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006 - chapter 4 - clinical assessment

006 - chapter 4 - clinical assessment

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Published by Joseph Eulo

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Published by: Joseph Eulo on Jan 29, 2009
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Clinical Assessment
THE BASIC ELEMENTS IN ASSESSMENT
The Relationship between Assessment and
Diagnosis
Taking a Social or Behavioral History
The Influence of Professional Orientation
Trust and Rapport between the Clinician
and the Client
ASSESSMENT OF THE PHYSICAL ORGANISM
The General Physical Examination
The Neurological Examination
The Neuropsychological Examination
PSYCHOSOCIAL ASSESSMENT
Assessment Interviews
The Clinical Observation of Behavior
Psychological Tests
Advantages and Limitations of Objective
Personality Tests
A Psychological Case Study: Esteban
THE INTEGRATION OFASSESSMENT DATA
Ethical Issues in Assessment
CLASSIFYING ABNORMAL BEHAVIOR
Reliability and Validity
Differing Models of Classification
Formal Diagnostic Classification of Mental
Disorders

e will focus in this chapter on the initial clinical assessment and on arriving at a clinical diagnosis according to DSM-IV-TR. Psychological assessment refers to a procedure by which clinicians, using psychological tests, observation, and interviews, develop a summary of the client's symptoms and problems. Clinical diagnosis is the process through which a clinician arrives at a general"summary classification" ofthe patient's symptoms by following a clearly defined system such as DSM-IV-TR or ICD-l0 (International Classification of Diseases) published by the World Health Organization.

Assessment is an ongoing process and may be important at other points dur-
ing treatment-for

example, to evaluate outcome. In the initial clinical assess- ment, an attempt is made to identify the main dimensions of a client's problem and to predict the probable course of events under various conditions. It is at this initial stage that crucial decisions have to be made-such

as what (if any)
treatment approach is to be offered, whether the problem will require hospital-
ization, to what extent family members will need to be included as co-clients,

and so on. Sometimes these decisions must be made quickly, as in emergency conditions, and without critical information. As will be seen, various psychologi- cal measurement instruments are employedto maximize assessment efficiencyin this type of pretreatment examination process (Beutler & Harwood, 2002).

A less obvious but equally important function of pretreatment assessment is establishing baselines for various psychological functions so that the effects of treatment can be measured. Criteria based on these measurements may be established as part of the treatment plan such that the therapy is considered successful and is terminated only when the client's behavior meets thesepre- determined criteria. Also, as we will see in later chapters, comparison of post- treatment with pretreatment assessment results is an essential feature of many research projects designed to evaluate the effectiveness of varioustherapies.

In this chapter, we will review some of themore com- monly used assessment procedures and show howthe data obtained canbe integrated into a coherent clinical picture for making decisions about referral and treat- ment. Our survey will include adiscussion of neurologi- cal andneuropsychological

assessment,the clinical
interview,
behavioral
observation,
and personality

assessment through theuseof projective and objective psychologicaltests.Later in this chapter wewill examine the process of arriving at a clinical diagnosis using DSM-IV-TR.

Let us lookfirst at what, exactly,a clinician is trying to
learnduring the psychologicalassessmentof a client.
THE BASIC ELEMENTS IN
ASSESSMENT
What does a clinician need to know? First, of course, the
presentingproblem,or major symptoms and behavior,
must be identified.Is it a situational problem precipitated
by some environmental stressor such asdivorce or unem-
ployment, a manifestation of a more pervasive and long-
term disorder, orsome combination of the two?Is there
any evidence ofrecentdeterioration in cognitive function-
ing? Whatis theduration of the current complaint and

howis the person dealing with the problem? What, if any, prior help has been sought? Are there indications of self- defeating behavior andpersonality deterioration, or isthe

individual using availablepersonaland environmental
resources in agoodeffortto cope?How pervasively has the
problemaffected the person's performance of important
social roles?Doestheindividual's symptomatic behavior
fit any of the diagnostic patterns in theDSM-IV-TR?
The Relationship between
Assessment and Diagnosis
It is importantto have anadequate classification of the

