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DOI: 10.1037/14048-002APA 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 ProCEssSara 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 InputInformation 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 QuestionsThe 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 EvaluationInformation 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.
Behavioral observations. Another potential important source of information is the psychologist’s careful description of client behavior, test-taking attitude, interactive style, and any special needs that necessitate accommodation or modification of the assessment process or standardized testing proce-dure. As Leichtman (2009) noted, these behavioral observations can be a rich source of data. In spite of this possibility, Leichtman noted that the behavioral observations section of most assessment reports typ-ically consists of just a few sentences, and training in behavioral observation and reporting tends to be given only superficial treatment in graduate training and supervision. Additionally, despite its descrip-tive name, the reporting of behavioral observations is prone to subjectivity and bias, another reason why this assessment component warrants care-ful attention in training as well as self-monitoring by the psychologist during the assessment process (Leichtman, 2009). The psychologist’s interpretation and documentation of client behaviors as well as interactive style can be influenced in several ways, such as lack of knowledge or misapplication of base rates for that population and the level of train-ing and competence in assessing clients from that
particular population. These topics are discussed in more detail in the section General Assessment Considerations.
Information OutputInformation output refers to the utilization of the assessment data to derive conclusions and recom-mendations that address the referral questions (Weiner, 2003). Accurately synthesizing these data is a complex process that requires critical thinking skills; knowledge of psychological principles, guide-lines, and standards related to testing and working with diverse populations; and competence in devel-oping an effective working alliance. These critical thinking skills include an awareness of the relative weight to give to clinical judgment versus actuarial or statistical prediction rules in formulating one’s con-clusions and guarding against various types of bias in the interpretation and reporting of assessment data.
GENERAL ASSESSMENT CONSIDERATIONS
There are general considerations that apply to all three phases of the assessment process (information input, information evaluation, and information out-put). For this reason, awareness of these issues guides an appropriate, objective assessment of the client and mitigates the potential for inaccuracy in assessment, synthesis, reporting, and recommenda-tions. These issues include the potential for the introduction of bias and moderator and mediator variables that may influence the working alliance or assessment validity. These two issues may affect any or all of the three phases of the assessment process.
BiasTest popularity may be considered a type of bias because common usage perpetuates the mistaken belief that an instrument is valid and reliable. For example, the Thematic Apperception Test and other projective techniques are used frequently in clinical and forensic settings, although their use has been seriously questioned (Hunsley & Mash, 2007). An exception may be the Rorschach inkblot method, which has received research support regarding test protocol validity when compared with MMPI protocols (Hiller, Rosenthal, Bornstein, Berry, &
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Brunell-Neulieb, 1999). The use of the Rorschach in clinical and forensic settings also has been endorsed by the Society for Personality Assessment (SPA). A thoughtful review of the relevant literature and dis-cussion of the appropriate uses of the Rorschach can be found in the 2005 SPA position statement.
Psychologists also should be aware of the poten-tial for confirmatory bias, in which one selectively attends to behaviors that are consistent with the psy-chologist’s expectations or theoretical orientation. These assumptions may be based on the client’s cul-tural or clinical group membership (Sandoval, 1998). A closely related phenomenon is the avail-ability bias, in which recent behavior or extreme, vivid behavior is weighted more heavily and is more influential than is warranted by its frequency or clinical significance. These biases result in overinter-pretation of assessment data and the potential for overpathologizing the client’s behavior or presenta-tion. Seeking out and evaluating sources of potential divergent, as well as convergent (confirmatory), data during the assessment process assists in guarding against confirmatory and availability biases.
Theoretical orientation. The practitioner’s theo-retical orientation influences the assessment process in terms of instrument selection, questions asked during the clinical interview, and interpretation of client responses and assessment data (Craig, 2009). For these reasons, the psychologist is encouraged to consider the potential for bias. This potential is particularly salient if the psychologist has a back-ground in counseling or clinical mental health and decides to develop competence in complet-ing parental capacity or forensic risk assessments. Theoretical orientation may guide the selection of particular instruments (Lambert & Lambert, 1999). Theoretical orientation or adherence to a particular clinical model also may influence the psychologist’s interpretation of test results, resulting in interpre-tive error regarding diagnosis, etiology, or treatment recommendations. Such errors were first described by Rosenthal (1966) and constitute a phenomenon distinct from experimenter expectancy because they do not influence the client’s behavior. This phenomenon also is distinct from test bias because score differences may be statistically and clinically
significant (Reynolds & Ramsay, 2003). However, this phenomenon may be associated with (a) the failure to consider relevant base rates (Weiner, 2003); (b) environmental impressions, a bias that is based on the particular assessment environment within which the psychologist works (Weiner, 2003); or (c) failure to consider the client’s social context, environment, and person–environment interaction (Wright, Lindgren, & Zakriski, 2001).
