When I teach abnormal psychology, I often start out by asking my students to brainstorm various symptoms and signs of the particular disorder we are discussing for that lesson. This has gone a lot less smoothly than I initially thought. Students come up with a few key components, but not many or even most signs or symptoms. They typically are unable to paint me a picture of what a particular disorder actually looked like in the real world. Of course, I realize that my job as their professor is to teach them how to do this. A few guiding questions are usually helpful such as, "What exactly does PTSD look like?" or "How would someone with PTSD behave, think, or feel differently than someone without PTSD?" After we derive a fairly comprehensive list of indicators, I put a crucial and core question of psychology right back to them:
Professor: How do you know that these people are behaving, thinking, or feeling the way you describe? This usually elicits a long silence with many strange looks.
Students: What do you mean?
Professor: How do you know your uncle the Vietnam veteran acts wound up and irritable?
Students: He yells a lot, he tells us he is pissed off all the time, and he's always jumpy, looking over his shoulder or out the window.
Professor: That's what I mean. You know that people are behaving, thinking, or feeling in a particular way because you have observed, recorded, or measured these variables in some way.
At the heart of psychology and clinical practice is systematic and scientific measurement, and psychological assessment is the means by which this is achieved. What is being measured? Human psychological phenomena within a biopsychosocial model are being measured (thoughts, feelings, personality characteristics, physiological reactivity, etc.). There are numerous data gathering and measurement methods and procedures, including the following:
Interviews (e.g., structured or semistructured interviews)
Observation (e.g., behavioral observation or mental status exam)
Questionnaires (e.g., self-report, clinician administered, or third-party sources)
Projective tests (e.g., TAT or the Rorschach Inkblot Test)
Objective tests (e.g., intelligence, neuropsychological, personality, cognitive)
Psychobiological measures (e.g., EEG, MRI, blood tests, or electrophysiological)
Before we go on, a key distinction needs to be made between psychological evaluation and psychological assessment. Psychological evaluation is a broader term and a procedure that may or may not include psychological assessment. The evaluation process involves collection of relevant data and subsequent case formulation for the purpose of arriving at a diagnosis, setting up a treatment plan, making recommendations, or answering relevant referral questions. Psychological assessment involves the use of psychological instruments, such as questionnaires and tests, and is a subcomponent of the evaluation process. Not all evaluations include psychological assessment, however. Psychological assessment as part of the evaluation process is considered a critical component to the study and treatment of PTSD. Clarity in identification and diagnosis is often difficult with PTSD because of the complex nature of symptoms and difficulties of individual patients or clients. As was discussed in Chapters 3 and 8, the wide range of posttraumatic consequences and complications, including comorbid disorders, taxes researchers' and clinicians' abilities to grasp what exactly they are dealing with in any particular case. Human psychological functioning is extremely complex, and the naked clinical eye often requires help in seeing clearly or seeing what cannot be seen upon initial presentation. Here, power and utility of psychological assessment is demonstrated. Psychological assessment is simply a more formal and systematic approach to evaluation as Maloney and Ward (1976) state: "[Psychological assessment is] an extremely complex process of solving problems (answering questions) in which psychological tests are often used as one of the methods of collecting relevant data" (p. 5).
Relevant questions are derived from your general clinical model and orientation and your typical clinical method. Let me make a quick point about clinical method. Formal evaluation and psychological assessment is a particular method of psychological science. Other sciences and practices have different methods, techniques, and tools for evaluation. Psychologists use psychological tests as tools of observation. Orthopedists use X-rays. Microbiologists use microscopes. Astronomers use telescopes.
Let's get back to the issue of orientation for a minute. Consider that different clinicians of different orientations may not want to measure the same variables or gather the same data. Of course, sound clinical practice dictates that some information should be universally gathered, but we will return to this issue in a moment. A cognitive therapist may not want to measure a patient's object relations the way a psychodynamic-oriented clinician might. The key thing to remember is that the purpose of assessment should drive the particular variables being measured.
Assessment aids in the establishment of an accurate diagnosis and facilitates professional communication and reliability. This is particularly important in forensic evaluations when the presence of PTSD in a particular individual may be in dispute and a professional's method for arriving at his or her conclusions are closely scrutinized.
