PSY650 Week Two Case Studies

You are a psychologist working for an agency whose policy states that an assessment and

diagnosis must be rendered within 48 hours of an initial session with a client. Please review and

choose one of the following cases to diagnose.

The Case of Amanda

Amanda is a 16-year-old Hispanic female that was referred to treatment due to body image issues.

Her parents believe that she has an eating disorder because she restricts her food intake and

exercises excessively. Amanda denies any compensatory behaviors, but reports the following

symptoms: anxiety, trouble sleeping through the night, and not feeling like a worthwhile person.

She has reservations about seeking treatment because confidentiality is not guaranteed. She has

agreed to attend the first session and opted to use insurance to pay for it. Her insurance company

will allot her 8 sessions upon receipt of her diagnosis. What diagnosis would you give Amanda?

The Case of Charles

Charles is a 33-year-old African American male seeking treatment due to suicidal ideation. He is

currently going through divorce proceedings and reports feeling agitated, angry, sad, and stressed

most days. He is concerned that his relationship issues have begun to impact his responsibilities at

work and fears losing his job. Charles is open to seeking treatment, but his insurance provider is

out-of-network. His insurance company is willing to reimburse him for up to 8 sessions if an

acceptable diagnosis is submitted. What diagnosis would you give Charles?

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DOI: 10.1037/14048-001 APA Handbook of Testing and Assessment in Psychology: Vol. 2. Testing and Assessment in Clinical and Counseling Psychology, K. F. Geisinger (Editor-in-Chief) Copyright © 2013 by the American Psychological Association. All rights reserved.

C h a P t e r 1

ClInICal and CounsElInG TEsTInG

Janet F. Carlson

Many clinical and counseling psychologists depend on tests to help them understand as fully as possible the clients with whom they work (Camara, Nathan, & Puente, 2000; Hood & Johnson, 2007; Masling, 1992; Naugle, 2009). A broad and comprehensive understanding of an individual supports decisions to be made by or regarding a client. Tests provide a means of sampling behavior, with results used to promote better decision making. Decisions may include such matters as (a) what diagnosis or diag- noses may be applicable, (b) what treatments are most likely to produce behavioral or emotional changes in desired directions, (c) what colleges should be considered, (d) what career options might be most satisfying, (e) whether an individual quali- fies for a gifted educational program, (f) the extent to which an individual is at risk for given outcomes, (g) the extent to which an individual poses a risk of harm to others or to himself or herself, (h) the extent to which an individual has experienced dete- rioration in his or her ability to manage important aspects of living, and (i) whether an individual is suitable for particular types of roles or occupations such as those that involve high risk or extreme stress or where human error could have catastrophic effects. The foregoing list is certainly not exhaustive.

The term assessment as used in clinical and counseling settings is a broader term than testing because it refers to the more encompassing integra- tion of information collected from numerous sources. Tests comprise sources of information that often contribute to assessment efforts. Discussion within this chapter focuses on procedures used in

clinical and counseling assessment, all of which provide samples of behavior and, thus, qualify as tests. The narrative begins with a consideration of how clinical assessment may be framed and then addresses briefly ethics and other guidelines perti- nent to assessment practices. Next, specific assess- ment techniques used in clinical and counseling contexts are reviewed, followed by a discussion of concerns related to interpretation and integration of assessment results. The chapter concludes with a section devoted to the importance of providing assessment feedback.

TRADITIONAL AND THERAPEUTIC ASSESSMENT

A diverse collection of procedures may be viewed as falling within the purview of clinical and counseling assessment (Naugle, 2009). The disparate array of procedures makes it somewhat difficult to appreciate commonalities among them, particularly for individu- als who are relatively new to the field of assessment. Although clinical and counseling assessment proce- dures take many forms, nearly all are applied in a manner that facilitates an intense focus on concerns of a single individual or small unit of individuals, such as a couple or family (Anastasi & Urbina, 1997). The clinician who works one-on-one with a client during a formal assessment effectively serves as data collector, information processor, and clinical judge (Graham, 2006). Procedures that may be adminis- tered to groups of people often serve as screening measures that identify respondents who may be at

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risk and, therefore, need closer clinical attention (i.e., further testing conducted individually).

