Clinical Assessment: Psychodiagnostic Decision Making
Witteman, C., Van der Heijden, P., & Claes, L. (2018)
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,Table of Contents
Clinical Assessment: Psychodiagnostic Decision Making.......................................................................1
Chapter 1: Psychological Assessment: Definition and Introduction...................................................3
1.1 What is psychological assessment?.........................................................................................3
1.2 Using assessment instruments.................................................................................................3
1.3 Defining normal and abnormal behaviour...............................................................................6
Chapter 2: Judging and Deciding........................................................................................................8
2.1 Judging and deciding in the assessment process.....................................................................8
2.2 What clinicians do in practice: Heuristic and intuitive decisions............................................11
2.3 Team decisions.......................................................................................................................17
2.4 Improved judgment and decision making..............................................................................19
Chapter 3: Start of the Assessment Process: Referral, Presenting Complaints and Classification. . .23
3.1 Referral..................................................................................................................................24
First contact.................................................................................................................................25
3.2 Classification..........................................................................................................................26
Chapter 4: Explanation....................................................................................................................29
4.1 Guidelines for constructing a theoretical explanatory model................................................33
Chapter 5: Indication for Psychotherapy.........................................................................................34
5.1 Indication for Psychotherapy.................................................................................................34
Chapter 6: The Report.....................................................................................................................38
6.1 Section 1: The client...............................................................................................................38
6.2 Section 2: Classifications........................................................................................................38
6.3 Section 3: Explanations..........................................................................................................39
6.4 Section 4: Treatment proposal...............................................................................................39
6.5 Section 5: Conclusion.............................................................................................................39
Epilogue: In Conclusion....................................................................................................................40
Appendix 1: Flowchart of the Psychological Assessment Process....................................................41
Appendix 2: The Diagnostic Cycle....................................................................................................42
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,Chapter 1: Psychological Assessment: Definition and Introduction
1.1 What is psychological assessment?
Definition psychological assessment:
Psychological assessment is a shared decision-making process in which a clinical iteratively defines a
diagnostic question, formulates and tests hypotheses about the client’s cognitive-affective functions
and behaviour, and integrates the information thus collected from a number of sources and using
different methods based on scientific psychology in a dynamic fashion.
In psychological assessment we analyse the behaviour, thoughts, and emotions of clients in a
systematic way and based on psychological theories, in order to understand and predict their
courses.
Four basic question categories in psychological assessment:
1. Classification question
2. Explanation
3. Prediction & Indication
4. Evaluation
The assessment process
Because of the lack of gold standard and adequate feedback, it is important to configure the
assessment process as scientifically as possible. The empirical cycle describes the blueprint for this
logical-methodological research. Using the following steps:
1. Observation
2. Induction
3. Deduction
4. Testing
5. Evaluation
In each step of the empirical cycle the following phases are all followed:
1. Formulating hypotheses
2. Formulating verifiable predictions based on these hypotheses
3. Choosing instruments to be used to test these hypotheses
4. Determining the testing criterion or the expected scores on the instruments
5. Administering methods and instruments and scoring and interpreting their results
6. Evaluating and confirming or refuting the hypotheses based on the results
1.2 Using assessment instruments
Observation is the most commonly used method in the assessment process. In the first place it is
important to consider the question why we should observe. Observation provides a lot of unique
information that we cannot always obtain by asking questions or taking tests. Especially because
clients themselves do not always have an overall perspective on these contexts.
It is important to standardise observation as much as possible in order to prevent judgment errors
and incorrect conclusions. It is advisable to observe normal/problematic behaviour in different
contexts and to be aware of the informant problem.
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,Forms of observing behaviour
Self-registration:
Advantages:
o Often used in behaviour therapy
o Enables the observation of behaviour that others cannot easily observe
Thoughts & feelings
Disadvantages:
o Observations may differ in quality
o For some people it is virtually impossible to self-register
Children & elderly
Observing Internal processes:
Ask the client to report on what is going on
Observing externalising behaviour:
Observation by informant are observations done by someone else than the client
Quite possible that various informants may not reach the same conclusion
about the nature and severity of the problems
Important to inform as many different informants as possible
Observations of other informants tend to be more useful
Problems with observing behaviour
The problem with observing behaviour is that people are quick to interpret behaviour instead of just
observing it.
