may be complex because significant others lack needed skills, have interfering beliefs, or are threatened by proposed changes. Distinguishing between problems and efforts to resolve these will avoid confusion between the results of attempted solutions and effects of the original concern. Expected role behavior in a certain culture may limit change. Ongoing discrimination against a group may limit opportunities. Clients may lack needed information or skills. A behavior deficit may exist (the client may not know how to perform a given behavior).

A. Other People/The Nature of the Client’s Social Relationship

With any presenting problem, the possible influence of significant others in the maintenance of a problem should be explored. Behavior occurs in a context. How significant others respond makes up an important part of our environment. Significant others are those who interact with clients and influence their behavior. Examples include family members and staff in residential settings. Significant others are often involved in assessment. For example, in family therapy, family members participate in assessment. Understanding relationships among family members is a key part of assessment in family therapy. Interactions between couples is closely examined in relationship counseling. Clients may lack social support such as opportunities for intimacy, companionship, and validation or the opportunity to provide support to others. Social interactions may be a source of stress rather than a source of pleasure and joy. It is important to assess the nature and quality of the client’s social network and social support system.

B. The Physical Environment

The influence of the physical environment should be examined. Physical arrangements in residential and day care settings influence behavior. Unwanted behaviors may be encouraged by available materials. For example, toys that are visible to children may distract them from educational tasks. Temperature changes affect behavior as do degree of crowding and noise level. Characteristics of the community in which clients live that may influence complaints and possible intervention options should be assessed. Neighborhood quality influences well-being. For example, children who live in lower quality environments (e.g., there is little play space, housing is in industrial neighborhoods, upkeep of streets is poor) are less satisfied with their lives, experience more negative emotions, and have more restricted and less positive friendship patterns. There is a relationship between number of nonaccidental injuries to children and the physical conditions of the home which is related to socioeconomic status.

C. Tasks and Activities

The kind of task confronting an individual may influence the rate of problem behavior. Particular tasks or activities may be high-risk situations for unwanted behavior. Many studies have found a relationship between the kind of task and deviant behavior such as self-injury. Problems may occur because a task is too tedious or difficult or because an individual is uncomfortable or bored, or is told to do something in an unpleasant manner. In these instances, altering antecedents may correct the problem.

D. Biophysiological Factors

Presenting problems may be related to neurological or biochemical factors. Such factors may place boundaries on how much change is possible. Malnutrition, hypoglycemia, and allergic reactions have been associated with hyperactivity, learning disabilities, and mental retardation. Biochemical abnormalities are found in some children with serious behavior disturbances such as those labeled autistic. However, this only establishes that abnormalities in biochemistry are present, not that they cause a certain disorder (e.g., cause certain behaviors). Biochemical changes may be a result of stress related to social conditions such as limited opportunities due to discrimination. Drugs, whether prescribed or not, may influence how clients appear and behave. Certain kinds of illness are associated with particular kinds of psychological changes.

Drugs, alcohol, environmental pollutants, and nutritional deficiencies may influence health and behavior. Accidents may result in neurological changes which result in concomitant psychological changes. Even when brain damage can be shown to exist, this does not show that it causes any particular behavior. Premature acceptance of biophysical explanations will interfere with discovering alternative explanations that yield intervention knowledge. Behavior changes may be due to brain tumors. Hormonal changes associated with menopause may result in mood changes which may be misattributed to psychological causes. On the other hand psychological changes may be misattributed to hormonal changes. There are gender differences in return of diffuse physiological arousal (DPA) to baseline levels; men take longer to return to baseline levels. These gender differences have implications for understanding and altering aggression among family members. Whenever physiological factors may be related to a problem as, for example, with seizures, depression, fatigue, or headaches, a physical examination should be required. Overlooking physical causes including nutritional deficiencies and coffee, alcohol, or drug intake may result in incorrect inferences.

E. Cognitive–Intellectual Characteristics

People differ in their intellectual abilities which may influence problems and outcomes. Genetic differences have been found in intelligence as well as in shyness, temperament, and conditioning susceptibility. The importance of assessing what people say to themselves in relevant situations is emphasized in many assessment frameworks. For example, in cognitive–behavioral approaches, clients’ internal dialogues (what they say to themselves) and the way this relates to complaints and desired outcomes is explored and altered as necessary. Certain thoughts may occur too much, too seldom, or at the wrong time. A depressed client may have a high frequency of negative self-statements and a low frequency of positive self-statements. In a radical behavioral perspective, thoughts are viewed as covert behaviors to be explained, not as explanations for other behaviors, although it is assumed they can serve a mediating function and influence both feelings and behaviors. The thoughts and feelings in a situation are assumed to be a function of the contingencies experienced in this situation or in situations that are similar or associated in some way. A causal role may be misattributed to thoughts because the histories related to the development of thoughts is overlooked. The role of thoughts can be examined by varying certain ones and determining the effects on behavior.