Base rates. Base rate refers to the actuarial proba-bility that a particular clinical phenomenon, such as a particular diagnosis, will be present in a particular population or assessment context. For example, psy-chotic disorders are more prevalent in acute inpa-tient psychiatric settings than in student counseling centers. Bias is introduced when the psychologist inadvertently, or consciously, erroneously applies a base rate probability and fails to consider compet-ing hypotheses or fails to conduct an appropriate differential diagnosis when evaluating assessment data (Weiner, 2003). Understanding the base rates within a particular population also provides a con-text for evaluating the sensitivity and specificity—and, hence, clinical utility and predictive power—of a particular instrument (Faust, Grimm, Ahern, & Sokolik, 2010).
Assessment of diverse populations. The validity of assessment results generally and test scores in particular may be attenuated when instruments are used inappropriately cross-culturally. In addition to culture, ethnicity, and race, variables known to influence test results and thereby warranting consid-eration when selecting instruments, include client’s primary language, socioeconomic status, and level of education (Gray-Little & Kaplan, 1998).
A starting point in developing cross-cultural competence may be a self-assessment of one’s own cultural membership(s). Hays (2008) articulated a clear and structured process for this self-evaluation, which can serve to identify potential biases as a first step in the development of cross-cultural competen-cies. Migration or immigration history, level of acculturation, and acculturative stress are just three areas of knowledge with which the psychologist should be familiar (Acevedo-Polakovich et al., 2007). When working with culturally diverse
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clients, it is important for psychologists to be aware of an instrument’s conceptual equivalence—that is, the test’s ability to measure the same construct across cultures in order to determine its validity for use with a particular client population (Geisinger, 2003). This ability can be determined by comparing evidence of construct validity collected in the “host” language and culture with evidence of con-struct validity collected in additional linguistic and cultural populations (Geisinger, 2003). Because psychological assessments go beyond test adminis-tration and interpretation, Acevedo-Polakovich et al. (2007) suggested “proactive steps” related to initial training that were first offered by Hansen (2002, as reported in Acevedo-Polakovich et al., 2007). These suggestions were specific to the Latina/o population but reflect general principles that could be applied to working with other populations. They include the need to (a) develop an understanding of Latina/o-specific cultural variables, constructs, and syn-dromes to promote accurate assessment and mitigate the potential for misinterpreting culture-specific beliefs or behaviors; (b) be familiar with instruments of known, and acceptable, validity and reliability with U.S. Latina/os; (c) interpret tests and complete assessments that are consistent with, and relevant to, Latina/o culture; and (d) provide test feedback in a language and style that meet the needs of the client.
The client’s personal history and context also influence decision-making regarding the direction of the clinical interview, types of collateral information to collect, and appropriate testing (Comas-Diaz & Grenier, 1998). For example, assessing newcomers (refugees and asylum seekers) includes a careful but nonthreatening querying of where the client came from, when the client left his or her country of ori-gin, and what was going on in that country at that time. The responses to these questions provide a context within which to evaluate the probability that the client experienced torture and consequent men-tal health symptomatology (Maltzman, 2004).
Sandoval (1998) made the following recommen-dations to facilitate critical thinking and to guard against bias, particularly when assessing clients from diverse populations: (a) Identify one’s own precon-ceptions in advance to better guard against their
influence, (b) ensure that conclusions are drawn after careful consideration, (c) seek appropriate cul-tural consultation to prevent the misinterpretation of normal behaviors, and (d) ensure that careful notes are taken to prevent reliance on memory.
Moderator and Mediator VariablesModerator and mediator variables may influence the assessment process in a manner similar to the effects seen in counseling and psychotherapy. Mod-erator variables include client and psychologist expectations and attitudes about the assessment process. Mediator variables include the behaviors (covert and overt) and client–psychologist interac-tion that occur during the assessment (Hill & Wil-liams, 2000). Both moderator (input) and mediator (process) variables influence the development of rapport and thus can influence the assessment pro-cess and the validity of the collected data and data interpretation.