Observation in natural context:
Advantages:
o Sequences of behaviour can be observed as they occur in everyday situations
Disadvantages:
o Labour-intensive & expensive
o People often change their behaviour as soon as they are aware of being observed
Standardised and non-standardised observing
Observing and registering behaviour a distinction can be made between standardised and non-
standardised observation.
Standardised: Uses evaluation scales
Advantage:
o Reduces probability of judgment errors
Disadvantage:
o No suitable assessment scale for every type of problematic behaviour
Non-standardised:
Disadvantage:
o risk judgment errors
o Actor-observer effect: fundamental attribution error
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,There are two ways of observing behaviour
From specific fixed time period or point in time (time sampling)
Behaviour itself (event sampling)
Clinical interviews
There are different ways of doing a psychological assessment.
Ideographic or person-oriented approach:
The uniqueness of the individual is key
Nomothetic or norm-oriented approach:
Emphasis lies on general laws
Person is understood through analytical thinking, theory formation and empirical testing
Advantage: Statistical judgment leads to better prediction of human behaviour than clinical
judgment
The book recommends that, if possible, a systematic approach is followed, and that clinicians do not
rely on their own untested judgments.
Semi structured interviews
An intuitive modus operandi is fast but can lead to unreliable and incorrect classifications. The use of
semi-structured interviews has the main advantages of yielding a higher reliability of the diagnostic
judgment.
Reliability:
Interrater reliability
Test-retest reliability
The problem with semi-structured interviews is that they are time-consuming, and do not facilitate
development of a therapeutic relationship or alliance with the client. Furthermore, it is important
not to get entangled in all the details of the client’s symptoms, but to also have an eye for the
context in which they occur.
Despite of the disadvantages, the use of semi-structured interviews in the classification of mental
disorders is still strongly recommended.
Psychological tests
Psychological tests play an important role in the assessment process. It is important to think about
the pros and cons of the chosen test. Each test and questionnaire serves a more substantial
objective than ‘gathering information’: More information is not always better, and may even impede
correct decision because sight of the bigger picture is lost.
Definition psychological test:
An evaluative instrument or procedure that allows sampling a client’s behaviour in a given domain,
to be obtained and then evaluated and scored following a standardised process.
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,Psychological tests:
Often involve self-report
o Drawbacks self-report:
Knowledge and expertise are needed to recognise and understand
psychopathology
Many people have limited access to their own cognitive processes
Scores on questionnaires are often distorted by clients’ psychological
defences and all kinds of judgment errors about their own abilities
Quality of psychological tests
Reliability:
Says something about the stability of the scores
o How well do I measure what I want to measure?
Test-retest reliability (stability)
Cronbach’s Alpha (internal consistency)
Standard Error of Measurement
Validity:
Does the test measure what it tries to predict?
Construct validity
Criterion validity
Lay persons often see scores on psychological tests as objective measures, but they must be seen as
probabilities or scores within a confidence interval.
1.3 Defining normal and abnormal behaviour
There are different views on normality and mental disorders, and thus different definitions. The lack
of a definition of normal and abnormal behaviour makes it difficult to formulate general assessment
criteria in terms of what is deviant or what is normal.
Normal as an absence of mental disorders
Problems with the definition:
o Dysfunction in an individual can almost never be determined objectively
o Abnormality could be defined as a deviation from a statistical norm
Statistical norms are not always available
Normality as a successful adaptation to (changing) circumstances
Advantage of this definition:
o Includes reference to the context
The advantage is its main disadvantage: In extreme situations, extreme behaviour is needed
for survival, which may be difficult to comprehend as normal behaviour.
