psychology

ebscohost-2.pdf

Home >Psychology homework help >psychology

Co py ri gh t © 2 01 3. O xf or d Un iv er si ty P re ss . Al l ri gh ts r es er ve d. M ay n ot b e re pr od uc ed i n an y fo rm w it ho ut p er mi ss io n fr om t he p ub li sh er , ex ce pt f ai r us es p er mi tt ed u nd er

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 9/25/2023 5:45 AM via BRENAU UNIVERSITY AN: 603952 ; Robert A. DiTomasso, Stacey C. Cahn, Susan M. Panichelli-Mindel, Roger K. McFillin.; Specialty Competencies in Clinical Psychology Account: bre1

ONE

Introduction to Competencies in Clinical Psychology

In this chapter we introduce the reader to the burgeoning movement toward competence-based training, functioning, and credentialing. We trace the evolution of the competency movement from its beginnings, to current status, to future directions. The literature associated with the competency movement uses the term “professional psychology” as related disciplines such as counseling psychology are participating in the move- ment. While this book focuses on clinical psychology, we use the term “professional psychology” in this chapter in the interest of accuracy and consistency with the literature.

The services provided by clinical psychologists typically include (a) clinically relevant research and the application of scientific principles; (b) assessment (including evaluation, diagnosis, formal psychological testing); (c) interdisciplinary consultation; (d) supervision, teaching, and management activities (including administration and program develop- ment); and (e) evidence-based practice and intervention (within theo- retical paradigms such as interpersonal therapy, cognitive-behavioral therapy, and psychodynamic therapy). Further, clinical psychologists exhibit and value professionalism, practice ethically, are interpersonally skilled, respect diversity, and advocate for change. Benchmarks of com- petency are defined within each of the individual competency domains. Within this volume, we define competence within these domains along a developmental continuum. We further address how competence in these domains can be evaluated and documented (i.e., credentialing).

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Introduction4

WHAT IS COMPETENCY?

Competency has also been an area of keen interest within other health-related disciplines. For instance, in the field of medicine, Epstein and Hundert (2002) defined competence as “the habitual and judicious use of commu- nication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and com- munity being served” and is contingent upon “habits of mind, including attentiveness, critical curiosity, self-awareness, and presence” (p. 227). Competency in professional psychology has been defined as “an individu- al’s capability and demonstrated ability to understand and do certain tasks in an appropriate and effective manner consistent with the expectations for a person qualified by education and training in a particular profession or specialty thereof” (Kaslow, 2004, p. 775). Competence is a reflection of one’s knowledge, skills, and attitudes and is conceptualized as “develop- mental, incremental, and context dependent” (Rubin et al., 2007).

Not only is competence recognized as integral to the ethical practice of professional psychology and the protection of the public, it is an expecta- tion of consumers, regulators, and legislators. The American Psychological Association (APA)’s Ethics code, amended in 2010, includes a specific standard on competence (Standard 2), which includes the following:

Boundaries of Competence—2.01: (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on education, training, supervised experience, consultation, study or professional experience.

Maintaining Competence—2.03: Psychologists undertake ongoing efforts to develop and maintain their competence.

Thus, the APA clearly defines practice within one’s competence, and the maintenance of one’s competence, as essential to the ethical practice of psychology (Rubin et al., 2007).

As an extension of this focus on competence, the field of clinical psy- chology has witnessed growing interest in competency-focused train- ing and credentialing (e.g., Belar & Perry, 1992; Kaslow, 2004; Peterson, Peterson, Abrams, & Stricker, 1997; Sumerall, Lopez, & Oehlert, 2000). The discipline is increasingly evolving toward a “culture of com- petence” (see Kaslow et al., 2009; Roberts, Borden, Christiansen, & Lopez, 2005). Co

py ri gh t © 2 01 3. O xf or d Un iv er si ty P re ss . Al l ri gh ts r es er ve d. M ay n ot b e re pr od uc ed i n an y fo rm w it ho ut p er mi ss io n fr om t he p ub li sh er , ex ce pt f ai r us es p er mi tt ed u nd er