Developing and maintaining rapport and an effective working alliance is critical to facilitating the assessment process. Despite this necessity, the psychologist has limited time within which to estab-lish a working relationship with the client that pro-motes cooperation, motivation, and forthrightness in the assessment process.
Client factors. The client’s affective state can influence testing and self-report. Anxiety or fear about the testing process may negatively affect attention and concentration and may contribute to mistakes and accidental random responding. In their description of obstacles to establishing rap-port from the client’s perspective, Lerner and Lerner (1998) described Schafer’s (1954, as cited in Lerner & Lerner, 1998) observation that the assessment process requires the client to cede control over what information to hold private and allows intrusiveness by the psychologist without the establishment of a requisite level of trust. The assessment context also can influence the client’s approach to participating in the assessment. For example, clients may attempt to minimize symptoms to facilitate discharge from the hospital (Bagby et al., 1997) or present with a defensive style in forensic settings, such as parental custody evaluations (e.g., Bagby, Nicholson, Buis,
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Radovanovic, & Fidler, 1999). Traumatized clients may experience the assessment as inherently stress-ful. They may minimize or deny symptoms in an attempt to avoid remembering and discussing the traumatic events, resulting in the denial of symp-toms during the clinical interview and suppressed test scores (Briere, 2004).
Psychologist factors. The psychologist is chal-lenged to engage the client quickly and effectively to promote a collaborative, nondefensive style. In forensic settings, this goal may be difficult to achieve because of the investigative nature of forensic assess-ments that necessitates a probing, neutral stance in comparison with a more supportive, collaborative role appropriate for a clinical setting (Craig, 2009). In clinical contexts, development of a collaborative working alliance may be impeded if the psychologist is perceived as too distant or inappropriately sym-pathetic (Briere, 2004). Creed and Kendall (2005) identified therapist variables associated with a posi-tive alliance in therapy with children. These factors included a collaborative stance (in which the thera-pist encouraged child involvement), not pushing the child to talk when the child was not ready to do so, and emphasizing common ground. Although these variables predicted child ratings of the strength of the therapeutic relationship early in therapy, they did not predict therapist ratings (Creed & Kendall, 2005). This finding suggests that therapists may not be sufficiently sensitive to client responses and reac-tions in therapy that may mediate the working rela-tionship. These same variables and processes also may be present in and affect the assessment process with children and youths.
As noted earlier, allowing insufficient time to develop a collaborative working relationship and pushing prematurely or inappropriately for informa-tion are two psychologist-related variables that may negatively affect the assessment process. Perhaps these behaviors are due, at least in part, to the pres-sure that psychologists feel to obtain the necessary and sufficient data to answer the referral questions (Lerner & Lerner, 1998). This pressure may feel more acute when the assessment is initiated by a third-party referral who is the payer and the assess-ment is time sensitive.
Clinical Judgment, Actuarial Prediction, and Utilization of Empirical GuidelinesMeehl’s 1954 monograph was the first description of the equivalence or superiority of actuarial predic-tion in comparison with clinical judgment. Garb (2003) described actuarial prediction as decision rules that are based on empirical data. Actuarial prediction is equivalent to statistical prediction when the latter refers to mathematical equations that are based on empirical data (Garb, 2003). The superiority of actuarial prediction has been con-firmed consistently in research, particularly in forensic settings (Ægisdóttir et al., 2006; Garb, 2003). Applied to the assessment process, actuarial prediction is consistent with the utilization of empirical guidelines for deriving assessment con-clusions. Weiner (2003) described empirical guide-lines as the utilization of decision rules “derive[d] from the replicated results of methodologically sound research” (p. 12). Applying these rules facili-tates objective decision-making and mitigates the potential for biases. Empirical guidelines, including the application of appropriate cutoff scores applied within the particular referral context, also mitigate the potential for false-positive or false-negative con-clusions (Weiner, 2003). The adoption of an empir-ical approach also assists in guarding against the influence of confirmatory and personal biases in clinical and counseling settings (Garb, 2003; Heilb-run, DeMatteo, Marczyk, & Goldstein, 2008; Strohmer & Arm, 2006). Despite these findings, psychologists have tended to resist adoption of an empirical approach to assessment and diagnosis (Graham & Naglieri, 2003).
