COURSE: CLINICAL ASSESSMENT-1,

BS-7B

Chapter 1

CONTEXT OF CLINICAL ASSESSMENT

Instructor: Ms. Amna Rasheed

Department of Psychology
Foundation University
 CONTEXT OF CLINICAL ASSESSMENT

• Although general knowledge regarding tests and test construction is essential, practitioners
must consider a wide range of additional issues to place testing procedures and test scores
in an appropriate context.
• These considerations include;
• clarifying the referral question,
• understanding the referral context,
• following ethical guidelines,
• identifying and working with test bias,
• selecting the most appropriate instrument for the variable or problem being studied,
• making appropriate use of computer-assisted interpretation.
 REFERRAL SETTINGS

 Throughout the assessment process, practitioners should try to understand the unique
problems and demands encountered in different referral settings.
 Examiners—despite being skilled in administering and interpreting tests—may provide
much useless information to their referral source and perhaps even administer a needless
series of tests.
 That is, a thorough investigation of the underlying motive for a referral can sometimes lead
to the discovery that evaluation through testing is not warranted.
 Errors in test interpretation frequently occur because clinicians do not respond to the
referral question in its broadest context.
Conti..

 In turn, requests for psychological testing are often worded unclear: “I would like a
psychological evaluation on Mr. Smith,” or “Could you evaluate Jimmy because he is
having difficulties in school?” The request seldom states a specific question that must be
answered or a decision that must be made, when in fact this is usually the position that the
referral source is in.
 For example, a school administrator may need testing to support a placement decision, a
teacher may want to prove to parents that their child has a serious problem, or a psychiatric
resident may not be comfortable with the management of a patient.
 An organization’s motive for the requirement of testing may be as unclear as a statement
that the procedure is a matter of policy. Greater clarification is necessary before clinicians
can provide useful problem-solving information.
 Furthermore, many of these situations have hidden agendas that may not be adequately
handled through psychological testing alone. One of the most useful questions in
addressing these issues is to ask what decisions need to be made regarding the patient.
Conti..

 It must be stressed that the responsibility for exploring and clarifying the referral question
lies with the clinician, who should actively work with the referral source to place the
client’s difficulty in a practicable context.
 Clinicians must understand the decisions that the referral source is facing as well as the
available alternatives and the relative usefulness of each of these alternatives.
 Clinicians also need to specify the relevance of the psychological evaluation in determining
different alternatives and their possible outcomes.
 They should make clear the advantages and usefulness of psychological testing but should
also explain the limitations inherent in test data.
 To help clarify the referral question, as well as develop a relevant psychological evaluation,
clinicians should become familiar with the types of environments in which they will be
working. .
Types of referral settings

• Psychiatric Setting
• General Medical Setting
• Legal Context
• Educational Context
• Psychological Clinic
 Psychiatric Setting

 Levine (1981) has summarized the important factors for a psychologist to be aware of in a
psychiatric setting. These referrals typically come from a psychiatrist, who may be asking
the referral question in the role of administrator, psychotherapist, or physician.
 Each role presents unique issues for the psychiatrist, and clinicians have a primary
responsibility to develop evaluations that directly address the problems at hand.
 Ward administrator: One of the main roles a psychiatrist fills is administrator in a ward.
Ward administrators frequently must make decisions about problems such as suicide risk,
admission/discharge, and the suitability of a wide variety of medical procedures. While
retaining primary responsibility, a psychiatrist often uses information from other persons to
help with decisions.
 Once the patients have been admitted to a psychiatric setting, many practical questions
have to be answered, such as the type of ward in which to place them, the activities in
which they should be involved, and the method of therapy that would be most likely to
benefit them.
 Psychologists in psychiatric settings who receive unclear requests for “a psychological
issue” sometimes develop a standard evaluation based on their preconception.
 They may evaluate the patient’s defense mechanisms, diagnosis, cognitive style, and
psychosocial history without addressing the specific decisions that have to be made or
perhaps covering only two or three relevant issues and omitting others.
 To maximize the usefulness of an evaluation, examiners must be especially aware of, and
sensitive to, psychiatric administrators’ legal and custodial responsibilities.
Standard referral questions from psychiatrists evaluating a patient for
possible psychotherapy involve:

• the appropriateness of the client for such therapy,

• the strategies that are most likely to be effective,
• the likely outcome of therapy.
These assessments are usually clear-cut and typically do not present any difficulties. Such an
evaluation can elaborate on likely problems that may occur during the course of therapy,
capacity for insight, diagnosis, coping style, level of resistance, degree of functional
impairment, and problem complexity
Referral during therapy

