Assessment And Diagnosis “Under The Gun”

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DOI: 10.1037/14048-002 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 2

ThE assEssmEnT ProCEss Sara Maltzman

This chapter reviews the historical purposes of psy- chological assessment, the components and process of psychological assessment, current issues, and emerging trends. In keeping with the emphases of this handbook, the discussion focuses on the use of assessments and the assessment process within clini- cal, counseling, and forensic psychology.

THE HISTORY OF PSYCHOLOGICAL ASSESSMENTS

McGuire (1990) traced the development of formal psychological testing to James McKean Cattell in the 1890s and early 20th century. McGuire noted that Cattell and the first few experimental psychologists who came to define themselves as clinical psycholo- gists advocated for education, training, and the establishment of professional standards for the assessment of intellectual and personality function- ing. Thus, the assessment and diagnosis of intellec- tual functioning and personality were the fundamental functions of clinical psychologists. Witmer, who made significant contributions to the development of clinical, developmental, and educa- tional psychology, established the first psychological clinic in 1896 (Baker, 1988). The clinic assessed and treated children who presented with possible mental retardation, learning disabilities, or emotional concerns that prevented attainment of their academic potential. Witmer utilized a multidimensional, functional approach that included a comprehensive psychosocial history taking as well as behavioral observations in multiple environments (e.g., home, school) over time.

A physician completed the physical examination, and often the behavioral observations were made by a social worker. These data were summarized into an integrative assessment of the child’s deficiencies, along with treatment recommendations (Baker, 1988). Thus, a primary focus within clinical psy- chology at the beginning of the 20th century was the multimodal assessment, diagnosis, and treatment of children and youths.

The treatment recommendations made for these youths often included vocational direction (Baker, 2002). With the stock market crash and high unem- ployment of the 1930s, the vocational needs of adults began to predominate and the vocational assessment of youths transitioned to adult voca- tional counseling and later into the field of counsel- ing psychology for adults (Baker, 2002; Super, 1955). The assessment of aptitudes as well as of abil- ities emerged out of the necessity to assist the unem- ployed. At the same time, Rogerian theory and its associated nondirective, client-centered therapeutic approach began to emerge. The Rogerian approach was applied to vocational counseling in recognition that such an orientation was theoretically compati- ble with counseling focused on the achievement of vocational aspirations (Super, 1955). These three foci—the assessment of aptitudes, the assessment of abilities, and a Rogerian conceptualization of the person and the therapeutic relationship—converged into a cohesive approach for addressing the psycho- social concerns of the unemployed. Over time, this approach was modified to address the needs of returning World War II (WWII) veterans and to

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assist them in maximizing their psychosocial strengths. Addressing the vocational, educational, and adjustment needs of returning WWII veterans led to the establishment of counseling psychology as a distinct position within the U.S. Veterans Admin- istration (VA) system (Meara & Myers, 1999). To meet the needs of returning veterans, the VA encouraged the American Psychological Association (APA) to accredit counseling as well as clinical psy- chology programs to ensure the training of compe- tent psychologists for the VA system. The VA also was instrumental in encouraging the development of university-based counseling centers to assist veter- ans with educational and work-related adjustment issues (Meara & Myers, 1999). For these reasons, counseling psychology has historical roots and expertise in career and vocational counseling. Assessments in these areas consider individual dif- ferences in career development needs, interests, and barriers to career or employment (Armstrong & Rounds, 2008; Whiston & Rahardja, 2008). Coun- seling psychologists are in a unique position to address the mental health, educational, and career- planning needs of military veterans and their fami- lies because of this historical role and the number of counseling psychologists in college and university settings (Danish & Antonides, 2009).

Currently, one of the primary distinctions between clinical and counseling psychology is the historical focus in clinical psychology on research and practice in the assessment, diagnosis, and treat- ment of clients with significant psychopathology and emotional disorders. Forensic psychology devel- oped as a subdiscipline within clinical psychology. Although the provision of legal testimony by psy- chologists dates back to the 1900s, it was not until 2001 that the APA formally recognized forensic psy- chology as a distinct psychological specialty (Ogloff & Douglas, 2003). In comparison, counseling psy- chology historically has focused on leveraging and maximizing psychosocial functioning and strengths in individuals who are not experiencing significant psychopathology but are experiencing transitional life stressors (Meara & Myers, 1999).

Thus, the development of clinical and counseling psychology initially was based on the needs of dis- tinct populations. Over time, each discipline has

expanded in scope, and each has contributed to assessment process research and practice on the basis of the respective specialty’s history and strengths.