This perceived resistance has been attributed to two primary considerations that reflect an apparent scientist–practitioner split: (a) the need to ensure the construct validity of clinical diagnoses in clinical research versus the time and resource limitations encountered by the clinician in practice and (b) the suboptimal utility of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) to facilitate treatment planning versus the paramount need for clinical utility of an assessment in treatment settings (Mullins-Sweatt & Widiger, 2009). What do not appear to have consistent support in the literature are the hypotheses that practitioners are
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reluctant to adopt empirically derived assessment practices because of philosophical differences or that practitioners believe that empirically derived diagnoses are simplistic or invalid (Widiger & Samuel, 2009).
Conversely, researchers have acknowledged that the psychological assessment of an adult or child in a clinical mental health setting must address diag-nostic clarification for the purpose of treatment planning, prediction of response to treatment, and prognosis for future level of functioning (Bagby et al., 2003; Lachar, 2003). In other words, the clinical utility of the assessment is paramount (Mullins-Sweatt & Widiger, 2009). Despite the research and general consensus supporting the superiority of empirically based assessment, formal psychological testing and structured or semistructured interviews are not always utilized in clinical practice (Widiger & Samuel, 2009). Failure to use standardized assessment procedures potentially compromises the validity and reliability of the resulting clinical diag-noses. This possibility is magnified if, as reported, clinicians do not consistently and routinely adhere to DSM–IV diagnostic criteria when utilizing an unstructured interview format (Mullins-Sweatt & Widiger, 2009; Widiger & Samuel, 2009). Such lapses may occur because the client’s self-report may not be candid or because the clinician may not adequately query the client. For this reason, there is an increased risk that the assessment will be com-promised, resulting in a diagnosis (or diagnoses) that does not fully describe the client’s presentation and functioning. The resulting diagnoses may, in turn, result in inappropriate or inadequate treat-ment. In particular, failure to assess for the presence of personality disorder or maladaptive personality traits may compromise not only appropriate treat-ment but also the accuracy of the predicted response to treatment and posttreatment prognosis (Widiger & Samuel, 2009). Widiger and Samuel suggested a tiered approach to the assessment of personality disorder to bridge this schism. The ini-tial tier would be administration of a self-report inventory, such as the MMPI–2–RF (Restructured Form) (Ben-Porath & Tellegen, 2008) or the MCMI-III (Millon, 1994), which would be followed by a semistructured interview targeting personality
traits identified as maladaptive through the self-report inventory. The goal of this tiered approach is to shorten the semistructured interview to target more carefully the personality traits that appear most salient, thus saving the practitioner time. Whether this approach is disseminated and adopted within the practice community remains to be seen. How-ever, a potential obstacle to this approach may be the reluctance of third-party payers to reimburse for any testing or low reimbursement rates when test-ing is authorized.
Therefore, rather than a philosophical reluc-tance, it may be that reimbursement and resource issues are primary factors contributing to practitio-ners’ reluctance to implement empirical assessment approaches.
EMERGING TRENDS
Multiple factors, including the mental health con-sumer movement, government oversight, and reim-bursement policies of third-party payers, have contributed to the call for psychology to demon-strate that its services are cost effective, are measur-able, and benefit clients in tangible ways. Three emerging trends in assessment are particularly salient within this context: assessing psychosocial functioning, assessing outcomes, and utilizing the assessment as treatment.
Assessment of Psychosocial FunctioningOver the past 20 years, there has been increasing emphasis within clinical settings to assess the cli-ent’s psychosocial functioning in addition to psychi-atric symptomatology. Psychosocial functioning includes assessment of the client’s hobbies, leisure activities, and pursuit of values that are hypothe-sized to contribute to psychological and subjective well-being (Robbins & Kliewer, 2000). Thus, psy-chosocial functioning as a construct is expanded to include the assessment of self-enhancing activities in addition to traditional areas of basic functioning such as activities of daily living, interpersonal rela-tionships, and participation in work or school. This conceptualization of psychosocial functioning more clearly articulates the assessment of client strengths in addition to deficits. This strengths-based
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approach is the result of several converging areas of research and public policy, including the following:
■■ the mental health consumer movement (e.g., Campbell & Leaver, 2003; Pulice & Miccio, 2006),
■■ the rise of the biopsychosocial model in psychol-ogy (e.g., Maltzman, 2012), and
■■ developmental research in the physiological and psychosocial bases of resilience (e.g., Greenberg, 2006; Werner, 2005).