 An area of potential conflict arises when psychiatrists are attempting to fulfill roles of both
administrator (caretaker) and psychotherapist and yet have not clearly defined these roles
either for themselves or for their patients.
 The resulting ambiguity may cause the patient to feel defensive and resistant and the
psychiatrist to feel that the patient is not living up to the therapist’s expectations.
 Elaboration of a specific trait or need in the patient cannot resolve this conflict, but must
occur in the context of interactions between the therapist and the patient. A standard
psychological evaluation investigating the internal structure of the patient does not address
this issue.
 A second possible problem area for clients referred in the middle of therapy can be the
result of personal anxiety and discomfort on the therapist’s part.
 Issues such as countertransference and possibly the therapist’s unreasonable expectations
may be equally or even more important than looking at a patient’s characteristics. If role
ambiguity, countertransference, or unreasonable expectations are discovered, they must be
elaborated and communicated in a sensitive manner.
Difference between Psychiatrist and Psychologist

 Psychiatrists are acting in the role of physician, they and the psychologist may have
different conceptual models for describing a patient’s disorder.
 Psychiatrists function primarily from a disease or medical model.
 Psychologists may speak in terms of difficulties in living with people and society.
 Example: Psychiatrist may ask whether a patient is schizophrenic, whereas a psychologist
may not believe that the label schizophrenic is useful or even a scientifically valid concept.
 Psychiatrist are faced with some practical decisions. Legal requirements or hospital
policies might require that the patient be given a traditional diagnosis.
 The psychiatrist may also have to decide whether to give antipsychotic medication,
electroconvulsive therapy, or psychotherapy.
 For a patient who is diagnosed as schizophrenic rather than brain-damaged or personality-
disordered, then (given a hospital’s current and economic policy considerations), the
psychiatrist may decide on antipsychotic medication.
General Medical Setting

 It has been estimated that as many as two-thirds of patients seen by physicians have
primarily psychosocial difficulties, and of those with clearly established medical diagnoses,
between 25% to 50% have specifically psychological disorders in addition to medical ones.
 Most of these psychological difficulties are neither diagnosed nor referred for treatment. In
addition, many traditionally “medical” disorders such as coronary heart disease, asthma,
allergies, arthritis, ulcers, and headaches have been found to possess a significant
psychosocial component.
 The treatment and prevention of psychosocial aspects of “medical” complaints have been
demonstrated to be cost-effective (productive) for areas such as preparation for surgery,
smoking cessation, rehabilitation of chronic pain patients, obesity, interventions for
coronary heart disease, and patients who are somatizing psychosocial difficulties.
Requirement of a complete approach

 A complete approach to the patient is required that involves an awareness of the interaction
between physical, psychological, and social variables.
 Psychologists have the potential to make an extremely important contribution. To
adequately work in general medical settings, psychologists must become familiar with
medical descriptions, which often means learning a complex and extensive vocabulary.
 Another issue is that, even though physicians often draw information from several sources
to aid in decision making, they must take ultimate responsibility for their decisions.
Psychologist’s services used by Physicians

 Most frequent situations in which physicians might use the services of a psychologist
involve the presence of an underlying psychological disorder, possible emotional factors
associated with medical complaints, assessment for neuropsychological deficit,
psychological treatment for chronic pain, the treatment of chemical dependency and patient
management.
 Although a medical exam may not suggest any physical basis for the patient’s complaints,
the physician still has to devise some form of treatment or at least an appropriate referral.
 A significant problem of patients referred to physicians do not have any detectable physical
difficulties and their central complaint is likely to be psychological. The psychologist can
then elaborate and specify how a patient can be treated for possible psychosocial
difficulties.
Specialized standard assessment instruments:
 Millon Behavioral Health Inventory
 Millon Behavioral Medicine Diagnostic
(Bockian, Meagher, & Millon, 2000; Maruish, 2000; Millon, 1997).
Physician and Neuropsychologist

 Increase in neuropsychological status: Patient’s psychological assessment of

neuropsychological status has greatly increased now.
 Physicians attempt to detect physical lesions in the nervous system. Evaluates how the
brain is functioning.
 Neuropsychologist are more concerned with the status of higher cortical functions.
Evaluates how the person is functioning as a result of possible brain abnormalities.
 Areas of assessment focus on the presence of possible intellectual deterioration in areas
such as memory, sequencing, abstract reasoning, spatial organization, and executive
abilities. Referral screening for neuropsychological deficit account for psychological
referrals in psychiatric and medical settings.
 What physicians want to know whether a test profile suggests a specific diagnosis,
particularly malingering, conversion disorder, hypochondriasis, organic brain syndrome, or
depression.
 Physician and Neuropsychologist