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

5Introduction to Competencies in Clinical Psychology

Brief History of Defi ning Competence in Professional Psychology

Historically, the marker of competence was the acquisition of knowl- edge and “time practiced,” as evidenced by markers such as attainment of an advanced degree, number of required clinical hours, and success- ful completion of a national exam. For example, the Association of State and Provincial Psychology Boards recommends that independent practice require a scaled score of at least 500 on the national exam for psychologists, the Examination for Professional Practice of Psychology (EPPP). While most states adhere to this recommendation, state boards independently decide upon their own minimum requirements. Notably, this scaled score is an aggregate across a number of knowledge domains from wide areas as disparate as industrial psychology and development. Thus, an obvious limitation of using a passing score on the EPPP as a benchmark of compe- tence is that one may achieve a passing score on the test while failing mul- tiple content domains. It is possible, for example, to answer every question on the statistics or ethics portion of the exam incorrectly and pass the test by a wide margin. The use of the hours accrued in practice as a benchmark of competence has obvious limitations; hypothetically, one could spend every single hour practicing incompetently. While one may argue that this is precisely why such training hours are practiced under supervision, how does one establish a supervisor’s competence? Traditionally, such “competence” has been established by hours accrued (e.g., until recently, Pennsylvania required only that a supervisor be licensed for at least two years). Thus, such an argument is circular. In sum, the use of the EPPP and “time practiced” as benchmarks of competency clearly highlighted the necessity for a better system of certifying competence.

COMPETENCY MOVEMENT IN PROFESSIONAL PSYCHOLOGY

The first widely disseminated model of competency in professional psy- chology was advanced by the National Council of Schools and Programs of Professional Psychology at its Mission Bay Mid-Winter conference in 1986 (see Peterson et al., 1997). Consensus was reached on six core areas of competency: relationship, intervention, assessment, research and evaluation, consultation and education, and management and supervi- sion. This model marked a paradigm shift, a departure from the pre- vailing doctoral training model of accumulating extensive knowledge in particular aspects of psychology (Peterson et al., 1997). Building on this model, additional efforts focused on revising curricula to reflect “knowledge, skills, and attitudes” in these competencies, in addition to Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Introduction6

ethical practice and values (Fouad et al., 2009; Peterson et al., 1997). Following this initiative, the Committee on Accreditation of the APA modified its accreditation standards and required doctoral training pro- grams to articulate their education and training goals vis- à -vis expected competencies, which, accordingly, must be congruent with the program’s philosophy and training model (Fouad et al., 2009). As the competency movement gained further momentum, attention increasingly focused on how to (a) identify specific competencies, (b) train psychologists to be competent in these domains, and (c) assess and certify their competence. It was with these laudable aims that the “Competencies Conference: Future Directions in Education and Credentialing in Professional Psychology” was initiated.

THE 2002 CONFERENCE

This landmark conference to identify competencies in clinical psychol- ogy was held in Scottsdale, Arizona, in 2002 with 126 invited delegates. The Association of Psychology Postdoctoral and Internship Centers ini- tiated and hosted the conference (Kaslow et al., 2004). Delegates repre- sented undergraduate, graduate, internship, and postdoctoral training, as well as private practice. The conference was intended to identify the core competencies necessary for clinical practice (see Collins, Kaslow, & Illfelder-Kaye, 2004). Moreover, this conference was predicated on the fol- lowing convictions: that “(a) core or foundational competencies can be identified, (b) individuals can be educated and trained to develop these core competencies, and (c) core competencies can be assessed” (Kaslow et al., 2004, p. 701). This conference marked the first time that people from a variety of professions, representing a wide range of organizations, col- laborated to further “competency-based education, training, assessment, and credentialing in professional psychology” (Kaslow et al., 2004).

Expert consensus from the conference generated the following eight domains of “knowledge, skills, and attitudes” that were deemed inte- gral to the training of ethical, and competent, professional psycholo- gists: (a) scientific foundations of psychology and research methods; (b) ethical, legal, and public policy issues; (c) cultural and individual diversity; (d) interdisciplinary relationships and consultation; (e) inter- vention; (f) psychological assessment; (g) supervision; and (h) profes- sional development issues (Kaslow et al., 2004; Rodolfa et al., 2005). These eight domains served to prescribe the Competence Conference’s “work groups,” which were charged with (a) defining each competency Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

7Introduction to Competencies in Clinical Psychology

domain; (b) examining how these competencies are attained in educa- tion, and in what developmental sequence; and (c) determining how the respective competence should be assessed (Kaslow et al., 2004; Rodolfa et al., 2005). Two additional subgroups were charged with how attain- ment of the competencies could be assessed and how education and training could be reconfigured with respect to both the competencies and professional development (Kaslow et al., 2004; Rodolfa et al., 2005). One important product of the Competencies Conference was the “cube model” described by Rodolfa and colleagues (Rodolfa et al., 2005), which has garnered increasing acceptance from training groups in professional psychology.