presentingproblem for a number of reasons. In many cases, aformal diagnosisis necessary beforeinsurance claims can be filed. Clinically, knowledge of a person's type ofdisorder canhelp inplanning andmanaging the appro-

priate treatment.Administratively, it is essentialto know
the range of diagnostic problems that are represented

among the patient orclient population and for which treatmentfacilities need to beavailable. If most patients at a facility have been diagnosed as having personality disor- ders, for example, thenthe staffing, physical environment,

and treatment facilities should be arranged accordingly.
Thus the nature of the difficulty needs to be understood as
clearly aspossible, including adiagnosticcategorization if
appropriate(see the section"Classifying Abnormal Behav-
ior" at the end of thischapter).
Taking a Social or Behavioral History
For mostclinical purposes, assigning a formal diagnostic
classification per seismuch less important than having a
clear understanding of the individual'sbehavioral history,

intellectual functioning, personality characteristics, and environmental pressures and resources. That is, an ade- quate assessment includes much more than the diagnostic label.Forexample, itshould includean objective descrip- tion of the person's behavior. How does the person charac- teristicallyrespond toother people? Are there excesses in behavior present,suchas eating or drinking too much? Are there notable deficits, forexample, in social skills? How appropriate is the person's behavior? Is the person mani- festing behavior thatisplainly unresponsive or uncooper- ative? Excesses, deficits, and appropriateness

are key
dimensions to be noted if theclinician is to understand the
particular disorder that has brought the individual to the
clinic or hospital.
PERSONALITY FACTORSAssessment should include a

description of any relevant long-term personality charac- teristics. Has the person typically responded in deviant ways to particular kindsof situations-for

example, those requiring submission to legitimateauthority? Are there personality traitsor behavior patterns that predispose the

individual tobehave in maladaptive ways? Does the person

tend to become enmeshedwith others to the point of los- ing his or her identity, or is he or she so self-absorbed that intimate relationships are not possible? Is the person able to accept helpfromothers? Is the person capable of gen- uine affectionand ofaccepting appropriate responsibility

for the welfareof others?Such questions are at the heart of
many assessmentefforts.
THE SOCIAL CONTEXT
It is also important toassess the
socialcontext in which the individual operates. What kinds
of environmental demandsaretypicallyplaced on theper-

son, andwhat supportsor special stressors exist in his or her life situation? For example, being the primary care- takerfora spouse suffering fromAlzheimer's disease isso challenging that relatively few people can manage the task

without significant psychological impairment, especially
where outside supportsarelacking.
The diverseandoften conflicting bits of information
about the individual'spersonalitytraits,behavior patterns,
environmental demands, and so on, must then be inte-
Some patients with cognitive deterioration are difficult to evaluate
and to provide health care, often requiring special facilities.
grated into a consistentand meaningful picture. Some
clinicians refer to this picture asa "dynamic formulation;'

because it not only describes the current situation butalso includes hypotheses about what is driving the person to behave in maladaptive ways. At this point in the assess- ment, theclinicianshould havea plausible explanation for why a normally passive and mild-mannered man suddenly flew into a rage andstarted breaking up furniture, for example. The formulationshould allowthe clinician to develop hypotheses about the client's future behavioras well. What is the likelihood of improvement or deteriora- tion if the person's problems are left untreated? Which behaviors should be the initial focus of change, andwhat treatment methods are likely to be mostefficientin pro- ducing this change? How much change might be expected from a particular type of treatment?

Where feasible, decisions about treatment are made collaboratively with the consent and approval of the indi- vidual. In cases ofsevere disorder, however, they may have to be made without the patient's participation or, in rare instances, even without consulting responsible family members. As has already beenindicated, knowledge of the patient's strengths and resources is important; in short, what qualities does the patient bring to treatment that can

enhancethechancesof improvement?
Because a wide range offactors can play important
rolesin causingand maintainingmaladaptivebehavior,

assessment may involve the coordinated use of physical, psychological, and environmentalassessment procedures. As we have indicated, however, the natureand comprehen- siveness ofclinical assessments vary withthe problemand the treatmentagency's facilities.Assessment by phone ina

suicide prevention center (Stolberg& Bongar,2002),for

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