Psychological assessment and testing is a complicated endeavor that should only be undertaken and utilized by qualified professionals. Evaluation and assessment results should always be safeguarded against abuse or misuse, and issues of confidentiality and test security should always be observed and maintained. The following is quick summary of established ethical guidelines:
■ Only valid, reliable, and appropriately normed instruments should be used.
■ Only qualified professionals should administer, score, and interpret instruments.
■ Test results should be safeguarded against abuse or misinterpretation.
■ Professionals should respect the privacy of persons being evaluated and assessed and only examine what is clinically relevant. No psychological voyeurism!
■ Persons being evaluated should be properly informed and formally consent to the evaluation process, with the ability to withdraw or stop the process at any time.
■ Confidentiality shall be observed and maintained at all times.
■ Results shall be presented and communicated in a meaningful, effective, and useful manner to the consumer of the results.
The Importance of Norms, Validity, and Reliability
All assessment instruments are developed by administering a particular procedure or set of questions to a given group of people, the norm, to establish a comparative and distributive performance level for that particular instrument. An instrument developed on veterans for use with veterans should not be used with children, for example. Using a test on persons that are not part of the norming sample yields meaningless and useless results. Always be aware if you are comparing apples to oranges or oranges to apples, and so on! If an instrument's norming parameters are not observed, the results are essentially not valid.
Validity refers to the issue of whether a particular instrument is measuring what it purports to be measuring. If I develop a test to measure intelligence but it is never put through the rigors of establishing its validity, I may not be measuring intelligence at all but some other variable. Or I might not be measuring anything at all.
That brings us to the issue of reliability. Validity refers to measuring what we think we are measuring, and reliability refers to the issue of whether a person's performance or score on a particular instrument reflects their actual performance or some source or error inherent in the test. We want to measure the person taking the test, not the test's inability to capture the person's performance. Test scores and performances tell us the measurable difference between person A and person B. If a test is unreliable, then we may not be able to trust that the difference between person A and person B is due to the actual measured construct or due to some error produced by factors inherent in the instrument or method. If I measure the height of a wall three times and get three different measurements each time, I am not a very reliable wall-height measurer. This is, unfortunately, a true example!
Getting started first requires the selection of a given method, technique, and instrument. In order to do so, the clinician needs to consider the following questions and issues:
1. What is the setting? (clinic, school, jail, etc.)
2. What questions are being asked, by whom are the questions being asked, and what is the purpose of the evaluation?
3. What is the person reporting?
The setting in which a particular evaluator or assessor works will determine the extent, degree, and particular method utilized in the process. If I am a crisis worker in the field going door to door looking for people who might need psychological first aid, crisis intervention, or more comprehensive treatment, I am not going to carry around with me a suitcase full of psychological tests and sit each person down for 2 to 4 hours of testing. I might bring a simple questionnaire or no instruments at all. In addition to the issues of norms, validity, and reliability, the appropriateness of a particular method, technique, or tool is determined by the setting, the urgency of which the relevant questions need to be answered, and the ability of the person or persons being evaluated to engage in the process. Time frames are important and so is the ability of a particular person to engage in the evaluation and assessment process. Whether you have the required time and whether the examinee is actually testable (e.g., are they hearing impaired, visually impaired, acutely psychotic, etc.?) are very important determinants in the process. Make sure you can get the information you are looking for in the time allowed, and make appropriate adaptations and adjustments. Whether you choose to use an informal, unstructured interview or a 2hour pencil-and-paper test will be determined by these factors. A test that requires a patient to read may be useless if the person in question does not read at a requisite level, for example.
The second question addresses the issue of the referral question and referral source. The method employed by a clinician (or even a researcher) will depend on what the important and relevant parties want to know. The referring party can be the patient (i.e., self-referral); you, the clinician; or some third party, such as an employer, judge, or agency. Don't measure personality if you're asked for mental status, for example.
Finally, in the third question—what the person(s) being evaluated presents in observation, self-report, report by third party, or through documentation or records—will determine the method and instrument(s) used. You may assess for depression if someone presents with anxiety, but if they are reporting anxiety, your focus in going to center on the most salient issues and only then work your way out from there. Start with what is central and then work your way outward.
Once the clinician has the answers to these questions and methods and instruments have been selected, the actual process can begin in a stepwise fashion, employing relevant techniques and arriving at appropriate and valid conclusions.
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