Chapter 1 The Diagnostic Process
Clinical psychodiagnostics is an exclusive specialism of the clinical psychologist. At first it
was perceived as a bad thing. Labeling people based on unreliable and lengthy techniques.
Right now, a thorough diagnosis is perceived as necessary for adequate care.
Clinical psychodiagnostics is a professional activity based on 3 elements:
1. Theory development of the problems
Hypotheses based on a theory
2. Operationalization and its subsequent measurement
Step-by-step diagnostic process
3. Application of relevant diagnostic methods
This thought to action process offers a framework for analyzing complex problems.
Five Basic Questions in Clinical Psychodiagnostics
They form the basis for most of the questions posed by clients, referrers and diagnosticians:
1. Recognition: what are the problems?
Identify both the complaints and adequate behavior of the client and his/her environment.
It includes:
- Inventory and description
- Organization and categorization in dysfunctional behavior clusters or disorders
- Examination of the seriousness of the problem behavior
Recognition is usually the result of:
- Criterion-oriented measurement
Comparison to a predefined standard
- Normative measurement
Comparison to a representative comparison group
- Ipsative measurement
Comparison to the individual himself; maybe at a previous point in time
Another important distinction here:
- Classification
The clinical picture is assigned to a class of problems.
Either all-or-not principle or more-or-less principle
Example: DSM.
Advantage: lets experts communicate about it.
Disadvantage: labeling.
- Diagnostic formulation
Focus on the individual and his own unique clinical picture.
Example: holistic theory. Interdependent problems behaviors and context are
more important here.
Advantage: allows for the uniqueness of the individual.
Disadvantage: little empirical support.
Recognition + explanation at the same time.
2. Explanation: why do certain problems exist and what perpetuates them?
This includes:
- The main problem or problem component
- The conditions that explain the problem’s occurring
- The causal relationship between the previous 2 points.
Classification can happen according to:
- Locus:
Person-oriented: the explanatory factor lies in the person himself
Situation-oriented: when there is a well-known context beforehand or afterwards
- Nature of control
Either cause or reason (unintentional or intentional).
This is a continuum, not a dichotomy. It can be both.
Causes explain; reason make the behavior understandable.
, Psychological Diagnostics in Health Care
- Synchronous and diachronous conditions
Synchronous: explanatory conditions coincide with the behavior (disorder)
Diachronous: these precede the behavior (problems in the past)
- Induced and persistent conditions
Induced conditions give rise to a problem
Persistent conditions perpetuate the problem
When you want to fix the problem, it is better to look at factors perpetuating the behavior.
These can be influenced.
Theory hypotheses. Usually more theories can be used. Some diagnosticians, however,
choose to only use one. This limits the process.
People are also trying to get a generally accepted, central theory, identifying all different
kinds of influences at the same time.
3. Prediction: how will the problems subsequently develop in the future?
It’s a chance statement. It plays a part in determining the treatment proposal.
Predictor is present behavior – criterion is the future behavior. Look at this relation.
Correlations are never perfect, that’s why this phase is also called risk assessment (Maris).
When you do need to make a prediction, it is best to use as much information as possible.
Even so, mistakes can be made and legal or other societal contexts can’t be met. This is due
to the standard errors of an estimation.
Disadvantage: these predictions are antitherapeutic because it doesn’t take into account
future changes.
4. Indication: how can the problems be resolved?
This phase is an orientation done by the therapist. 3 additional elements besides the
previous steps:
- Knowledge of treatments and therapists
This is hard because most treatments aren’t clearly defined. Exceptions:
o Ambulant vs. residential treatment
o Psychotherapeutic vs. pharmacological treatment
o Individual vs. group treatment
- Knowledge of the relative usefulness of treatments
Many outcome studies but often not enough support.
- Knowledge of the client’s acceptance of the indication.
There is a strategy to take the client’s preferences into account. 4 principles:
o Client’s perspective is examined and explicated
o The diagnostician provides the client with info about the courses of
treatment, processes and therapists
o Client’s expectations and preferences are compared to those that the
diagnostician deems to be suitable and useful
o Client selects a therapist and treatment after mutual consultation
5. Evaluation: have the problems been adequately resolved as a result of the
intervention?
This is based on the progress of the therapeutic process and the results of the treatment. It
establishes:
- Whether the therapy took account of the diagnosis and treatment proposal
- Whether the process and the treatment have brought about a change in the
client’s behavior and experience
You can look at it in 2 ways:
- Whether there was a desired decrease without discussing whether this change
was because of the therapy
- Prove that the changes were caused by the therapy
, Psychological Diagnostics in Health Care
Diagnostic Cycle
The empirical cycle of scientific research is a way of regulating the diagnostic process:
1. Observation
Collecting and classifying empirical materials. This is the basis for forming thoughts
about the creation and persistence of problem behavior
2. Induction
Formulation of theory and hypotheses about the behavior
3. Deduction
Testable predictions are derived from these hypotheses
4. Testing
New materials are used to determine whether the predictions are (in)correct
5. Evaluation
This cycle, however, is not specifically for psychodiagnostic practice.