 Issues addressed by neuropsychologists include the nature and extent of identified

lesions, localization of lesions, emotional status of neurologically impaired patients, extent
of disability, and suggestions for treatment planning such as recommendations for
cognitive rehabilitation, vocational training, and readjustment to family and friends.
 Pre-surgical evaluation A physician might also request a psychologist to conduct a pre-
surgical evaluation to assess the likelihood of a serious stress reaction to surgery.
 Pediatric physician’s concerned with detecting early signs of serious psychological
disorder, which may have been brought to their attention by parents, other family members,
or teachers.
 Psychologist’s evaluation should assess not only the patient’s present psychological
condition but also the contributing factors in his or her environment, and should provide a
prediction of the patient’s status during the next few months or years.
 When the patient’s current condition, current environment, and future prospects have been
evaluated, the examiner can then recommend the next phase in the intervention process.
Legal Context

 During the past 30 years, psychologists in legal settings has become more prevalent and
important. Psychologists might be called in at any stage of legal decision making.
 During investigation stage, they might be consulted to assess the reliability of a witness or
to help evaluate the quality of information by a witness.
 The prosecuting attorney might also need to have a psychologist evaluate the quality of
another mental health professional’s report, evaluate the accused person’s competency, or
help determine the effectiveness of a crime.
 A defense attorney might use a psychologist to help in supporting an insanity plea (mental
disorder defense) , to help in jury selection, or to document that brain damage has occurred.
 A judge might use a psychologist’s report as one of a number of factors to help determine a
sentence.
 A penal officer might wish consultation to help determine the type of confinement or level
of dangerousness
 Parole officer might need assistance to help plan a rehabilitation program. Even though a
psychologist might write a legal report, he or she is likely to actually appear in court in
only about 1 in every 10 cases
 Increasing use and acceptance of psychologists in legal contexts have resulted in a
gradual clarification of their roles as well as a production of forensic assessment
instruments.
 Psychologists are also required to become increasingly sophisticated in their evaluation of
possible malingering and deception. Each psychologist appearing in court must have his or
her qualifications approved.
 Important areas of consideration are the presence of clinical expertise in treating
specialty disorders and relevant publication credits. Evaluation of legal work by
psychologists indicates they are generally viewed favorably by the courts and may have
reached similarity with psychiatrists
 American Board of Forensic Psychology outlined the practice of forensic psychology
includes training/consultation with legal practitioners, evaluation of populations likely to
encounter the legal system, the translation of relevant technical psychological knowledge
into usable information.
 Psychologists are used most frequently in;
 child custody cases
 competency of a person to dispose of property,
 juvenile (youth) commitment,
 comprehension of legal rights,
 potential for having given a false confession
 personal injury.
 Frequently used tests in Legal Context settings

 The Historical Clinical Risk-20 (for violence risk assessment)

(Webster, Douglas, Eaves, & Hart, 1997)
 The Static 99 (for sexual reoffending risk)
(Hanson & Thornton, 1999).

• An essential requirement when working in the legal context is for psychologists to modify
their language.
• Many legal terms have exact and specific meanings that, if misunderstood, could lead to
extremely negative consequences. Psychologists must familiarize themselves with this
terminology and the different tones involved in its use.
• Psychologists may also be requested to explain in detail the meaning of their conclusions and
how these conclusions were reached.
Guidelines for developing child custody evaluations

 Psychologists are sometimes asked to help with child custody decisions. Guidelines for
developing child custody evaluations and child protection evaluations have been developed
by the American Psychological Association (APA) are;
 Central consideration is to determine which arrangement is in the child’s best interest.
 Areas to be considered include the mental health of the parent
 The quality of love and affection between the parent and child
 The nature of the parent-child relationship
 The long-term effect of the different decisions on the child .
 Often psychological evaluations are conducted on each member of the family using
traditional testing instruments. Specific tests developed are;
Bricklin Perceptual Scales (Bricklin, 1984).
Academic / Educational Context

 Psychologists are frequently called on to assess children who are having difficulty in, or
may need special placement in, the school system.
 The most important areas are evaluating the nature and extent of a child’s learning
difficulties, measuring intellectual strengths and weaknesses, assessing behavioral
difficulties, creating an educational plan, estimating a child’s responsiveness to
intervention, and recommending changes in a child’s program or placement.
 Any educational plan should be sensitive to the interactions among a child’s abilities,
diversity considerations, the child’s personality, the characteristics of the teacher, and the
needs and expectations of the parents.
Conti..