F. Feelings

When feelings are presented as a problem or are related to a problem, associated personal and environmental factors must be identified. Assessment frameworks differ in the role attributed to feelings and in factors sought to account for feelings. Some emphasize the role of thoughts in creating feelings. Others emphasize the role of unconscious conflicts and motives related to early childhood experiences. Other frameworks focus on the role of environmental contingencies in influencing emotional reactions. For example, in a radical behavioral approach, feelings are viewed as by-products of the relationships between behavior and environmental events. Feelings can be used as clues to contingencies (relationships between behavior and environmental events). Changing feelings will not make up for a lack of required skills, or rearrange contingencies required to attain desired outcomes.

G. Cultural Differences

Cultural differences may affect both the problems that clients experience as well as the communication styles and assessment and intervention methods that will be successful. An individualized assessment requires attention to cultural differences that may be related to problems and potential resolutions. Culturally sensitive practice requires knowledge of the values of different groups and their historical experience in the United States, and how these differences may influence the client’s behavior, motivation and view of the helping process.

Different groups may prefer different problem-solving styles and have different beliefs about the causes of problems. The norms for behavior vary in different groups. It is important to be knowledgeable about cultural differences that may be mistakenly viewed as pathology. The degree of acculturation (the process of adaptation to a new or different culture) is important to assess. This influences drop-out rate, level of stress, attitude toward clinicians, and the process and goals that are appropriate. Knowledge of problems faced and preferred communication styles of people in different generations will be useful. Bicultural individuals are members of two or more ethnic or racial groups.

H. Developmental Considerations

Assessment requires knowledge about developmental tasks, norms, and challenges. Information about required behaviors at different ages and life transitions can be helpful in assessment. Knowledge of what is typical behavior at different times (developmental norms) can be useful in ‘‘normalizing’’ behavior— helping clients to realize that reactions they view as unusual or ‘‘abnormal’’ are in fact common. Knowledge about typical changes in different phases of the life cycle (e.g., adolescence, parenthood, retirement) allows preventative planning. The following kinds of information will be helpful: (1) norms for behavior in specific contexts; (2) tasks associated with certain life situations such as parenthood and retirement; (3) the hierarchical nature of some developmental tasks (some behaviors must be learned before others can be acquired). Different kinds of norms may be used in the selection of outcomes. Criterion referenced norms rely on what has been found to be required to attain a certain outcome through empirical analysis. Another kind of norm is what is usual in a situation. However, what is usual may not be what is desirable. For example, although it may be typical for teachers to offer low rates of positive feedback to students in their classroom, it is not optimal. The similarities of contingencies for many people at a given age in a society may lead one to assume incorrectly that biological development is responsible. The role of similar contingencies may be overlooked. Acceptance of a stage theory of development may get in the way of identifying environmental factors that can be rearranged.

I. Reviewing Resources and Obstacles

Assessment involves identification of personal assets and environmental resources that can be used to help clients attain desired outcomes, as well as personal and environmental obstacles. Personal resources and/or obstacles include cognitive–intellectual abilities and deficiencies, physical abilities and handicaps, social skills and social-skill deficits, vocational and recreational skills, financial assets, and social support systems. Clients differ in their ‘‘reinforcer profile’’ and in degree of motivation to alter problematic circumstances. Environments differ in opportunities for certain kinds of experiences (see discussion of physical environment). Resources such as money, housing, vocational training programs, medical care, or recreational facilities may be unavailable. Limited community resources (such as day care programs, vocational training programs, recreational centers, high-quality educational programs, parent training programs) and limited influence over environmental circumstances may pose an obstacle. Child maltreatment is related to poverty. Unemployment is related to substance abuse and spouse violence. Agency policies and practices influence options. Lack of coordination of services may limit access to resources. Clients may receive fragmentary, overlapping, or incompatible services.

V. Sources of Information

Sources of data include interviews, responses to written or pictorial measures, data gathered by clients and significant others (self-monitoring), observation in the interview as well as in role play or in real-life settings, and physiological indicators. A variety of electromechanical aids are available for collecting data such as wrist counters, timers, biofeedback devices, and audio- and videotape recorders. Familiarity with and knowledge about different methods, as well as personal and theoretical preferences and questions of feasibility influence selection. Preferred practice theories strongly influence selection of assessment methods. For example, in individually focused psychodynamic approaches, self-report and transference effects within the interview may be the main source of data used.