Ro and Clark (2009) described their initial efforts to clarify the construct of psychosocial func-tioning. The goal of the factor analysis was to initi-ate the development of a psychometrically sound instrument that could be used to assess the psycho-social deficits associated with DSM Axis I and Axis II psychopathology. A community sample (N = 429) that included almost equivalent numbers of students and nonstudent residents completed measures assessing quality of life, daily functioning, and per-sonality functioning. Two principal-axis factor anal-yses with promax rotation were conducted that included measures of functioning across a variety of domains and with varying levels of specificity and breadth. The first factor analysis excluded the two measures of personality functioning, the Measure of Disordered Personality and Functioning (MDPF; Parker et al., 2004, as cited in Ro & Clark, 2009) and the Severity Indices of Personality Problems (SIPP; Verheul et al., 2008, as cited in Ro & Clark, 2009). By excluding and then including these mea-sures, these investigators were able to explore whether personality functioning, as defined by these instruments, improved the factor solution. A four-factor solution, which included these personality functioning measures, yielded the most psychologi-cally interpretable solution (Ro & Clark, 2009). The resulting four dimensions reflected Basic Function-ing (activities of daily living and microlevel func-tioning), Well-Being (subjective sense of well-being, satisfaction, and high social functioning), and two factors on which the MDPF and SIPP loaded: Self-Mastery (impulsivity, inability to learn from experi-ence, and lack of self-control) and Interpersonal and Social Relationships (lack of empathy or caring for others, difficulty fitting in socially). These two
personality functioning measures were interpreted by these investigators as reflecting social and envi-ronmental functioning associated with personality traits. Ro and Clark noted that they could only include general measures of psychosocial function-ing that were applicable across a range of client populations.
The growing emphasis on psychosocial function-ing reflects the growing imperative to demonstrate the clinical utility of the assessment, defined as the ability to demonstrate that the assessment “makes a difference with respect to the accuracy, outcome, or efficiency of clinical activities” (Hunsley & Mash, 2007, p. 45). This imperative has been an impetus for developing assessment instruments with ade-quate external validity to ensure that assessment results reflect the client’s capacity to function in “real-world” settings (Kubiszyn et al., 2000). Neuro-psychologists have acknowledged this need as their field has shifted from an emphasis on descriptive diagnosis toward clarifying functional capacity and recommending specific rehabilitative interventions (Rabin, Burton, & Barr, 2007). In particular, there is increased emphasis in ensuring instrument ecologi-cal validity defined as the generalizability of test results assessed in a controlled setting to the actual skill sets required in daily living (Rabin et al., 2007). A potential advantage of developing and utilizing ecologically oriented instruments (EOIs) is that they could minimize the potential for the misinterpreta-tion of test scores on the basis of client variables known to influence neuropsychological test results.
The confluence of three factors—(a) the growing emphasis on psychosocial functioning, (b) the emer-gence of EOIs in neuropsychology, and (c) the acknowledgment of the superiority of actuarial and evidence-based assessment measures—may provide the impetus to look beyond self-report instruments in clinical psychology toward the development of more ecologically valid assessments of psychological functioning.
Assessment as TreatmentAs noted earlier in this chapter, the assessment con-text as well as psychologist-related and client-related variables can influence the establishment of rapport and the working alliance. In clinical settings, the
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psychological assessment is often the precursor to treatment. One consistent finding in psychotherapy process and outcomes research is that a strong posi-tive working alliance established early in therapy correlates with a decreased probability of early ter-mination and predicts achievement of treatment goals and positive therapy outcomes (Hilsenroth & Cromer, 2007). Extrapolating from these findings, Finn and colleagues (e.g., Finn & Tonsager, 1997) developed the Therapeutic Model of Assessment (TMA), the goal of which is the use the assessment process as a treatment intervention. For a detailed treatment of therapeutic assessment, readers should consult Chapter 26, this volume.
The TMA integrates the multimethod approach to information gathering with an empathic, collab-orative approach in which the test feedback session becomes an intervention: “The major goal is for clients to leave their assessments having had new experiences or gained new information about them-selves that subsequently helps them make changes in their lives” (Finn & Tonsager, 1997, p. 378). This client-empowering, collaborative, strengths-based approach to clinical assessment is consistent with counseling psychology’s historical approach to voca-tional, career, and personal counseling (Delworth, 1977; Fretz, 1985; Super, 1955). In the TMA, the assessment and, particularly, the test feedback ses-sion become the first phase of treatment. Because the TMA facilitates treatment by means of the assessment process, it may be viewed favorably by third-party payers who otherwise might be reluctant to preauthorize and pay for a formal psychological assessment. The TMA assumes that the same psy-chologist conducts the assessment and provides the therapy. In some clinical settings, this may be appro-priate from an ethical perspective (APA, 2010). In other settings and contexts, particularly forensic set-tings, the provision of assessment and treatment by the same psychologist could be considered a viola-tion of professional standards (APA, 2010, in press).