Dimensional and Categorical presentations of disorders
Mental problems and personality characteristics can be arranged categorically or dimensionally. In
categorical presentations, a mental disorder is either present or absent, whilst in a dimensionally
presentation there is no strict distinction between normal and abnormal.
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,Assumptions of categorical presentation
A qualitative, clear distinction can be made between a disorder and normal behaviour.
There is a certain homogeneity within categories.
The different categories together comprise all possible mental disorders and that the
individual categories are mutually exclusive.
The DSM-V uses a predominantly categorical approach to classifying psychopathology. Yet, there are
five shortcomings, meaning that these systems are far from optimal.
1. There is extensive comorbidity between many supposedly classified mental disorders.
2. Psychopathology is dimensional rather than categorical in nature.
3. Classifications have limited validity in predicting course of the disorder.
4. Many classifications are heterogeneous in nature, due to the polythetic system in which
different numbers and combinations of symptoms can be classified as the same
disorders.
5. The classifications not otherwise specified (NOS) are the most prevalent group of
classifications.
Research Doman Criteria (RDoC) is a research framework in which psychological function and
dysfunction are described in terms of transdiagnostic processes, which play a role in the
development of mental health and illness. These five domains, which can be divided into
subdomains from genes to the behavioural level, are:
1. Positive valence systems
2. Negative valence systems
3. Cognitive systems
4. Systems for social processes
5. Arousal/Modulatory systems
Multifinality of Psychopathology
The biological predispositions to psychopathology and their behaviour manifestation are distinct
phenomena.
Hierarchical Taxonomy of Psychopathology
An empirically-based dimensional taxonomy of psychopathology that is means as an over-arching
quantitative model for the study and treatment of psychopathology, describing four higher-order
factors of psychopathology. Combined with RDoC it may result in individualised assessments.
1. Internalising disorders
2. Externalising disorders
3. Somatoform disorders
4. Cognitive disorders
Dimensions do reality more justice
A dimensional approach to symptoms is more reliable and more valid. Moreover, a categorical
approach involves major loss of information.
However:
o Clinicians usually think in prototypes or categories, not dimensions.
o Decisions in clinical practice are usually categorical.
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, Relation between personality and mental disorders
Insight into possible relations between personality and personality problems is important when
conducting an explanatory analysis. Personality and mental disorders can be seen as a continuum, as
described by the spectrum hypothesis.
Vulnerability hypothesis:
Personality is a potential risk factor for the development of clinical syndromes, although personality
can also be a protective factor. The reverse is also possible; a mental disorder influences the
personality and its development, which is called the ‘Scar hypothesis’.
Chapter 2: Judging and Deciding
This chapter will assess and discuss judgment and decision making by mental health practitioners. A
clinician makes judgments and decisions right from the moment clients present themselves to their
clinical institute or practice. He does this by answering questions, yet these questions can rarely be
answered unambiguously since we cannot avail ourselves of objective facts or algorithmic decision
rules.
2.1 Judging and deciding in the assessment process
To make correct decisions, clinicians need valid information. To gain this information, the clinical
preferably follows a structured process and the guidance of the Empirical cycle. This information is
consequently integrated into a diagnostic conclusion and discusses with the client.
There are some risks that occur during this process:
Clinicians will use assessments instruments because they happen to be available, without
asking what these instruments may imply or how good they are.
Clinicians often think that more information is better, whilst too many details can distract
from the main question.
Deciding about a treatment
After classifying the problems, the answer to the question whether a treatment is necessary
automatically seems to be affirmative. However, there are reasons to refrain from treatment
because pharmacological or psychotherapeutic treatments can also have adverse consequences.
Shared decision making
If it has been concluded that a treatment is necessary and possible, the next decision is which
treatment to propose to the client, ideally using shared decision making. As it is important to do that
for which there is most empirical evidence, provided the client is agreeable.
Different treatment options
In the case there are different treatment options, when there is not one unambiguously diagnosed
disorder but a combination of disorders, or if no empirically supported treatment is available, the
different options should be considered and weighted to each other.
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