In behavioral approaches, self-report is supplemented whenever possible by other sources of data such as observation in real-life settings, role play, and/ or self-monitoring. (Clients keep track of some behaviors, thoughts, or feelings and surrounding circumstances in real-life). Some sources, such as self-report in the interview, are easy to use and are flexible in the range of content provided. However, accuracy varies considerably. The question is: what methods will offer a fairly accurate description of reactions or conditions of concern and related events? Individual differences will influence a client’s willingness to participate in a given manner. Accuracy of decisions can be improved by using multiple methods, drawing especially on those most likely to offer accurate relevant data.

Self-report is the most widely used source of information. There are many different types of self-report including verbal reports during interviews and answers on written inventories. Interviews also provide an opportunity to observe clients. Advantages of self-report include ease of collecting material and flexibility in the range of material that may be gathered. Structured interviews have been developed for both children and adults in a number of areas. These may be completed by the clinician, the client, or significant others. The accuracy of self-reports depends on a number of factors including the situation in which data are collected and the kinds and sequence of questions asked. Helpful questions in assessing the accuracy of self-reports include the following: (1) Does the situation encourage an honest answer? (2) Does the client have access to the information? (3) Can the client comprehend the question? (4) Does the client have the verbal skills required to answer questions? Special knowledge and skills may be required when interviewing children. Play materials and storytelling may be used to gather data about children’s feelings and experiences.

Measures that have uniform procedures for administration and scoring and that are accompanied by certain kinds of information are referred to as standardized measures. Thousands of standardized questionnaires have been developed related to hundreds of different personal and/or environmental characteristics. Standardized measures are used for a variety of purposes including: (1) describing populations or clients, (2) screening clients (for example, making a decision about the need for further assessment or finding out if a client is eligible for or likely to require a service), (3) assessing clients (a more detailed review resulting in decisions about diagnosis or assignment to intervention methods), (4) monitoring (evaluating progress), and (5) making predictions about the likely futures of clients (for example in relation to use of a particular intervention method). As always, a key concern is validity. Does a measure assess what it is presumed to assess? Reliability must also be considered. How stable are responses on a measure given a lack of real change? Unstable measures are not likely to be valid. How sensitive will a measure be to change?

Personality tests may be used to collect assessment data. Objective tests include specific questions, statements, or concepts. Clients respond with direct answers, choices, or ratings. Projective tests such as the Thematic Apperception Test, incomplete sentences test, and the Rorschach Inkblot Test are purposefully vague and ambiguous. It is assumed that each person will impose on this unstructured stimulus presentation unique meanings that reflect his or her perceptions of the world and responses to it. Psychoanalytic concepts underlie use of most projective tests. These tests focus on assessing general personality characteristics and uncovering unconscious processes. Tests are used not as samples of the content domain (as in behavioral approaches), but as signs of important underlying constructs. Whereas content validity is of great concern in a behavioral perspective, this is not so within a traditional approach. In fact, items may be made deliberately obscure and vague.

Valuable information can be obtained from data clients collect (self-monitoring). As with any other source of data, not all clients will be able or willing to participate. Observation of relevant interactions in real-life settings offers a valuable source of information. This is routinely used in applied behavior analysis. If observation in real-life settings is not possible, observation in role plays may provide a useful alternative. Physiological measures have been used with a broad array of presenting problems including illness such as diabetes and dermatitis and problems such as smoking, anxiety, sexual dysfunction, and rape. Measures include heart rate, blood pressure, respiration rate, skin conductance, muscle tension, and urine analysis. Physiological measures are useful when verbal reports may be inaccurate. Certain kinds of desynchronies between verbal reports of fear and physiological measures may provide useful assessment data. Whenever presenting problems may be related to physical causes, a physical examination should be obtained. Failure to do so may result in overlooking physical causes.

VI. Assessing the Value of Data

Assessment methods differ in their accuracy. For example, self-report of clients or significant others may not accurately reflect what occurs in real life. Observers may be biased and offer inaccurate data. Measurement inevitably involves error. One cause of systematic error is social desirability; people present themselves in a good light. Criteria that are important to consider in judging the value of assessment data include: (1) reliability, (2) validity, (3) sensitivity, (4) utility, (5) feasibility, and (6) relevance. Reliability refers to the consistency of results (in the absence of real change) provided by the same person at different times (time-based reliability), by two different raters of the same events (individual-based reliability) as in inter-rater reliability, or by parallel forms of split-halfs of a measure (item-bound reliability). Reliability places an upward boundary on validity. For example, if responses on a questionnaire vary from time to time (in the absence of real change), it will not be possible to use results of a measure to predict what a person will do in the future.

