3.1: Clinical Assessment of Abnormal Behavior

Learning Objectives

• Define clinical assessment.
• Clarify why clinical assessment is an ongoing process.
• Define and exemplify reliability.
• Define and exemplify validity.
• Define standardization.
• List and describe seven methods of assessment.

What is Clinical Assessment?

For a mental health professional to be able to effectively help treat a client and know that the treatment selected worked (or is working), they first must engage in the clinical assessment of the client, or collecting information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews to determine the person’s problem and the presenting symptoms. This collection of information involves learning about the client’s skills, abilities, personality characteristics, cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors particular to them such as their language or ethnicity. Clinical assessment is not just conducted at the beginning of the process of seeking help but throughout the process. Why is that?

Consider this. First, we need to determine if a treatment is even needed. By having a clear accounting of the person’s symptoms and how they affect daily functioning, we can decide to what extent the individual is adversely affected. Assuming a treatment is needed, our second reason to engage in clinical assessment will be to determine what treatment will work best. As you will see later in this module, there are numerous approaches to treatment. These include Behavior Therapy, Cognitive and Cognitive-Behavioral Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological treatments (psychopharmacology). Of course, for any mental disorder, some of the aforementioned therapies will have greater efficacy than others. Even if several can work well, it does not mean a particular therapy will work well for that specific client. Assessment can help figure this out. Finally, we need to know if the treatment we employed worked. This will involve measuring before any treatment is used and then measuring the behavior while the treatment is in place. We will even want to measure after the treatment ends to make sure symptoms of the disorder do not return. Knowing what the person’s baselines are for different aspects of psychological functioning will help us to see when improvement occurs.

In recap, obtaining the baselines happens in the beginning, implementing the treatment plan that is agreed upon happens more so in the middle, and then making sure the treatment produces the desired outcome occurs at the end. It should be clear from this discussion that clinical assessment is an ongoing process.

Key Concepts in Assessment

The assessment process involves three critical concepts – reliability, validity, and standardization. These three are important to science in general. First, we want the assessment to be reliable or consistent. Outside of clinical assessment, when our car has an issue and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with our car is the same as what another says, or even two others. If not, the measurement tools they use to assess cars are flawed. The same is true of a patient who is suffering from a mental disorder. If one mental health professional says the person suffers from major depressive disorder and another says the issue is borderline personality disorder, then there is an issue with the assessment tool being used. Ensuring that two different raters are consistent in their assessment of patients is called interrater reliability. Another type of reliability occurs when a person takes a test one day, and then the same test on another day. We would expect the person’s answers to be consistent, which is called test-retest reliability. For example, let’s say the person takes the MMPI on Tuesday and then the same test on Friday. Unless something miraculous or tragic happened over the two days in between tests, the scores on the MMPI should be nearly identical to one another. What does identical mean? The score at test and the score at retest are correlated with one another. If the test is reliable, the correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive means as one score goes up, so does the other, so the correlation for the two tests should be high on the positive side).

In addition to reliability, we want to make sure the test measures what it says it measures. This is called validity. Let’s say a new test is developed to measure symptoms of depression. It is compared against an existing and proven test, such as the Beck Depression Inventory (BDI). If the new test measures depression, then the scores on it should be highly comparable to the ones obtained by the BDI. This is called concurrent or descriptive validity. We might even ask if an assessment tool looks valid. If we answer yes, then it has face validity, though it should be noted that this is not based on any statistical or evidence-based method of assessing validity. An example would be a personality test that asks about how people behave in certain situations. Therefore, it seems to measure personality, or we have an overall feeling that it measures what we expect it to measure.

Predictive validity is when a tool accurately predicts what will happen in the future. Let’s say we want to tell if a high school student will do well in college. We might create a national exam to test needed skills and call it something like the Scholastic Aptitude Test (SAT). We would have high school students take it by their senior year and then wait until they are in college for a few years and see how they are doing. If they did well on the SAT, we would expect that at that point, they should be doing well in college. If so, then the SAT accurately predicts college success. The same would be true of a test such as the Graduate Record Exam (GRE) and its ability to predict graduate school performance.

Finally, we want to make sure that the experience one patient has when taking a test or being assessed is the same as another patient taking the test the same day or on a different day, and with either the same tester or another tester. This is accomplished with the use of clearly laid out rules, norms, and/or procedures, and is called standardization. Equally important is that mental health professionals interpret the results of the testing in the same way, or otherwise, it will be unclear what the meaning of a specific score is.

Methods of Assessment

So how do we assess patients in our care? We will discuss observation, psychological tests, neurological tests, the clinical interview, and a few others in this section.

3.1.3.1. Observation. In Section 1.5.2.1 we talked about two types of observation – naturalistic, or observing the person or animal in their environment, and laboratory, or observing the organism in a more controlled or artificial setting where the experimenter can use sophisticated equipment and videotape the session to examine it later. One-way mirrors can also be used. A limitation of this method is that the process of recording a behavior causes the behavior to change, called reactivity. Have you ever noticed someone staring at you while you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did you become self-conscious? Likely yes, and this is an example of reactivity. Another issue is that the behavior made in one situation may not be made in other situations, such as your significant other only acting out at the football game and not at home. This form of validity is called cross-sectional validity. We also need our raters to observe and record behavior in the same way or to have high inter-rater reliability.