Cube Model

This conceptual “cube model” uses the three-dimensional image of a cube to illustrate competencies in professional psychology and their develop- ment. The three orthogonal axes that make up the cube are Foundational Competencies (x-axis), Functional Competencies (y-axis), and Stages of Professional Development (z-axis; Rodolfa et al., 2005). The competen- cies are viewed as somewhat overlapping, with some, such as ethics and diversity, cutting across other competencies. Additionally, the underlying Foundational Competencies are seen as being intertwined, or embedded, within the Functional Competencies.

FOUNDATIONAL COMPETENCIES

The Foundational Competencies are the knowledge bases fundamen- tally underlying what professional psychologists do (Table 1.1). They include “(a) reflective practice/self-assessment, (b) scientific knowledge/ methods, (c) ethical/legal standards/policy, (d) relationships, (e) indi- vidual/cultural diversity, and (f) interdisciplinary systems” (Rodolfa et al., 2005).

FUNCTIONAL COMPETENCIES

On the y-axis, Functional, or Core, Competencies refer to the knowledge, skills, and attitudes necessary to perform ethically and competently as a professional psychologist (Table 1.2). The model proposes that the foun- dational competencies are integrated into the skill-based, functional competencies. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Introduction8

TABLE 1.1 Foundational Competencies

DOMAIN DESCRIPT ION

Refl ective practice/self-assessment Practice within the scope of one’s competence, commitment to lifelong learning, critical thinking, and scholarship

Scientifi c knowledge/methods Ability to critically evaluate research, appreciation of evidence-based treatments, data collection and analysis, biopsychology, cognitive-affective bases of behavior, and human development

Relationships Ability to effectively interact with individuals, groups, and communities Ethical/legal standards/policy Advocating for the profession, knowledge and application of ethics and

legal standards Individual/cultural diversity Knowledge and sensitivity of cultural diversity among individuals

and groups with diverse backgrounds Interdisciplinary systems Ability to collaborate with professionals in related disciplines, and an

understanding of the important issues within those disciplines

TABLE 1.2 Functional Competencies

DOMAIN DESCRIPT ION

Assessment/diagnosis/case conceptualization

Assessment, diagnosis, and conceptualization of problems within individuals, families, and/or organizations

Intervention Knowledge of interventions designed to ameliorate suffering, including empirically supported treatments

Consultation Ability to seek or provide professional assistance or expert guidance toward meeting a client’s needs or goals

Research/evaluation Generates research that furthers knowledge base of profession; evaluates outcomes

Supervision/teaching Supervision and training of profession’s knowledge base Management/administration Overseeing provision of mental health services, administration of programs,

organizations, and agencies

STAGES OF PROFESSIONAL DEVELOPMENT

The z-axis of this conceptual model represents the increasing levels of competence trainees should be attaining at stages throughout the con- tinuum of professional training (i.e., graduate school, internship, post- doctoral training, lifelong learning). This may also include specialization, including board certification as a specialist through the American Board of Professional Psychology, for example, given that the Foundational and Functional Competencies are broadly applicable in all specialties of profes- sional psychology. For example, the assessment competence will certainly

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

9Introduction to Competencies in Clinical Psychology

look different for neuropsychologists than for industrial-organizational psychologists. Moreover, specialties such as forensics may have specific competencies in addition to those detailed above that are necessary for all professional psychologists (Rodolfa et al., 2005). One implication of this shift is that the EPPP can be reviewed and updated to be consistent with the core Foundational Competencies, thus maximizing face and content validity.

IMPLICATIONS OF THE CUBE MODEL

Practicum Training After the cube model was introduced, the Council of Chairs of Training Councils (CCTC) made the identification of competen- cies an ongoing priority (Fouad et al., 2009). The CCTC is an association of chairs representing the major professional psychology education and training councils in the United States and Canada, such as the Council of University Directors of Clinical Psychology and the National Council of Schools and Programs of Professional Psychology, and is separate from APA. The CCTC provides comment and recommendations to various APA boards and committees, including the Board of Education Affairs (BEA) and Committee on Accreditation (COA). Utilizing the cube model, the CCTC is largely responsible for the Practicum Competencies Outline, which expanded upon earlier work by the Association of Directors of Psychology Training Clinics (Hatcher & Lassiter, 2007). This outline is developmentally based and conceptualizes the practicum students as progressing within competency domains from novice to intermediate to advanced. Descriptive benchmarks are provided for each of the three lev- els appropriate to the practicum stage of training. These progressive levels are conceptualized as successive steps building toward eventual expertise, which may ultimately be attained with future training (Fouad et al., 2009).