Validity concerns the question: Does the measure reflect the characteristic it is supposed to measure? For example, does behavior in a role play correspond to what a client does in similar real-life situations? Assessment is more likely to be informative if valid methods are used—methods that have been found to offer accurate information. Direct (e.g., observing teacher– student interaction) in contrast to indirect measures (e.g., asking a student to complete a questionnaire assumed to offer information about classroom behavior) are typically more valid. Validity (accuracy) is a concern in all assessment frameworks; however, the nature of the concern is different in sign and sample approaches. In a sign approach, behavior is used as a sign of some entity (such as a personality trait) that is at a different level. The concern is with vertical validity. Is the sign an accurate indicator of the underlying trait? Horizontal validity is of concern in a sample approach. Different levels (e.g., behavior and personality dispositions) are not involved. Examples include: (1) Does self-report provide an accurate account of behavior and related circumstances? (2) Does behavior in role play reflect what occurs in real life? Different responses (overt, cognitive, and physiological) may or may not be related to an event. For example, clients may report anxiety but show no physiological signs of anxiety. This does not mean that their reports are not accurate. For those individuals, the experience of anxiety may be cognitive rather than physical.

The sensitivity of measures is important to consider; will a measure reflect changes that occur? The utility of a measure is determined by its cost (time, effort, expense) balanced against information provided. Feasibility is related to utility. Some measures will not be feasible to gather. Utility may be compromised by the absence of empirically derived norms for a measure. Norms offer information about the typical (or average) performance of a group of individuals and allow comparison of data obtained from a client with similar clients. The more representative the sample is to the client, the greater the utility of a measure in relation to a client. Relevance should also be considered. Is a measure relevant to presenting problems and related outcomes? Do clients and significant others perceive it as relevant?

VII. The Social Context of Assessment

Assessment takes place in the context of a helper– client relationship. The nature of this relationship is considered important in all practice frameworks. Influence of the clinician on the client has been found even in very nondirective approaches. The role of the relationship is viewed differently in different practice perspectives. Great attention is given to the diagnostic value of transference and countertransference effects in psychodynamic therapies and the relationship itself is viewed as the primary vehicle of change. Traditionally, transference has been viewed as a reenactment between the client and the counselor of the client’s relationship with significant others in the past, especially parents.

Countertransference effects refer to feelings on the part of helpers toward their clients. Transferences are distinguished from therapeutic or working alliances within psychodynamic perspectives. Understanding and analyzing how the client relates to the clinician are of major importance. The way the client relates to the clinician is considered to be indicative of the client’s past relationships with significant figures in the past and is thus viewed as a key source of information about the client. Within other perspectives such as cognitive–behavioral approaches, the relationship is viewed as the context within which helping occurs. The interpersonal skills of the clinician are viewed as essential for facilitating a collaborative working relationship, validating and supporting the client, and encouraging clients to acquire valued behaviors.

There is a continuing need throughout assessment to explain the roles and requirements of the client and the counselor, the process that will occur, and the rationale for this. Introductory explanations include an overview of mutual responsibilities and of the framework that will be employed. Because different client behaviors may be required during different phases of assessment and intervention, this ‘‘socialization’’ of the client is an ongoing task. Behavioral clinicians tend to be more directive than psychoanalytically oriented clinicians. They more frequently give instructions, provide information, influence the conversation, and talk more. Clinicians may err by being too directive or too nondirective. Overly directive clinicians may not recognize the need to help clients to explore and to understand their behavior. In contrast, nondirective counselors may err by assuming that self-understanding is sufficient to achieve desired outcomes (when it is not).

VIII. Common Assessment Errors and Their Sources

Errors may occur in any of the three steps involved in assessment: (1) detection of characteristics of the client and his or her life situation that are related to problems and desired outcomes; (2) integration and interpretation of data gathered; and (3) selection of outcomes to pursue in order to remove complaints. Errors made in the first two steps will result in errors in the third step. Examples of common errors are noted below. They result in incomplete or misleading assessment. Some errors involve or result in inappropriate speculation—assuming that what is, can be discovered simply by thinking about the topic.