Assessing OutcomesWith the advent of managed health care and time-limited treatments, there is increased interest on the part of third-party payers for psychologists to dem-onstrate the clinical utility of the psychological
assessment to justify its cost (Hunsley & Mash, 2005). The public sector (i.e., government agencies) and the private sector (behavioral health care insur-ance companies) have increased the pressure on mental health professionals to demonstrate the effectiveness of their treatments and interventions (e.g., APA Practice Directorate, 2007; Cavaliere, 1995). This pressure is not likely to abate as finan-cial resources dwindle and public scrutiny regarding the expenditure of government money increases. Although these external bodies are cited as the sources of this pressure, psychology as a profession also historically has demanded that services demon-strate effectiveness to justify reimbursement and inclusion in national health care initiatives. These pressures, from outside and within psychology, were a significant impetus for the development of treat-ment outcomes research (Maltzman, 2012).
Hill and Corbett (1993) defined outcomes as the changes that result, either directly or indirectly, from the treatment utilized in counseling or psycho-therapy. Assessment instruments that can monitor progress in treatment as well as address the referral question have fundamental advantages over instru-ments that can be used as part of the assessment but whose cost, time, length, or other factors preclude their use over the course of treatment. In addition to tracking individual client progress over time, instru-ments that can be used as a repeated measure for tracking individual progress over time also can facil-itate continuous quality improvement efforts at the organizational or system level by aggregating and analyzing data across clients. The assessment of out-comes necessitates a multimodal approach to ensure that the clinically salient variables targeted in treat-ment are adequately assessed over time and suffi-ciently sensitive to detect change over time (Lambert & Lambert, 1999).
Historically, the assessment of outcomes has focused on Axis I clinical disorders, which exclude personality disorders and mental retardation (Ameri-can Psychiatric Association, 2000), and areas of func-tioning compromised by these disorders. However, development of instruments for the assessment and change over time of personality functioning, such as capacity for empathy and tendency toward impulsiv-ity, would be enormously helpful in mitigating risk
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in forensic settings as well as for potentiating treat-ment of Axis I disorders in clinical and counseling settings (Widiger & Samuel, 2009). For additional discussion of risk assessment in forensic settings, readers are directed to Chapter 16, this volume.
SUMMARY AND DISCUSSION
The assessment process historically has consisted of a multimethod approach integrating interview, col-lateral, and formal test data. Both clinical and coun-seling psychology have brought strengths to the process that are based on the historical populations served by each discipline and referral questions addressed. Clinical psychology introduced psycho-logical testing and the multimethod approach for the assessment of emotional disturbance in children. Counseling psychology emerged to address the vocational needs of these youths. Both disciplines transitioned into the assessment of adults with clini-cal psychology focusing on the assessment and treat-ment of major psychopathology. Counseling psychology historically has focused on the assess-ment and treatment of life-associated stressors in individuals functioning along the continuum of nor-mal psychological functioning. Both specialties have strong bases in empiricism and formal psychological testing. Their historical convergence may be in the assessment process itself. One emerging trend is the increasing focus on psychologist–client collabora-tion during the assessment, which essentially becomes the initiation of treatment (e.g., Tharinger et al., 2009). Counseling psychologists historically have collaborated with clients, together reviewing test data and their application to vocational and career choices (Swanson & Gore, 2000). This approach has naturally segued into personal coun-seling for adjustment issues. Clinical psychology appears to be adapting this approach to the process of the clinical assessment for psychotherapy. The assessment context and referral questions will deter-mine the extent to which this collaborative approach is appropriate. In most forensic settings, it may be very limited or inconsistent with applicable profes-sional standards and guidelines.
Balancing the use of subjective sources of data (e.g., the clinical interview and most self-report
instruments) and objective sources of data (e.g., behavioral analyses, test instruments with validity scales) is a topic of continuing discussion and varied practice. Ensuring that multiple methods are used for data collection helps guard against the introduc-tion of biases that can occur if subjective data sources predominate. Adherence to professional standards and guidelines, education and training in assessing diverse populations, and awareness of vari-ous sources of bias also facilitate an assessment pro-cess that results in a data synthesis and report that can objectively address the referral questions.
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an Psy
chological Association. Not for fu
rthe
r di
stri
buti
on.