The immediate goals of clinical and counseling assessment frequently address mental illness and mental health concerns. Testing can help practitio- ners to better address an individual’s mental illness or mental health needs by identifying those needs, improving treatment effectiveness, and tracking the process or progress of interventions (Carlson & Geisinger, 2009; Kubiszyn et al., 2000). Tests that assist clinicians’ diagnostic efforts also may be important in predicting therapeutic outcome (i.e., prognosis) and establishing expectations for improvement. On a practical level, testing can be used to satisfy insurance or managed care require- ments for evidence that supports diagnostic determi- nations or progress monitoring.

Within this basic framework, practitioners view the assessment process and their role within it dif- ferently. Indeed, some clinicians regard their role as similar to that of a technician or skilled tradesper- son. From this traditional vantage point, skillful assessment begins to develop during graduate train- ing, as trainees become familiar with the tools of the trade—tests, primarily. They learn about a variety of tests and how to use them. As trainees become practitioners, they accumulate experience with spe- cific tests and find certain tests more helpful to their work with clients than other tests. It is not surpris- ing that clinicians rely on tests that have proven most useful to them in their clinical work (Masling, 1992), despite test selection guidelines and stan- dards that emphasize the importance of matching tests to the needs of the specific client or client’s agent (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 1999; Eyde, Robertson, & Krug, 2010). As Cates (1999) observed, “the temp- tation to remain with the familiar [test battery] is an easy one to rationalize, but may serve the client poorly” (p. 637). It is important to note that the clinical milieu is fraught with immediate practical demands to provide client-specific information that is accurate, is useful, and addresses matters such as current conflicts, coping strategies, strengths and weaknesses, degree of distress, risk for self-harm,

and so forth. The dearth of well-developed tests to assess certain clinical features does not alleviate or delay the need for this information in clinical prac- tice. Thus, practitioners may find it necessary to do the best they can with the tools at hand.

Therapeutic assessment represents an alternative to traditional conceptualizations of the assessment process (Finn & Martin, 1997: Finn & Tonsager, 1997; Kubiszyn et al., 2000). In this contemporary framework, test givers and test takers collaborate throughout the assessment process and work as partners in the discovery process. Test takers have a vested interest in the initiation and implementation of assessment as well as in evaluating and interpret- ing results of the procedures used. Advocates of therapeutic assessment value and seek input from test takers throughout the assessment process and regard their perspectives as valid and informed. Rather than dismissing client input as fraught with self-serving motives and inaccuracies, practitioners who embrace the therapeutic assessment model engage clients as equal partners. This stance, together with the participatory role of the test giver, led Finn and Tonsager (1997) to characterize the process as an empathic collaboration in which tests offer opportunities for dialogue as well as interper- sonal and subjective exchanges. A more thorough discussion of therapeutic assessment and its applica- tion is given in Chapter 26, this volume.

TEST USAGE

A survey of clinical psychology and neuropsychology practitioners (Camara et al., 2000) indicated that clin- ical psychologists most frequently used tests for per- sonality or diagnostic assessment. The findings were consistent with those from an earlier study (O’Roark & Exner, 1989, as cited by Camara et al., 2000), in which 53% of psychologists also reported that they used testing to help determine the most effective ther- apeutic approach. Testing constitutes an integral component of many practitioners’ assessment efforts as practitioners report using formal measures with regularity. Ball, Archer, and Imhof (1994) reported results from a national survey of a sample of 151 clini- cal psychologists who indicated they provided psy- chological testing services. The seven most used tests

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Clinical and Counseling Testing

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reported by respondents were used by more than half of the practitioners who responded to the survey. In order, these tests included the Wechsler IQ scales, Rorschach, Thematic Apperception Test (TAT), Min- nesota Multiphasic Personality Inventory (MMPI), Wide-Range Achievement Test, Bender Visual Motor Gestalt Test, and Sentence Completion. Camara et al.’s (2000) sample comprising 179 clinical psycholo- gists reported remarkably similar frequencies of use, with the Wechsler IQ scales, MMPI, Rorschach, Bender Visual Motor Gestalt Test, TAT, and Wide- Range Achievement Test heading up the list. The pre- ceding reports notwithstanding, considerable evidence suggests that test usage is in decline (Ben- Porath, 1997; Camara et al., 2000; Garb, 2003; Eis- man et al., 2000; Meyer et al., 2001), whereas other researchers have noted a corresponding decline in graduate instruction and training in testing and assessment (Aiken, West, Sechrest, & Reno, 1990; Fong, 1995; Hayes, Nelson, & Jarrett, 1987).