THE PURPOSE OF THE PSYCHOLOGICAL ASSESSMENT

The purpose of a psychological assessment is to answer particular questions related to an individu- al’s intellectual, psychological, emotional–behavioral, or psychosocial functioning, or some combination of these domains. These questions are determined by the assessment context and referral source. As Fernandez-Ballesteross (1997) described, a psycho- logical assessment typically is driven by a particular problem or referral question. A psychological assess- ment includes more than psychological testing. His- torically, the purpose of a psychological assessment has been to gather information directly from the cli- ent, obtain collateral information, administer psy- chological test instruments, interpret the test results, and provide a conceptualization of the client that integrates the test data with the collateral and interview data. This conceptualization is summa- rized, a diagnosis or diagnostic rule-out is offered (as applicable), and recommendations are made for consideration related to decision-making (e.g., in career- or education-related choices, personnel decision-making, or parental capacity assessments) and, where appropriate, for treatment. In contrast, psychological testing is one component of a psycho- logical assessment. It is measurement oriented. The purpose of testing is to provide a standardized administration of an instrument that has research evidence substantiating the reliability of its scores and the validity of these scores in identifying, quan- tifying, and describing particular characteristics or abilities when used with a specified population within a specified context. These test scores are interpreted within the context of the client’s history and the additional data gathered as part of the assessment process.

THE ASSESSMENT PROCESS

Weiner (2003) described the assessment process as consisting of three phases: information input,

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information evaluation, and information output. Each is described here.

Information Input Information input is the collection of information. It is influenced by the assessment context, referral questions, and referral source. These factors inform why the assessment is requested and what questions are expected to be answered. Such a contextual assessment considers the client’s culture and lan- guage proficiency when selecting instruments and interpreting instrument scales (Butcher, Cabiya, Lucio, & Garrido, 2007). The referral source and assessment context also influence which instru- ments are appropriate for use. For example, some instruments appropriate for personality assessment in an outpatient counseling or clinical setting have been found to be inappropriate in a forensic setting because of compromised validity (Carr, Moretti, & Cue, 2005). Selecting appropriate instruments, on the basis of the client’s cultural context and the referral context, is the first step in ensuring that the assessment provides valid results for answering the particular referral questions for that particular indi- vidual (e.g., Perlin & McClain, 2009).

The Assessment Context and Referral Questions The referral questions addressed by the assessment are determined by the assessment context. The assessment context also determines the potential sources of collateral information. In turn, the con- text and referral source determine what requisite education, training, and supervised experience are necessary to conduct the assessment as well as which additional professional standards and guide- lines for specialized practice might be applicable.

The assessment context and referral source rep- resent key factors in determining which formal instruments are appropriate, on the basis of the nor- mative sample and ability to identify response pat- terns. For example, the Millon Clinical Multiaxial Inventory (MCMI; Millon, 1977) was normed and standardized on clients engaged in mental health services. It was not normed on a general population standardization sample (Butcher, 2009). The test developers subsequently reported that the third

edition of the MCMI (MCMI-III; Millon, 1994) later was normed on a large sample of newly incarcerated prison inmates for the purpose of predicting adjust- ment to prison and treatment needs while incarcer- ated. However, the use of the MCMI-III with populations outside of these standardization sam- ples and for other purposes would be questionable (Butcher, 2009). For further discussion of self- report inventories (and the MCMI-III in particular), readers are referred to Chapter 11, this volume.

Conducting assessments consistent with profes- sional standards and guidelines necessitates staying current with the relevant research. For example, Carr et al. (2005) reported that the Personality Assessment Inventory (PAI; Morey, 1996, as reported in Carr et al., 2005) failed to detect positive self-presentation bias adequately in a sample of 164 parents completing capacity evaluations. This find- ing suggests that caution should be used in consid- ering the PAI for this type of assessment. However, Boccaccini, Murrie, and Duncan (2006) reported that the PAI Negative Impression Management scale performed as well as the comparison scale (Minne- sota Multiphasic Personality Inventory—2 [MMPI–2] F scale) in screening for malingering in a sample of defendants undergoing pretrial evaluations in fed- eral criminal court. Although cross-validation of the results of both studies is important for verifying these conclusions, they underscore the point that an instrument may be appropriate for addressing the referral question in one population yet not perform adequately when the referral question changes and the population differs. Thus, psychologists must pay particular attention to the specific population char- acteristics, context, and referral questions when selecting test instruments.