The Diagnostic Process: From Application to the Report
First, we have the application. There can be a difference between the referrer’s request,
which usually requires recognition or a recommendation with regard to treatment, and the
client’s request for help, which usually requires a solution. Both of these requests need to be
analyzed and clarified. This results in the file data consisting of:
1. Information about the referrer which usually included:
a. The referrer’s frame of reference. This contains his vision which is formed by
his education and experience. The diagnostician needs to be aware of
different types of models and concepts to do this.
b. The clarification of the relationship between the diagnostician and the referrer.
For instance, he should look at the setting of where they met and why.
c. A distinction between the referrer in name and the actual referrer.
Example: the former is the psychiatrist and the latter court.
d. The nature and extent of the powers available to the referrer. A psychiatrist
and someone responsible for the intake, have different types of power.
2. An understanding of the type and content of the request.
a. The referrer’s request may adhere an open-ended format – he doesn’t
formulate any hypotheses about the problems – or a closed format – he will.
b. The context might be important. In ambulant services or primary care centers,
they’ll ask for something specific (is this a phobia or relational?).
In residential psychiatric centers, the problems will be more complex.
c. The requests can be classified according to the 5 basic questions.
3. The analysis is supported by what the referrer already knew about the client and it
helps to determine whether the client consents to examination.
Analysis of the request is about exploring the client’s mindset. What is examined in the first
meeting:
- The client’s attitude to examination
- The content of the problem
His request for help and the main problem domain
- Questions about the complaints: when, how and what factors ‘helped’?
- Who will help him and what should be the results of intervention?
Keep it open, maybe use some screening tools. During the analysis, the file data is used and
information from other sources.
During the next phase, reflection, weight is given to various pieces of information. The
diagnostician’s character is also of importance here. Nobody is completely impartial. The
diagnostician should always be aware of possible biases and see whether his knowledge
about this problem is sufficient enough to help. This phase is also about new questions.
, Psychological Diagnostics in Health Care
The next phase is the diagnostic scenario. The diagnostician will organize all the questions
of the referrer and the client, his own questions and his knowledge. Based on this, he will
formulate a theory about the behavior. It is important that, in the recognition section, only the
relevant problems are listed.
Theory: recognition explanation prediction indication (cycle).
Practice: all the basic questions are examined simultaneously.
Not all the questions need to be considered all the time. However, most requests contain 3:
- Recognition – explanation – indication
Now comes the diagnostic examination, with 6 steps in diff contexts:
1. First, we have the hypothesis formulation based on the scenario and the theory. The
relationship between the hypotheses should be clear. They should lead to testable
statements about one’s behavior or experience. This is helpful for step 2:
2. Then, we have the search for appropriate examination tools. This is determined by
the nature of the question, the psychometric quality of the instruments and the
efficiency considerations such as the duration of the examination.
3. Next we have testable predictions. You need the have some criteria on which you will
reject or accept the hypotheses. This can either be a category or scores on specific
dimensions. This will help prevent misinterpretation and confirming an hypothesis
because you want to. Don’t make them too strict though.
4. After this, you have the administration and scoring stage to see, roughly, how the
client scores and whether there is an appropriate relationship between client and
diagnostician. First, analyze the data separately for each test. You don’t want to lose
any info and you might get new hypotheses. After this, compare them with criteria.
5. Later, you will link the results back to the hypotheses and predictions in
argumentation. Look at the cons and pros. Try to reach a conclusion with as much
information as possible.
6. Lastly, a report is build using the 5 steps of the diagnostic process. Also, it contains a
distinction between facts, interpretations and conclusions. It is judged by colleagues.
Aims:
a. Substantiate the conclusions from the examination. Never a yes or no answer,
but a “well-defined answer”
b. Effective communication about the client. Others should be able to interpret it
correctly.
c. Therapeutic reason to inform the client: the client should understand it and it
should be made for the needs and questions of the client specifically. This
way it motivates them to work on themselves.
Report for the client is often done verbally. In the past, they didn’t inform them, now
they do so they can maybe give extra information.
Recognition Explanation Prediction Indication Evaluation
Hypotheses Center on the Require a Based on Assumptions
presence of list of empirical about what
psychopathology explanatory knowledge treatment
or a differential factors and of and what
diagnosis their roles successful therapists
predictors are best *
Selection Objective These tools These An additional
tools instruments are focus on tools have questionnaire
used that can be explanatory predictive can be used
used for more factors ** validity
kinds of
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and
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