The now ubiquitous presence of managed care in all aspects of health care, including mental health care, clearly influences practitioners’ use of tests (Carlson & Geisinger, 2009; Yates & Taub, 2003). As is true for health care providers generally, mental health care providers can expect reimbursement for services they provide only if those services can be shown to be cost effective and essential for effective treatment. In a managed care environment, practi- tioners no longer have the luxury of making unilat- eral decisions about patient care, including test administration. Clinical assessments that pinpoint a diagnosis and provide direction for effective treat- ment are reimbursable, within limits, and typically are considered by third-party payers as therapeutic interventions (Griffith, 1997; Kubiszyn et al., 2000; Yates & Taub, 2003). Moreover, a number of studies have demonstrated that clinical tests have therapeu- tic value in and of themselves (Ben-Porath, 1997; Finn & Tonsager, 1997) and encourage their use as interventions.

STANDARDS, ETHICS, AND RESPONSIBLE TEST USE

Counseling and clinical psychologists who conduct assessments must maintain high standards and abide

by recommendations for best practice. In short, their assessment practices must be beyond reproach. Considering the important and varied uses to which assessment results may be applied, it is not surpris- ing that an array of rules, guidelines, and recom- mendations govern testing and assessment practices. For many years, the Standards for Educational and Psychological Testing (AERA, APA, & NCME, 1999) have served several professions well as far as delin- eating the standards for test users as well as for test developers, and clinical and counseling psycholo- gists must adhere to ethical principles and codes of conduct that influence testing practices.

The APA’s Ethical Principles of Psychologists and Code of Conduct (APA Ethical Principles; APA, 2010) addresses assessment specifically in Standard 9, although passages relevant to assessment occur in several other standards, too. The 11 subsections of Standard 9 address issues such as use of tests, test construction, release of test data, informed consent, test security, test interpretation, use of automated services for scoring and interpretation, and commu- nication of assessment results. In essence, the stan- dards demand rigorous attention to the relationship between the clinician (as test giver) and the client (as test taker) from inception to completion of the assessment process. Ultimately, practitioners must select and use tests that are psychometrically sound, appropriate for use with the identified client, and responsive to the referral question(s). Furthermore, clinicians retain responsibility for all aspects of the assessment including scoring, interpretation and explanation of results, and test security, regardless of whether they choose to use other agents or ser- vices to carry out some of these tasks.

The Standards for Educational and Psychological Testing (AERA, APA, & NCME, 1999) and Standard 9 of the APA Ethical Principles (APA, 2010) provide sound guidance for counseling and clinical psycholo- gists who provide assessment-related services. A number of other organizations concerned with good testing practices have official policy statements that offer additional assistance to practitioners seeking further explication of testing-related guiding princi- ples or whose services may extend to areas beyond traditional parameters. The policy statements most likely to interest counseling and clinical

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psychologists include the ACA Code of Ethics (Ameri- can Counseling Association, 2005), Specialty Guide- lines for Forensic Psychology (Committee on the Revision of Specialty Guidelines for Forensic Psychol- ogy, 2011), Principles for Professional Ethics (National Association of School Psychologists, 2010), and the International Guidelines for Test Use (International Test Commission, 2001). In addition to the forego- ing, many books about ethics in the professional practice of psychology include substantial coverage of ethical considerations in assessment (e.g., Cottone & Tarvydas, 2007; Ford, 2006). A particularly accessible volume by Eyde et al. (2010) provides expert analysis of case studies concerning test use in various settings, including mental health settings, and illustrating real- life testing challenges and conundrums.

ASSESSMENT METHODS

As in all assessment endeavors, tasks associated with assessment in clinical and counseling psychology involve information gathering. Clinical and counsel- ing assessments typically comprise evaluations of individuals with the goal of assisting an individual client in some manner. To determine the best way to help an individual, clinicians rely on comprehensive assessments that evaluate several aspects of an indi- vidual’s functioning. Thus, most such assessments involve collecting information using a variety of assessment techniques (e.g., interviews, behavioral observations). Moreover, the use of multiple proce- dures (e.g., tests) facilitates the overarching goal of clinical and counseling assessment and also reso- nates with the important principle of good testing practice. Specifically, Standard 11.20 of the Stan- dards for Educational and Psychological Testing (AERA, APA, & NCME, 1999) states that, in clinical and counseling settings, “a test taker’s score should not be interpreted in isolation; collateral informa- tion that may lead to alternative explanations for the examinee’s test performance should be considered” (p. 117). It follows that inferences drawn from a sin- gle measure must be validated against evidence derived from other sources, including other tests and procedures used in the assessment.