Standards and guidelines specific to the type of assessment required and population assessed pro- vide guidance for the selection of appropriate instru- ments. For example, the APA’s Guidelines for Psychological Practice with Older Adults (2003) rec- ommend an interdisciplinary approach to the assess- ment of psychological functioning in older adults. Such an approach facilitates consideration of medi- cation effects and medical conditions on cognitive and emotional functioning. Additional assessment considerations pertinent to this population include

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behavioral analyses to identify potential inappropri- ate or harmful behaviors and interventions to address these behaviors, and a repeated-measures approach to distinguish between stable cognitive and emotional characteristics versus characteristics that are temporally or situation dependent.

The APA (2009) also has issued guidelines for child custody evaluations. A custody evaluation is requested most often when the dissolution of the partner relationship is contentious. What is signifi- cant about these evaluations is that the parental assessment is from the perspective of the best psy- chological interests of the child. The psychologist’s role is to provide an impartial opinion that addresses the ability of the parent to provide caretaking con- sistent with the child’s best interests. This task requires that professional opinions or recommenda- tions are based on sufficient objective data to sup- port the psychologist’s conclusions (Martindale & Gould, 2007). The assessment assists the court in decision-making concerning the parent’s role regarding the physical care, access to, and legal decision-making for the child (APA, 2009).

Parental capacity assessments often are requested in juvenile dependency cases to determine whether a parent’s mental health concerns are so severe and incapacitating that the parent cannot safely parent the child or the parent is unable to benefit from ser- vices to mitigate the risk of future abuse or neglect of the child. Such assessments require not only req- uisite education, training, and experience in assess- ing serious mental illness, including character pathology, but an understanding of judicial and administrative regulations and timelines. Relevant guidelines include the Guidelines for Psychological Evaluations in Child Protection Matters (APA, 2011) and the Specialty Guidelines for Forensic Psychology (APA, in press). Additional information concerning legal issues in clinical and counseling testing and assessment is provided in Chapter 6, this volume.

Information Evaluation Information evaluation refers to the interpretation of the assessment data (Weiner, 2003). Accurate interpretation of testing data requires that the psychologist interpret instrument responses and scores according to the test developer’s instructions.

The general standards and guidelines applicable to conducting psychological assessments across set- tings and the interpretation of test data include the Standards for Educational and Psychological Testing (American Educational Research Association, APA, & National Council on Measurement in Education, 1999, currently under revision) and the Ethical Prin- ciples of Psychologists and Code of Conduct (APA, 2010). The psychologist should consult additional relevant professional standards and guidelines on the basis of the referral source, assessment context, and client characteristics.

An evaluation of the assessment data involves more than scoring and interpreting the instruments administered during the data collection phase of the assessment. The evaluation of assessment data requires a critical evaluation and synthesis of the testing data with the collateral data within the con- text of the specific referral: the reason for the assess- ment, the referral source, and referral questions (APA, 2010). Ideally, the psychological assessment utilizes a multidimensional, multisource approach (Allen, 2002; Lachar, 2003) consistent with the multitrait–multimethod matrix developed for con- struct validation by Campbell and Fiske (1959). A multidimensional, multisource approach entails obtaining formal collateral data by persons close to the client (e.g., family, teacher, probation officer, pro- tective services worker) by means of interview, records, or standardized instruments. Mental health records, school report cards, court reports, and crimi- nal history logs are examples of collateral records. The clinical interview of the client and behavioral observations during the assessment process are addi- tional important sources of data. All of these data pro- vide both convergent and divergent data that can be integrated, synthesized, and summarized to address the referral question. Disconfirming data are particu- larly useful for guarding against the influence of bias and in assisting in the development of an objective conceptualization of the client (Meyer et al., 2001).

The clinical interview. The client in interview is a central component of the psychological assessment. An unstructured clinical interview allows the psy- chologist to obtain psychosocial history, psychiatric symptomatology, and the perceived rationale for

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the assessment from the client’s perspective. These data reflect the client’s particular perspective and can be compared with test data and collateral infor- mation to assess consistency or divergence across data sources. However, if collateral data are scant or missing, an unstructured interview loses the value of reflecting the client’s perspective as clinically relevant information. The unstructured interview may not query symptomatology in a systematic manner. Structured and semistructured interview formats typically include critical diagnostic criteria to facilitate differential diagnosis. Client symptoms are assessed and scores are compared against norma- tive data. However, semistructured and structured interviews still rely on client self-report without the ability to assess response style and test-taking atti- tude. Thus, all three interview formats are subject to distortion and response bias (Bagby, Wild, & Turner, 2003). Because of this shortcoming, inclusion of formal testing is recommended for inclusion in psy- chological assessments.