CLINICAL ASSESSMENT: AN INTRODUCTION

I) WHAT IS CLINICAL ASSESSMENT

Clinical assessment is the systematic evaluation and measurement of biological,

psychological, and social factors in an individual presenting with a possible psychological
disorder. The process of clinical assessment and diagnosis are central to the study of
psychopathology, and ultimately to the treatment of psychological disorders. The process of
determining whether the particular problem afflicting the individual meets all the criteria for
a psychological disorder (as set forth by a standard classification manual, like the DSM or the
ICD) is called diagnosis.

Clinical assessment involves a host of techniques which all aid in making a sound and
informed diagnosis. Any person that presents symptoms or characteristics of abnormal
behavior undergoes clinical assessment so that a diagnosis can be made. The clinician begins
by collecting a lot of information across a broad range of the individual's functioning to
determine where the problem may lie, the nature of the problem, and its extent. Clinical
assessment has two main functions:

-it provides a direction as to what treatment models have to be applied because it gives
detailed information about the disorder,

-it provides a baseline of all the functions of the patient so that the effects of treatment can be
measured.

Further, a complete clinical assessment provides a basic understanding of the individual's

history, intellectual functioning, personality characteristics, environmental pressures, and
coping resources. Hence, it is more than just a diagnostic label. A wide range of factors can
play a role in causing or maintaining a maladaptive behavior. Therefore, in an assessment
there is a coordinated use of physical, psychological, and environmental assessment
procedure. Some of these procedures are conducting a clinical interview, behavioral
observation, and psychological assessment. Secondary data like information obtained from
caregivers, guardians, previous medical records, etc. may also be used.

II) PSYCHOLOGICAL ASSESSMENT

Psychological assessment attempts to provide a realistic picture of an individual in interaction

with his or her social environment. This picture includes relevant information about the
individual’s personality makeup and present level of functioning, as well as information
about the stressors and resources in her or his life situation. Clinicians typically formulate
hypotheses and discard or confirm them as they proceed. Starting with a global technique
such as a clinical interview, clinicians may later select more specific assessment tasks or tests.
The following are some of the psychosocial procedures that may be used:

1) Assessment interviews

An assessment interview, often considered the central element of the assessment process,
usually involves a face-to-face interaction in which a clinician obtains information about
various aspects of a client’s situation, behavior, and personality (Berthold & Ellinger, 2009).
The interview may vary from a simple set of questions or prompts to a more extended and
detailed format (Kici & Westhoff, 2004). It may be relatively open in character, with an
interviewer making moment-to-moment decisions about his or her next question on the basis
of responses to previous ones, or it may be more tightly controlled and structured so as to
ensure that a particular set of questions is covered. Although many clinicians prefer the
freedom to explore as they feel responses merit, the research data show that the more
controlled and structured assessment interview yields far more reliable results than the
flexible format.

Structured interviews follow a predetermined set of questions throughout the interview. The
beginning statements or introduction to the interview follow set procedures. The themes and
questions are predetermined to obtain particular responses for all items. The interviewer
cannot deviate from the question lists and procedures. All questions are asked of each client
in a preset way. Each question is structured in a manner so as to allow responses to be
quantified or clearly determined. On the negative side, structured interviews typically take
longer to administer than unstructured interviews and may include some seemingly tangential
questions. Clients can sometimes be frustrated by the overly detailed questions in areas that
are of no concern to them.

Unstructured assessment interviews are typically subjective and do not follow a

predetermined set of questions. The beginning statements in the interview are usually general,
and follow-up questions are tailored for each client. The content of the interview questions is
influenced by the habits or theoretical views of the interviewer. The interviewer does not ask
the same questions of all clients; rather, he or she subjectively decides what to ask based on
the client’s response to previous questions. Because the questions are asked in an unplanned
way, important criteria needed for a DSM-5 diagnosis might be skipped. Responses based on
unstructured interviews are difficult to quantify or compare with responses of clients from
other interviews. Thus, uses of unstructured interviews in mental health research are limited.
On the positive side, unstructured interviews can be viewed by clients as being more sensitive
to their needs or problems than more structured procedures.