Counseling and clinical assessment methods vary widely in their forms. The means of identifying what

information is needed and gathering relevant evi- dence may include direct communications with examinees, observations of examinees’ behavior, input from other interested parties (e.g., family members, peers, coworkers, teachers), reviews of records (e.g., psychiatric, educational, legal), and use of formal measures (i.e., tests). Interviews, behavioral observations, and formal testing proce- dures represent the primary ways of obtaining clini- cally relevant information.

Interviewing Intake or clinical interviews often represent a first point of contact between a client and a clinician in which information that contributes to clinical assessment surfaces. Many important concerns must be handled effectively within what is probably no more than a 50-minute session. Beyond practical (e.g., scheduling, billing, emergency contact infor- mation) and ethical (e.g., informed consent, confi- dentiality and its limits) matters, the practitioner must accurately grasp and convey his or her under- standing of the issues to the client. If this under- standing captures the client’s concerns, then it likely helps the client to believe that his or her problems can be understood and treated by the clinician. If the practitioner’s understanding of the client’s issues is not accurate, then the client has the opportunity to provide additional information that represents his or her concerns more accurately. At the same time and somewhat in the background, the clinician exudes competence and concern in a manner that inspires hope and commitment, while, in the fore- ground, he or she establishes a fairly rapid yet accu- rate appraisal of the client’s issues and concerns. Effective treatment depends on the establishment of rapport sufficient to suggest that a productive work- ing relationship is possible along with an appraisal that accurately reflects the severity of the concerns expressed and disruptions in the client’s ability to function on a day-to-day basis as well as attendant risks. For a more complete discussion, readers can consult Chapter 7, this volume, concerning clinical interviewing.

Many intake procedures involve clinical inter- viewing that is somewhat formalized by the use of a structured format or questionnaire. The quality of

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intake forms varies widely, partly as a function of how they were developed. For example, clinicians may complete an intake form developed or adopted by the facility in which he or she works. Such forms generally include questions about the client’s cur- rent concerns (e.g., “presenting problem” or “chief complaint”) as well as historical information that may bear on the client’s status (e.g., history of previ- ous treatment, family history, developmental his- tory). Depending on the quality of the intake form, practitioners may find it necessary to supplement the information collected routinely through comple- tion of the form. In the appendices of her book, The Beginning Psychotherapist’s Companion, Willer (2009) offers several lists of intake questions that may be used to probe specific areas of concern that may surface during the collection of intake informa- tion (e.g., depression and suicide, mania, substance use). Advisable in all clinical settings and essential in clinical settings that provide acute and crisis ser- vices, intake procedures must address the extent to which the client poses a danger to others or to him- self or herself.

Intake interviews may be considered semistruc- tured if they address specific content uniformly from one client to the next but are not tightly “scripted” as are structured interviews. According to Garb’s (2005) review, semistructured interviews are more reliable than unstructured clinical interviews, most likely because of the similarity of content (if not actual test items) across interviewers. An example of a semistructured technique is the mental status examination (MSE), which refers to a standardized method of conducting a fairly comprehensive inter- view. The areas of mental status comprising an MSE are summarized in Table 1.1. Many MSE elements may be evaluated through unobtrusive observations made during the meeting or through verbal exchanges that occur naturally in ordinary conversation.

The semistructured nature of the MSE ensures coverage of certain vital elements of mental status but is flexible enough to allow clinicians to ask follow-up questions if he or she believes it is neces- sary or helpful to do so. The MSE is used by a wide variety of mental health providers (counseling and clinical psychologists as well as social workers,

psychiatrists, and others) and typically is completed at intake or during the course of treatment to assess progress. There are several versions of the MSE, including standardized and nonstandardized forms (Willer, 2009). An example of a structured diagnos- tic interview is the Structured Clinical Interview for the DSM–IV–TR (SCID; First, Spitzer, Gibbon, & Williams, 2002), where DSM–IV–TR refers to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Associ- ation, 2000). Completion of the SCID allows practi- tioners to arrive at an appropriate psychiatric diagnosis.

