Section 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 various methods of assessment.

3.1.1. What is Clinical Assessment?

In order for a mental health professional to be able to effectively treat a client and know that the selected treatment actually worked (or is working), they first must engage in the clinical assessment of the client. Clinical assessment refers to collecting information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews to determine what the person’s problems are and what symptoms they are presenting with. This collection of information involves learning about the client’s skills, abilities, personality characteristics, cognitive and emotional functioning, social context (e.g., environmental stressors), and cultural factors particular to them such as their language, race, or ethnicity. Clinical assessment is not just conducted at the beginning of the process of seeking help but all 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 determine to what extent the individual is adversely affected. Assuming treatment is needed, our second reason to engage in clinical assessment is to determine what treatment will work best. As you will see later in this chapter, there are numerous approaches to treatment.  These include Behavior Therapy, Cognitive Therapy, Cognitive-Behavioral Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological treatments (e.g., psychopharmacology). Of course, for any psychological 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 the clinician figure this out. Finally, we need to know if the treatment worked. This will involve measuring symptoms and behavior before any treatment is used and then measuring symptoms and behavior while the treatment is in place. They will even want to measure symptoms and behavior after the treatment ends to make sure symptoms do not return. Knowing what the person’s baselines are for different aspects of psychological functioning will help the clinician see when improvement occurs. It should be clear from this discussion that clinical assessment is an ongoing process that occurs prior to treatment, during treatment, and even after treatment.

3.1.2. Key Concepts in Assessment

Important to the assessment process are three critical concepts – reliability, validity, and standardization. Actually, these three are important to science in general. First, we want clinical 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 experiencing a psychological disorder. If one mental health professional says the person has 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 (e.g., mechanics, mental health professionals) are consistent in their assessments is called inter-rater 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 with one another, which is called test-retest reliability. An example is if the person takes the Minnesota Multiphasic Personality Inventory (MMPI) on Tuesday and then the same test on Friday, then 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. In other words, the two scores (test and retest) should be correlated with one another. If the test is reliable, the correlation should be very high (remember, correlations can range from -1.00 to +1.00 and a positive value 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 is supposed to measure. 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 correlated with the ones obtained by the BDI. This is called concurrent or descriptive validity. We might even ask if an assessment tool appears, on the surface, to measure what it is supposed to measure. 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. It, therefore, seems to measure personality.

A tool should also be able to accurately predict what will happen in the future, called predictive validity. 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 should be true of the Graduate Record Exam (GRE) and its ability to predict graduate school performance.

Finally, we want to make sure that the experience one client has when taking a test or being assessed is the same as another client 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 for administering and scoring the test, and is called standardization. Equally important is that mental health professionals interpret the results of the tests in a standardized manner otherwise it will be unclear what the meaning of a specific score is.

3.1.3. Methods of Assessment

So how are clients assessed? We will discuss the clinical interview, psychological tests, neurological tests, behavioral assessment, and a few others in this section.

3.1.3.1. The Clinical Interview

A clinical interview is a face-to-face encounter between a mental health professional and a client 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 are able to follow up on specific issues that catch their attention.

A mental status examination is used to organize the information collected during the interview and to systematically evaluate the client through a series of observations and questions assessing appearance and behavior (e.g., grooming and body language), thought processes and content (e.g.,  disorganized speech or thought and false beliefs), mood and affect (e.g., hopelessness or elation), intellectual functioning (e.g., speech and memory), and awareness of surroundings (e.g., does the client know where they are, when it is, and who they 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 examination is that it lacks reliability, especially when conducted during an unstructured interview.

3.1.3.2. Psychological Tests and Inventories

Psychological tests are used to assess the client’s personality, social skills, cognitive abilities, emotions, behavioral responses, or interests and can be administered either individually or to groups. Projective tests consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They include the Rorschach test or inkblot test and the Thematic Apperception Test which requires 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 these responses, the clinician gains perspective on the client’s worries, needs, emotions, and conflicts.  Another projective test is the sentence completion test which requires individuals to finish incomplete sentences. Examples include ‘My mother’ …. or ‘I hope.’  These tests have problems with reliability and validity and are not standardized. As such, they should be used more as icebreakers and to gain insights into specific preoccupations rather than as standardized assessment tools.