The reliability of the assessment interview may be enhanced by the use of rating scales that
help focus inquiry and quantify the interview data. For example, the person may be rated on a
3-, 5-, or 7-point scale with respect to self-esteem, anxiety, and various other characteristics.
Such a structured and preselected format is particularly effective in giving a comprehensive
impression, or “profile,” of the subject and her or his life situation and in revealing specific
problems or crises that may require immediate therapeutic intervention.

In general, clinical interviews can be subject to error because they rely on human judgment to
choose the questions and process the information. Evidence of this unreliability includes the
fact that different clinicians have often arrived at different formal diagnoses on the basis of
the interview data they elicited from a particular client. Hence, clinical interviews are often
supplemented by:

-general physical examination: A detailed general physical examination and systemic

examination is a must in every patient. Physical disease, which is etiologically important (for
causing psychiatric symptomatology), or accidentally co-existent, or secondarily caused by
the psychiatric condition or treatment, is often present and can be detected by a good physical
examination.

-mental status examination: Mental status examination is a standardised format in which the
clinician records the psychiatric signs and symptoms present at the time of the interview.
MSE should describe all areas of mental functioning. Some areas, however, may deserve
more emphasis according to the clinical impressions that may arise from the history.

2) Clinical observation of behavior

One of the traditional and most useful assessment tools that a clinician has available is direct
observation of a client’s characteristic behavior (Hartmann et al., 2004). The main purpose
of direct observation is to learn more about the person’s psychological functioning by
attending to his or her appearance and behavior in various contexts. Clinical observation is
the clinician’s objective description of the person’s appearance and behavior. Ideally, clinical
observation takes place in a natural environment, but it is more likely to take place upon
admission to a clinic or hospital (Leichtman, 2009). Some practitioners and researchers use a
more controlled, rather than a naturalistic, behavioral setting for conducting observations in
contrived situations. These analogue situations, which are designed to yield information
about the person’s adaptive strategies, might involve such tasks as staged role-playing, event
reenactment, family interaction assignments, or think-aloud procedures (Haynes et al.,
2009).

In addition to making their own observations, many clinicians enlist their clients’ help by
providing them instruction in self-monitoring: self-observation and objective reporting of
behavior, thoughts, and feelings as they occur in various natural settings. This method can be
a valuable aid in determining the kinds of situations in which maladaptive behavior is likely
to be evoked. Alternatively, a client may be asked to fill out a more or less formal self-report
or a checklist concerning problematic reactions experienced in various situations.

As in the case of interviews, the use of rating scales in clinical observation and in self-reports
helps both to organize information and to encourage reliability and objectivity (Aiken, 1996;
Garb, 2007). That is, the formal structure of a scale is likely to keep observer inferences to a
minimum. The most useful rating scales are those that enable a rater to indicate not only the
presence or absence of a trait or behavior but also its prominence or degree.

3) Psychological testing

Interviews and behavioral observation are relatively direct attempts to determine a person’s
beliefs, attitudes, and problems. Psychological tests are a more indirect means of assessing
psychological characteristics. Scientifically developed psychological tests are standardized
sets of procedures or tasks for obtaining samples of behavior. A subject’s responses to the
standardized stimuli are compared with those of other people who have comparable
demographic characteristics, usually through established test norms or test score distributions.
From these comparisons, a clinician can then draw inferences about how much the person’s
psychological qualities differ from those of a reference group. Although psychological tests
are more precise and often more reliable than interviews or some observational techniques,
they are far from perfect tools. Their value often depends on the competence of the clinician
who interprets them. Pathology may be revealed in people who appear to be normal, or a
general impression of “something wrong” can be checked against more precise information.