Regardless of whether an initial clinical contact calls for formal assessment, a crucial area to evaluate during one’s initial interactions with clients is the presence of symptoms that indicate risk of harm to self or others. “Assessing risk of suicide is one of the most important yet terrifying tasks that a beginning clinician can do” (Willer, 2009, p. 245) and consti- tutes the ultimate high-stakes assessment. It is also frequently encountered in clinical practice (Stolberg & Bongar, 2002). Multiple factors contribute to overall risk status either by elevating or diminishing risk. Bauman (2008) describes four areas to examine when evaluating risk of suicide: (a) short-term risk factors, including stressors arising from environ- mental sources and mental health conditions; (b) long-term precipitating risk factors, including genetic traits or predispositions and personality traits; (c) precipitating events, such as legal matters, significant personal or financial losses, unwanted pregnancy, and so forth; and (d) protective factors or buffers, such as hope, social support, and access to mental health services. An individual’s overall risk of suicide represents a combination of risks emanating from the first three elements, which ele- vate overall risk, adjusted by the buffering effect of the last element, which reduces overall risk.

In practice, assessment of suicide risk relies heav- ily on clinical interviewing (Stolberg & Bongar, 2002). Specific tests designed to assess suicide risk, such as the Beck Hopelessness Scale (Beck, 1988) and the Suicide Intent Scale (Beck, Schuyler, & Her- man, 1974), appear to be used infrequently by prac- titioners (Jobes, Eyman, & Yufit, 1990; Stolberg & Bongar, 2002). Assessment of risk must consider

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several features of risk beyond its mere presence including immediacy, lethality, and intent. Immedi- acy represents a temporal consideration with higher levels of immediacy associated with imminent risk— a state of acute concern for the individual’s life. Assessment of imminent risk involves consideration of several empirically derived risk factors including (a) history of prior attempts (with recent attempts given greater weight than attempts that occurred longer ago); (b) family history of suicide or attempt; and (c) presence of mental or behavior disorders such as substance abuse, depression, and conduct disorder. Imminent risk is accelerated by an inability to curb impulses and a need to “blow off steam,”

which constitute poor prognostic signs. Lethality refers to the possibility of death occurring as a result of a particular act. In assessing risk of suicide, the act in question is one that is planned or contem- plated by the client. Use of firearms connotes higher lethality than overdosing on nonprescription drugs (e.g., aspirin). Lethality differs from intent, which refers to what the person seeks to accomplish with a particular act of self-harm. Serious suicidal intent is not necessarily associated with acts of high lethality.

Behavioral Observations One of the earliest means by which assessment information begins to accumulate is the test taker’s

TABLE 1.1

Major Areas Assessed During a Mental Status Examination

Area Content

Appearance The examiner observes and notes the person’s age, race, gender, and overall appearance. Movement The examiner observes and notes the person’s gait (manner of walking), posture, psychomotor excess or

retardation, coordination, agitation, eye contact, facial expressions, and similar behaviors. Attitude The examiner notes client’s overall demeanor, especially concerning cooperativeness, evasiveness, hostility,

and state of consciousness (e.g., lethargic, alert). Affect The examiner observes and describes affect (outwardly observable emotional reactions), as well as

appropriateness and range of affect. Mood The examiner observes and describes mood (underlying emotional climate or overall tone of the client’s

responses). Speech The examiner evaluates the volume and rate of speech production, including length of answers to questions,

the appropriateness and clarity of the answers, spontaneity, evidence of pressured speech, and similar characteristics.

Thought content The examiner assesses what the client says, listening for indications of evidence of misperceptions, hallucinations, delusions, obsessions, phobias, rituals, symptoms of dissociation (feelings of unreality, depersonalization), or thoughts of suicide.

Thought process The examiner assesses thought processes (logical connections between thoughts and how thoughts connect to the main thread or gist of conversation), noting especially irrelevant detail, verbal perseveration, circumstantial thinking, flight of ideas, interrupted thinking, and loose or illogical connections between thoughts that may indicate a thought disorder.

Cognition The evaluation assesses the person’s orientation (ability to locate himself or herself) with regard to person, place, and time; long- and short-term memory; ability to perform simple arithmetic (e.g., serial sevens); general intellectual level or fund of knowledge (e.g., identifying the last several U.S. presidents, or similar questions); ability to think abstractly (explaining a proverb); ability to name specific objects and read or write complete sentences; ability to understand and perform a task with multiple steps (e.g., showing the examiner how to brush one’s teeth, throw a ball, or follow simple directions); ability to draw a simple map or copy a design or geometrical figure; ability to distinguish between right and left.

Judgment The examiner asks the person what he or she would do about a commonsense problem, such as running out of shampoo.

Insight The examiner evaluates degree of insight (ability to recognize a problem and understand its nature and severity) demonstrated by the client.

Intellectual The examiner assesses fund of knowledge, calculation skills (e.g., through simpl

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