3.1.3.2. The clinical interview. A clinical interview is a face-to-face encounter between a mental health professional and a patient in which the former observes the latter and gathers data about the person’s behavior, attitudes, current situation, personality, and life history. The interview may be unstructured in which open-ended questions are asked, structured in which a specific set of questions according to an interview schedule are asked, or semi-structured, in which there is a pre-set list of questions, but clinicians can follow up on specific issues that catch their attention. A mental status examination is used to organize the information collected during the interview and systematically evaluates the patient through a series of questions assessing appearance and behavior. The latter includes grooming and body posture, thought processes and content to include disorganized speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be examined further. The limitation of the interview is that it lacks reliability, especially in the case of the unstructured interview.

3.1.3.3. Psychological tests and inventories. Psychological tests assess the client’s personality, social skills, cognitive abilities, emotions, behavioral responses, or interests. They can be administered either individually or to groups in paper or oral fashion. Projective tests consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They include the Rorschach or inkblot test and the Thematic Apperception Test which asks the individual to write a complete story about each of 20 cards shown to them and give details about what led up to the scene depicted, what the characters are thinking, what they are doing, and what the outcome will be. From the response, the clinician gains perspective on the patient’s worries, needs, emotions, conflicts, and the individual always connects with one of the people on the card. Another projective test is the sentence completion test and asks individuals to finish an incomplete sentence. Examples include ‘My mother…’ or ‘I hope…’

Personality inventories ask clients to state whether each item in a long list of statements applies to them, and could ask about feelings, behaviors, or beliefs. Examples include the MMPI or Minnesota Multiphasic Personality Inventory and the NEO-PI-R, which is a concise measure of the five major domains of personality – Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. Six facets define each of the five domains, and the measure assesses emotional, interpersonal, experimental, attitudinal, and motivational styles (Costa & McCrae, 1992). These inventories have the advantage of being easy to administer by either a professional or the individual taking it, are standardized, objectively scored, and can be completed electronically or by hand. That said, personality cannot be directly assessed, and so you do not ever completely know the individual.

3.1.3.4. Neurological tests. Neurological tests are used to diagnose cognitive impairments caused by brain damage due to tumors, infections, or head injuries; or changes in brain activity. Positron Emission Tomography or PET is used to study the brain’s chemistry. It begins by injecting the patient with a radionuclide that collects in the brain and then having them lie on a scanning table while a ring-shaped machine is positioned over their head. Images are produced that yield information about the functioning of the brain. Magnetic Resonance Imaging or MRI provides 3D images of the brain or other body structures using magnetic fields and computers. It can detect brain and spinal cord tumors or nervous system disorders such as multiple sclerosis. Finally, computed tomography or the CT scan involves taking X-rays of the brain at different angles and is used to diagnose brain damage caused by head injuries or brain tumors.

3.1.3.5. Physical examination. Many mental health professionals recommend the patient see their family physician for a physical examination, which is much like a check-up. Why is that? Some organic conditions, such as hyperthyroidism or hormonal irregularities, manifest behavioral symptoms that are like mental disorders. Ruling out such conditions can save costly therapy or surgery.

3.1.3.6. Behavioral assessment. Within the realm of behavior modification and applied behavior analysis, we talk about what is called behavioral assessment, which is the measurement of a target behavior. The target behavior is whatever behavior we want to change, and it can be in excess and needing to be reduced, or in a deficit state and needing to be increased. During the behavioral assessment we learn about the ABCs of behavior in which Antecedents are the environmental events or stimuli that trigger a behavior; Behaviors are what the person does, says, thinks/feels; and Consequences are the outcome of a behavior that either encourages it to be made again in the future or discourages its future occurrence. Though we might try to change another person’s behavior using behavior modification, we can also change our own behavior, which is called self-modification. The person does their own measuring and recording of the ABCs, which is called self-monitoring. In the context of psychopathology, behavior modification can be useful in treating phobias, reducing habit disorders, and ridding the person of maladaptive cognitions.

3.1.3.7. Intelligence tests. Intelligence testing determines the patient’s level of cognitive functioning and consists of a series of tasks asking the patient to use both verbal and nonverbal skills. An example is the Stanford-Binet Intelligence test, which assesses fluid reasoning, knowledge, quantitative reasoning, visual-spatial processing, and working memory. Intelligence tests have been criticized for not predicting future behaviors such as achievement and reflecting social or cultural factors/biases and not actual intelligence. Also, can we really assess intelligence through one dimension, or are there multiple dimensions?

Key Takeaways

You should have learned the following in this section:

• Clinical assessment is the collecting of information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews.
• Reliability refers to consistency in measurement and can take the form of interrater and test-retest reliability.
• Validity is when we ensure the test measures what it says it measures and takes the forms of concurrent or descriptive, face, and predictive validity.
• Standardization is all the clearly laid out rules, norms, and/or procedures to ensure the experience each participant has is the same.
• Patients are assessed through observation, psychological tests, neurological tests, and the clinical interview, all with their own strengths and limitations.

Review Questions

1. What does it mean that clinical assessment is an ongoing process?
2. Define and exemplify reliability, validity, and standardization.
3. For each assessment method, define it and then state its strengths and limitations.