a) Intelligence tests
A clinician can choose from a wide range of intelligence tests. The Wechsler Intelligence
Scale for Children-Revised (WISC-IV) (Weiss et al., 2006) and the current edition of the
Stanford-Binet Intelligence Scale (Kamphaus & Kroncke, 2004) are widely used in clinical
settings for measuring the intellectual abilities of children (Wasserman, 2003). Probably the
most commonly used test for measuring adult intelligence is the Wechsler Adult Intelligence
Scale-Revised (WAIS-IV) (Benson et al., 2010).

b) Projective personality tests

Projective personality tests are unstructured in that they rely on various ambiguous stimuli
such as inkblots or vague pictures rather than on explicit verbal questions, and in that the
person’s responses are not limited to the “true,” “false,” or “cannot say” variety. Through
their interpretations of these ambiguous materials, people reveal a good deal about their
personal preoccupations, conflicts, motives, coping techniques, and other personality
characteristics. An assumption underlying the use of projective techniques is that in trying to
make sense out of vague, unstructured stimuli, individuals “project” their own problems,
motives, and wishes into the situation.

-Rorschach inkblot test: The Rorschach Inkblot Test is named after the Swiss psychiatrist
Hermann Rorschach (1884–1922), who initiated the experimental use of inkblots in
personality assessment in 1911. The test uses 10 inkblot pictures, to which a subject responds
in succession after being instructed. Use of the Rorschach in clinical assessment is
complicated and requires considerable training. Methods of administering the test vary; some
approaches can take several hours and hence must compete for time with other essential
clinical services. Furthermore, the results of the Rorschach can be unreliable because of the
subjective nature of test interpretations.

-Thematic apperception test: The Thematic Apperception Test (TAT) was introduced in 1935
by its authors, C. D. Morgan and Henry Murray. The TAT uses a series of simple pictures,
some highly representational and others quite abstract, about which a subject is instructed to
make up stories. The content of the pictures, much of them depicting people in various
contexts, is highly ambiguous as to actions and motives, so subjects tend to project their own
conflicts and worries onto it. Several scoring and interpretation systems have been developed
to focus on different aspects of a subject’s stories. It is time-consuming to apply these
systems, and there is little evidence that they make a clinically significant contribution.
Hence, most often a clinician simply makes a qualitative and subjective determination of how
the story content reflects the person’s underlying traits, motives, and preoccupations. The
TAT has been criticized on several grounds (Lilienfeld et al., 2001). There is a “dated”
quality to the test stimuli. Additionally, the TAT can require a great deal of time to administer
and interpret. As with the Rorschach, interpretation of responses to the TAT is generally
subjective and this limits the reliability and validity of the test.

-Sentence completion test: Another projective procedure that has proved useful in personality
assessment is the sentence completion test (Fernald & Fernald, 2010). A number of such
tests have been designed for children, adolescents, and adults. Such tests consist of the
beginnings of sentences that a person is asked to complete. Sentence completion tests, which
are related to the free-association method, a procedure in which the client is asked to respond
freely, are somewhat more structured than the Rorschach and most other projective tests.
They help examiners pinpoint important clues to an individual’s problems, attitudes, and
symptoms through the content of her or his responses. Interpretation of the item responses,
however, is generally subjective and unreliable. Despite the fact that the test stimuli are
standard, interpretation is usually done in an ad hoc manner and without benefit of normative
comparisons.

c) Objective personality tests

An objective personality test is a structured—that is, they typically use questionnaires,

self-report inventories, or rating scales in which questions or items are carefully phrased and
alternative responses are specified as choices. They therefore involve a far more controlled
format than projective devices and thus are more amenable to objectively based
quantification. One virtue of such quantification is its precision, which in turn enhances the
reliability of test outcomes.
-NEO-PI: the NEO-PI (Neuroticism-Extroversion-Openness Personality Inventory) provides
information on the major dimensions in personality and is widely used in evaluating
personality factors in normal-range populations (Costa & Widiger, 2002).
-MCMI: In addition, many objective assessment instruments have been developed to assess
focused clinical problems. For example, the Millon Clinical Multiaxial Inventory (Choca,
2004) was developed to evaluate the underlying personality dimensions among clients in
psychological treatment or prior to the beginning of therapy.
-MMPI: One of the major structured inventories for personality assessment is the Minnesota
Multiphasic Personality Inventory (MMPI), now called the MMPI-2 for adults after a
revision in 1989 (Butcher, 2011; Friedman et al., 2015). The original MMPI, a self-report
questionnaire, consisted of 550 items covering topics ranging from physical condition and
psychological states to moral and social attitudes. Typically, clients are encouraged to answer
all of the items either “true” or “false.” There are 10 clinical sales and various validity scales.