 A typical educational placement begins with a visit to the classroom for observation of a
child’s behavior under natural conditions.
 A valuable aspect of this is to observe the interaction between the teacher and child.
 Typically, any behavioral difficulty is closely linked with the child-teacher interaction.
Sometimes the teacher’s style of responding to a student can be as much a part of the
problem as the student.
 Consequently, classroom observations can cause discomfort to teachers and should be
handled sensitively.
 Assessments of children in a school context

 Most assessments of children in a school context include behavioral observations, a test of

intellectual abilities such as;
• WISC-IV,
• Stanford Binet-V,
• Psycho educational Battery-III,
• Tests of personality functioning

 Wide variety of behavioral ratings instruments are:

• Achenbach Child Behavior Checklist (Achenbach & Rescorla, 2001),
• Conners’ Parent Rating Scale Revised (Conners, 1997),
• Conners’ Teacher Rating Scale-Revised (Conners, Sitarenios, Parker, & Epstein, 1998)
• Behavior Assessment System for Children-2 (BASC-2; Reynolds & Kamphaus, 2004).
Conti..

 Well-designed scales that have become increasingly used are:

• Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984)

• Wechsler Individual Achievement Test-2 (WIAT-2; Psychological Corporation, 2001)
• Wide Range Achievement Test-IV (WRAT-IV; Wilkinson & Robertson, 2007).
Recommendations for an educational setting

 Any report written for an educational setting should focus not only on a child’s weaknesses
but also on his or her strengths.
 Understanding a child’s strengths can potentially be used to increase a child’s self-esteem
as well as to create change in a wide context.
 Recommendations should be realistic and practical.
 Recommendations can be developed most effectively when the clinician has a thorough
understanding of relevant resources in the community, the school system, and the
classroom environment.
 This understanding is particularly important because the quality and resources available
between one school or school system and the next can vary tremendously.
 Recommendations typically specify which skills need to be learned, how these can be
learned, a hierarchy of objectives, and possible techniques for reducing behaviors that
make learning difficult.
Assessment of Children

 The assessment of children should be carried out in two phases;

 The first phase should assess the nature and quality of the child’s learning environment. If
the child is not exposed to adequate quality instruction, he or she cannot be expected to
perform well. Thus, it must first be demonstrated that a child has not been learning even
with appropriate instruction.
 The second phase involves a comprehensive assessment battery, which includes measures
of intellectual abilities, academic skills, adaptive behavior, and screening out any
biomedical disorders that might disrupt learning. Intellectual abilities might involve
memory, spatial organization, abstract reasoning, and sequencing.
 Regardless of students’ academic and intellectual abilities, they will not perform well
unless they have relevant adaptive abilities, such as social skills, adequate motivation, and
ability to control impulses.
PSYCHOLOGICAL CLINIC

 In contrast to the medical, legal, and educational institutions where the psychologist
typically serves as a consultant to the decision maker, the psychologist working in a
psychological clinic is often the decision maker.
 A number of frequent types of referrals come into the psychological clinic. Perhaps the
most common ones are individuals who are self-referred and are seeking relief from
psychological disorder.
 For most of these individuals, extensive psychological testing is not relevant and, in fact,
may be contraindicated because the time spent in testing is usually time that could best be
applied toward treatment.
 However, brief instruments targeted toward assessing client characteristics most relevant
toward treatment planning can help to develop treatments that will speed the rate of
treatment as well as optimize outcome.
 Brief instruments can also be used to monitor response to therapy, make relevant
alterations, and thus increase the likelihood of successful intervention
Requirement of appropriate treatment for self referred client

 There may also be certain groups of self referred clients about whom the psychologist may
question whether the treatment available in a psychological clinic is appropriate.
 These clients can include persons with extensive medical problems, individuals with legal
complications that need additional clarification, and persons who may require inpatient
treatment.
 With these cases, it might be necessary to obtain additional information through
psychological testing. However, the main purpose of the testing would be to aid in decision
making rather than to serve as a direct source of help for the client.
Situations in which psychological assessment may be warranted

 Two other situations in which psychological assessment may be warranted involve children
who are referred by their parents for school or behavioral problems and referrals from other
decision makers.
 When referrals are made for poor school performance or behavioral problems involving
legal complications, special precautions must be taken before testing.
 Primarily, the clinician must develop a complete understanding of the client’s social
network and the basis for the referral. This complete understanding may include a history
of previous attempts at treatment and a summary of the relationship among the parents,
school, courts, and child.
Conti..

 Usually a referral comes at the end of a long sequence of events, and it is important to
obtain information regarding these events.
 After the basis of the referral has been clarified, the clinician may decide to have a meeting
with different individuals who have become involved in the case, such as the school
principal, previous therapists, probation officer, attorney, or teacher.
 This meeting may uncover many issues that require decisions, such as referral for family
therapy, placement in a special education program, a change in custody agreements
between divorced parents, individual therapy of other members of the family, and a change
in school.
Conti..

 A final point is that clinicians should not allow themselves to be placed into the role of a
“testing technician” or psychometrist.
 This role ultimately does a damage to the client, the practitioner, and the profession.
 Clinicians should not merely administer, score, and interpret tests but should also
understand the total referral context in its broadest sense.
 This means they also take on the role of an expert who can integrate data from a variety of
sources.
Thank You