• Hasty assumptions about causes (failure to search for alternative accounts)
• Speculating when data collection is called for
• Confusing the form and function of behavior
• Using misleading and/or uninformative labels
• Confusing motivational and behavior deficits
• Focusing on pathology and overlooking assets
• Collecting irrelevant material
• Relying on inaccurate sources (e.g., anecdotal experience)
• Being unduly influenced by first impressions
• Being misled by superficial resemblances of a client to other clients in the past or to a stereotype

Errors in detection include inadequate selection of modalities (e.g., confining attention to thoughts), inadequate selection of data collection methods (e.g., reliance on the interview alone), and errors in the data collection method itself (e.g., observer bias). Inaccurate or incomplete accounts of problems and related factors may occur because attention is too narrowly focused on one source (for example on thoughts or feelings). The fundamental attribution error is made when behavior is attributed to internal dispositions of the individual, overlooking the role of environmental causes. Sources of error in integrating and interpreting data include focusing on consistency rather than informativeness of data, hasty generalization based on limited samples, and inadequate conceptualization of problems due to theoretical biases (e.g., focus only on environmental factors) or superficial knowledge of practice frameworks. Another source of error at this stage is use of vague language that is not informative (e.g., psychological jargon). Errors in selection of outcomes to focus on may occur due to error in the first two phases.

Studies on clinical decision-making indicate that decisions are made on the basis of quite limited data. Even though a great deal of data are gathered, only a small subset is used. Clinicians tend to gather more data than are needed and, as the amount of data gathered increases, so does confidence in its usefulness, even though accuracy may not increase. Clinicians have a tendency to confuse consistency of data with informative value. Irrelevant as well as relevant data may be influential. Clinicians, like other individuals, are affected by limited information-processing capacities and motivational factors. As a consequence, they do not see all there is to see. Because of preconceptions and biases, things that are not actually present may be reported and events that do occur may be overlooked. There is a behavior confirmation tendency. Data are sought that are consistent with preferred theories and preconceptions, and contradictory data tend to be disregarded.

It is easy to recall bizarre behavior and pay excessive attention to this, ignoring less vivid appropriate behavior. The frequency of data that are available is overestimated. Many factors that are not correlated with the true frequency of an event influence estimates of its frequency and how important it seems (such as how visible it is, how vivid it is, and how easily it can be imagined—that is, how available it is). Chance availability may affect clinical decisions—that is, certain events may just happen to be available when thinking about a problem, and these have an impact on what is attended to. Clinicians in given settings are exposed to particular kinds of clients, which may predispose them to make certain assumptions. For example, a psychologist who sees many severely depressed individuals may be primed to attend to signs of depression. Base rate data that are abstract tend to be ignored, which increases the probability of inaccurate inferences. A lack of concern for sample size and sample bias can lead to incorrect judgments. General predictions about a person that are based on tiny samples of behavior in one context are not likely to be accurate, especially when behaviors of interest occur in quite different situations. Not distinguishing between description and inference may result in incorrect assumptions. Use of multiple methods in a contextual practice framework provides the greatest opportunity for sound assessment.

IX. Ethical Issues and Future Directions

Lack of assessment competencies may result in the selection of ineffective and/or harmful intervention methods. It is thus incumbent on clinicians to use valid methods that are useful in selecting effective intervention plans. This may require training. There are great stakes in how problems are framed and considerable resources are devoted to influencing how people think about problems. Many problems once viewed as sins were then seen as crimes and more recently are considered to be mental disorders. Explanations influence how people are viewed. In past years, pathology was often attributed to housewives who wanted to work. Incorrect explanations of problems often harm clients. Knowledge about social, political, and economic factors that influence the very definition of personal and social problems will help clinicians to consider problems in their social context and decrease the likelihood of pathologizing clients.

A discussion of clinical assessment would not be complete without noting the increased attention given to evolutionary influences. It is easy to lose sight of the fact that humans are the result of a long evolutionary process and that we carry anatomical, physiological, and psychological characteristics related to this history. An evolutionary perspective adds a valuable dimension to understanding aggression and caregiving in society, whether directed toward family members or strangers, as well as defeat states such as depression and the experiences that may be responsible. Computers will play an increasing role in helping clinicians to handle the many different kinds of data that must often be integrated. There has been considerable interest in the integration of different approaches to clinical practice. Some have explored the possible integration of behavioral and psychoanalytic approaches. Others have investigated the relationship between classical psychodynamics and object relations perspectives. Discussions here concern the nature of inferred conflict and how mental phenomena of interest are formed. Accurate descriptions of assessment perspectives will increase the likelihood that points of convergence and differences are correctly identified. Continuing research efforts are needed to identify valid assessment methods and indicate assessment frameworks that are most likely to help clients. Increased interest in clinical reasoning bodes well for enhancement of assessment competencies.

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