Self-report inventories are cost effective, highly reliable, and objective; they also can be
scored and interpreted (and, if desired, even administered) by computer. A number of general
criticisms, however, have been leveled against the use of self-report inventories. As we have
seen, some clinicians consider them too mechanistic to portray the complexity of human
beings and their problems accurately. Also, because these tests require the subject to read,
comprehend, and answer verbal material, patients who are illiterate or confused cannot take
the tests. Furthermore, the individual’s cooperation is required in self-report inventories, and
it is possible that the person might distort his or her answers to create a particular impression.

4) Cognitive assessment

Just as it is important to know what a person does, it is also important to assess thoughts that
may lie behind the behavior. Cognitive assessment provides information about thoughts that
precede, accompany, and follow maladaptive behavior. It can be carried out in a variety of
ways. For example, questionnaires can sample people’s thoughts after an upsetting event.
Electronic beepers have been used to signal subjects to record their thoughts at certain times
of the day. There are also questionnaires to assess the directions people give themselves while
working on a task. Break in concentration can be checked by cognitive interference. The
assessment of thoughts and ideas is a relatively new development which has gained impetus
from the growing evidence that thought processes and the context of the thought are related
to emotions and behavior. They provide information about adaptive and maladaptive aspects
of people’s thoughts, and about the role they play in the process of planning, making
decisions, and interpreting reality.

III) BIOLOGICAL ASSESSMENT

Along with a psychological assessment, a biological assessment is done as well. This is

because some biological conditions can produce symptoms which are psychological in
nature. That is, the cause of a psychological condition might be physiological. For instance,
hypothyroidism produces symptoms like depression. Certain psychotic symptoms like
hallucinations may be due to development of tumors. Withdrawal from a drug can also
produce panic attacks and hallucinations. Clinicians often conduct tests like blood test, blood
pressure, heartbeat abnormalities, etc. to assess physiological changes. Neuroimaging is also
conducted to study abnormalities of the brain. Common neuroimaging techniques are CT
scan, MRI scan, etc. brain functioning can also be studied by PET scans.
Yet another form of biological assessment is called psychophysiological assessment, which
refers to measurable changes in the nervous system or other body parts that reflect emotional
or psychological events. These can be useful in figuring out triggers a person has as well as
designing & administering treatment. Common tests for this are EEG (electroencephalogram)
which measures brain wave activity. GSR (galvanic skin response) measures sweat gland
activity controlled by the peripheral nervous system, in response to stress and arousal.
Biofeedback is being increasingly involved in treatments.

IV) RELIABILITY AND VALIDITY IN CLINICAL ASSESSMENT

The accuracy of a test in assessing what it is supposed to measure is called its validity. The
best way to determine the validity of a test is to see if the results of the test yield the same
information as an objective and accurate indicator of what the test is supposed to measure.
Various types of validity include face validity, content validity, construct validity, predictive
validity, and concurrent validity.

It is important that a test provides consistent information about a person. The reliability of a
test indicates its consistency in measuring what it is supposed to measure. As with validity,
there are several types of reliability, including test-retest reliability, inter-rater reliability,
internal reliability, and alternate form reliability.