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 Minnesota Multiphasic Personality Inventory (MMPI) 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 are completed either on the computer or through paper-and-pencil. That said, personality cannot be directly assessed and so you can never completely know the individual on the basis of these inventories.

Other self-report inventories ask clients to rate a series of statements about various symptoms to indicate how severe they are and/or how often they occur. For instance, the Beck Depression Inventory-II (BDI-II) is a valid, reliable, and standardized self-report inventory used to assess depression. It contains 21 groups of statements (each group describes increasingly more severe symptoms of depression) and clients are asked to pick the one statement in each group that best describes how they have felt over the past 2 weeks. Scores of 20 or higher are generally indicative of clinical levels of depression and warrant further assessment to confirm that the client meets the diagnostic criteria for a depressive disorder. The DSM-5-TR recommends the use of the DSM-5 Level 1 Cross-Cutting Symptom Measure during the assessment phase as well as at periodic follow-up visits to assess changes in symptoms throughout the course of treatment. The adult version of the DSM-5 Level 1 Cross-Cutting Symptom Measure contains 23 questions that assess 13 mental health domains including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use. For each item, clients use a 0-4 rating scale to indicate how much (or how often) they have been bothered by the specific symptom during the past 2 weeks. Scores of 2 or higher on an item are indicative of a problem in that domain that warrants additional inquiry and follow-up to determine if a more detailed assessment is necessary which may include the using the DSM-5 Level 2 Cross-Cutting Symptom Measure or a clinical interview. There is also a child version of the DSM-5 Level 1 Cross-Cutting Symptom Measure measure that consists of 25 items measuring 12 mental health domains.

3.1.3.3. Neurological Tests 

Neurological tests are also used to diagnose cognitive impairments caused by brain damage, due to tumors, infections, head injury; or changes in brain activity. Positron Emission Tomography or PET is used to study the brain’s functioning and begins by injecting the patient with a radionuclide that collects in the brain. Patients then 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 (MRI) produces 3D images of the brain or other body structures using magnetic fields and computers. They are used to detect structural abnormalities such as 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 that are then combined. They are used to detect structural abnormalities such as brain tumors and brain damage caused by head injuries. MRI is generally preferred over CT scans since CT scans involve radiation.

3.1.3.4. Physical Examination

Many mental health professionals recommend the client see their family physician for a physical examination which is much like a check-up. Why is that? Some organic conditions, manifest behavioral symptoms that are similar to psychological disorders and so ruling such conditions out can save costly therapy or the prescription of inappropriate medication. For instance, hyperthyroidism (overactive thyroid) is a medical condition that can produce symptoms of mania that would not be amendable to treatment with lithium (which is often used to treat bipolar disorder).

3.1.3.5. Behavioral Assessment

Within the realm of behavior modification and applied behavior analysis, is behavioral assessment which is simply the measurement of a target behavior. The target behavior is whatever behavior we want to change and it can be in excess (needing to be reduced), or in a deficit state (needing to be increased). During behavioral assessment we assess the ABCs of behavior:

• Antecedents are the environmental events or stimuli that trigger behavior.
• Behaviors are what the person does, says, thinks/feels.
• 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 using self-monitoring which refers to measuring and recording one’s own ABCs. In the context of psychopathology, behavior modification can be useful in treating phobias, reducing habit disorders, and ridding the person of maladaptive cognitions.

A limitation of this method is that the process of observing and/or recording a behavior can cause 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 that is made in one situation may not be made in other situations, such as your significant other only acting out at their favorite team’s football game and not at home. This form of validity is called cross-sectional validity. 

3.1.3.6. Intelligence Tests

Intelligence testing is occasionally used to determine the client’s level of cognitive functioning. Intelligence testing consists of a series of tasks requiring the client to use both verbal and nonverbal skills. An example is the Stanford-Binet Intelligence test which is used to assess fluid reasoning, knowledge, quantitative reasoning, visual-spatial processing and working memory. These tests are rather time-consuming and require specialized training to administer. As such, they are typically only used in cases where there is a suspected cognitive disorder or intellectual disability. Intelligence tests have been criticized for not predicting future behaviors such as achievement and reflecting social or cultural factors/biases and not actual intelligence.