1) Reliability and validity of behavioural observation

Controlled observations are likely to be carried out in a psychology laboratory. The

researcher decides where the observation will take place, at what time, with which
participants, in what circumstances and uses a standardised procedure. Participants are
randomly allocated to each independent variable group. They can be easily replicated by
other researchers by using the same observation schedule. This means it is easy to test
for reliability, making controlled observations more desirable. However, can lack validity due
to the Hawthorne effect/demand characteristics. When participants know they are being
watched they may act differently.
Naturalistic observation, on the other hand, involves observing involves studying the
spontaneous behavior of participants in natural surroundings. The researcher simply records
what they see in whatever way they can. By being able to observe the flow of behavior in its
own setting studies have greater ecological validity. But at the same time, natural
observations are less reliable as other variables cannot be controlled. This makes it difficult
for another researcher to repeat the study in exactly the same way.

2) Reliability and validity of interviews

Structured interviews are easy to replicate as a fixed set of closed questions are used, which
are easy to quantify – this means it is easy to test for reliability.

It isn’t surprising to know that as interviews become more unstructured, reliability also drops.
In a very authoritative review of a huge amount of data on selection interviews Conway,
Jako and Goodman (1995) found that problems with reliability were commonplace in
selection interviews. Achieving reliability in unstructured interviews is challenging because
each interview is unique in some way. This variation can be because there are differences
between interviewers in terms of the questions asked, the data collected and the way that the
data is interpreted. However, at the same time, these interviews have
increased validity because it gives the interviewer the opportunity to probe for a deeper
understanding, ask for clarification & allow the interviewee to steer the direction of the
interview etc. (McLeod, 2014).

3) Reliability and validity of psychological tests

-Intelligence tests: Because IQ tests are often used to predict either positive or negative
events in a person’s life span, they can be misinterpreted as proving that
intelligence causes certain outcomes. It is more likely, however, that environmental factors
contribute to both IQ scores and to outcomes in life. IQ tests measure personal scores based
on standard deviations from a well-established average and are thought to be relatively stable
over time. IQ tests are psychometric and person-centric tests that are statistically reliable and
valid, but do not necessarily represent the same type of intelligence across cultures.

-Projective personality tests: these tests are much more sensitive to the examiner's beliefs.
They have been criticized for having poor reliability and validity, for lacking scientific
evidence, and for relying too much on the subjective judgment of a clinician. Some projective
tests, like the Rorschach, have undergone standardization procedures so they can be relatively
effective. Others like TAT involve open-ended storytelling and the standardization of test
administration is virtually non-existent, thus making the test relatively low on validity and
reliability.

-Objective personality tests: these are thought to be relatively free from rater bias, or the
influence of the examiner's own beliefs. Because of this, objective tests are said to have more
validity than projective tests. The challenge of objective tests, however, is that they are
subject to the willingness and ability of the respondents to be open, honest, and self-reflective
enough to represent and report their true personality; this limits their reliability.

V) CULTURAL DIVERSITY AND CLINICAL ASSESSMENT

A number of challenges to assessment arise when there are significant cultural differences
between the assessor and the person being assessed (Manson, 1997; Tseng, 2001). One
problem is that of negligible or no understanding of the cultural background of the patient. If
the medical professional cannot understand the place where the patient is coming from, then
understanding his/her can be tough, and often a wrong understanding may be formed. Thus, it
is important that when we take history of the patient, his/her religious and moral beliefs are
understood, the type and dynamic of family is understood; things the person values are
understood, etc. If not a complete picture, noting these things can give a fair idea of the
person’s background and culture to the clinician.

Another issue which one runs into is that the client doesn’t speak the same language as the
assessor. There is evidence that symptoms can go both undiagnosed and over-diagnosed due
to language barriers. Over-diagnosis occurs because the client tries to describe his/her
symptoms in the assessor’s language, but the clinician interprets the client’s slow or
somewhat confused description of symptoms as indicating more pathology than is really
present. Under-diagnosis occurs when the client is unable to articulate complex emotions or
strange perceptual experiences in the assessor’s language and thus, doesn’t even try.

One solution is to find an interpreter to translate between the clinician and the client.
Interpreters can be invaluable to good communication. However, interpreters who aren’t
trained assessors themselves can misunderstand and mistranslate questions & answers.

VI) PROBLEMS IN CLINICAL ASSESSMENT

Apart from cultural diversity, there are three more problems encountered in clinical
assessment.
1) Lack of adequate information

One of the major problems is the client’s inability to provide or resistance to providing
information to the assessor. As a result, clients often hide information or even modify it. One
possible solution is that the clinician tries to form a good rapport with the client, gain their
trust, and make the client comfortable. The clients should be told that the clinician is there
solely to help them. If clients cannot give out information due to the nature of their illness,
reliable informants should be contacted.

2) Reliability and validity of tests

Another issue is that the tests used for assessment are neither reliable nor valid enough, i.e.,
they are weak. Multiple tests for the same issue can be conducted. Stronger tests that cater to
the population the client belongs to should be used.

3) Evaluation of children

Evaluating children is often tricky and problematic as children are unable to give an accurate
report of their own problems and emotions. This has led clinicians to rely on others, usually
adults, to provide information about the child’s functioning. Parents are often the first source
that clinicians refer to. A clinician may interview the child’s parents when the child is taken
for treatment and ask them to fill questionnaires to assess the child’s behavior in different
situations. However, the assessment isn’t always correct. A study by Yeh and Weisz (2001)
found that parents and children often disagreed as to what problems brought the child to a
psychiatrist in 63% of the cases. It may also be that in reality, parents are the cause of the
child’s psychological problem, especially parents who are physically or sexually abusive.
These parents are unlikely to acknowledge the harm they’re causing.

One possible solution is to seek information from other sources like teachers or school
counselors for they are often the first to recognize problems. But again, this might be
discrepant for one, teachers aren’t fully trained and second, children behave differently at
home and in school. Thus, these discrepancies in behavior may make reports invalid.

VII) ETHICAL CONSIDERATIONS IN CLINICAL ASSESSMENT

The decisions made on the basis of assessment may have far reaching implications for the
people involved. Therefore, a valid decision, based on accurate assessment data, is of far
more than just theoretical importance. Because of the impact assessment has on the lives of
other people, it is important to keep several factors in mind, including:

1) Potential cultural bias of the instruments or the clinician

There is a possibility that some psychological tests may not elicit valid information for a
patient from a minority group (Gray-Little, 2009). Similarly, a clinician from one
sociocultural background may have trouble objectively assessing the behavior of a patient
formso0meother cultural background.

2) Theoretical orientation of the clinician

Assessment is inevitably influenced by a clinician’s assumptions, perceptions, and theoretical

orientation. For instance, a behaviorist may assess the same behavior quite differently as
compared to a psychoanalyst. Here, different treatment recommendations are likely to result.
Hence, an eclectic approach is always preferred.

3) Under-emphasis on external situations

Many clinicians over emphasize personality traits as the cause of the person’s problems,
without paying adequate attention to the possible role of stressors and other external
circumstances in the patient’s life. This reduces focus form potentially critical environmental
factors.

4) Insufficient validation of assessment tools

Some tools of psychological assessment in use today have not been sufficiently validated, for
instance, projective techniques. They should, therefore, be used cautiously.

5) Inaccurate data or premature evaluation

There is always a possibility that some assessment data- and any diagnostic label or treatment
based on them- may be inaccurate, or that the team leader (usually the psychiatrist) may
choose to ignore the test data in favor of other information. Inaccurate data or premature
evaluations may not only lead to a misunderstanding of the patient’s problem, but also close
off attempts to get further information, with possibly grave consequences for the patient.

Thus, there are various ethical issues one must keep in mind while conducting assessments
and making diagnoses. Diagnoses made by clinicians have the potential of changing the life
of the patient in more than one way. Therefore, the clinician should try to minimize his/her
personal bias and be as objective, fair, and ethical as possible.

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Barlow, D. H. & Durand, V. M. (2012). Abnormal Psychology: An Integrative Approach (6th

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Butcher, J. N., Mineka, S. & Hooley, J. M. (2017). Abnormal Psychology (17th ed.). New
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Carson, R. C., Butcher, J. N. & Mineka, S. (1998). Abnormal Psychology and Modern Life
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