The APA’s Board of Educational Affairs appointed a task force in 2003 to move beyond defining competencies to measuring them (Fouad et al., 2009). This group investigated models of competency assessment and pro- duced the “guiding principles” for the assessment of competencies (Fouad et al., 2009; Kaslow et al., 2007). As consensus mounted for the competencies articulated in the cube model, the Board of Educational Affairs appointed a task force (the Assessment of Competency Benchmarks Work Group) in 2005 based upon a proposal from the CCTC. This work group was charged with the task of moving past defining such competencies to articulating how they should be operationalized and assessed (see Fouad et al., 2009).

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Introduction10

Competency Benchmarks The work group expanded on the cube model. Three new competency domains, which had previously been subsumed under other competencies, were added: professionalism, teaching, and advocacy (Fouad et al., 2009). The work group generated the “Competency Benchmarks Document” as a resource for those involved in training and assessing competence in professional psychology. Consistent with the cube model, the document categorizes the competencies as either Foundational or Functional.

The Foundational Competencies in the document include (a) profes- sionalism, (b) reflective practice/self-assessment/self-care, (c) scientific knowledge and methods, (c) relationships, (d) individual and cultural diversity, (e) ethical/legal standards and policy, and (f) interdisciplin- ary systems. The Functional Competencies in the document include (a) assessment, (b) intervention, (c) consultation, (d) research/evaluation, (e) supervision, (f) teaching, (g) management/administration, and (h) advocacy.

Within the benchmark document, each Foundational and Functional Competency is defined and the specific subcomponents, or “essential components,” of the competency are delineated. Behavioral anchors for the essential elements of the competency represent competent practice at that level of training for each essential component. The behavioral anchors are described for each of three sequential developmental levels: readiness for practicum, readiness for internship, and readiness for entry to practice (Fouad et al., 2009). For instance, the foundational compe- tence of ethical/legal standards and policy is defined as “Application of ethical concepts and awareness of legal issues regarding professional activities with individuals, groups, and organizations.” This competence has three essential elements, one of which is “knowledge of ethical, legal, and professional standards and guidelines.” Behavioral anchors for this component of ethical legal standards and policy are provided for each of the three developmental levels. One behavioral anchor for this com- ponent demonstrating “readiness for internship” is “Identifies ethical dilemmas effectively.”

In this way, the benchmarks document utilizes the cube model to oper- ationalize the expected professional development within the competen- cies, across three stages of training. The interested reader is referred to the “Competency Benchmarks Document” by Fouad et al. (2009) for a comprehensive list of the benchmarks and behavioral anchors for all of the Foundational and Functional Competencies.

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

11Introduction to Competencies in Clinical Psychology

Assessing Benchmark Competencies While the importance of articulat- ing specific competencies in clinical psychology is clear, the assessment of competence, or specific competencies, is more complex. As Kaslow (2004) points out, “assessment of competence fosters learning, evaluates progress, assists in determining the effectiveness of the curriculum and training pro- gram, and protects the public” (p. 778). Yet until recently, there have not been widely disseminated competence assessment methods with consen- sual validity. The Assessment of Competence in Professional Psychology work group published a “Competency Assessment Toolkit for Professional Psychology” as a companion resource to the “Competency Benchmarks Document.” The toolkit was informed by previous efforts to assess com- petence in medicine, namely the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties Toolkit of Assessment Methods (Kaslow et al., 2009). The toolkit reviews a set of rec- ommended evaluation methods and their administration, including the advantages and disadvantages to each, as well as their psychometric proper- ties. Information is provided on how useful each method is for evaluating the essential elements of each foundational and functional competency. The toolkit also reviews the suitability of various assessment methods to evalu- ate competence at the three levels of professional training described in the benchmarks document. In addition, the toolkit includes a fourth level of professional training: advanced credentialing. The toolkit describes 15 tools for assessing competence: 360-degree evaluations, annual/rotation perfor- mance reviews, case presentation reviews, client/patient process and out- come data, competency evaluation rating forms, consumer surveys, live or recorded performance ratings, obstructive structured clinical examinations, portfolios, record reviews, self-assessment, simulation/role-plays, standard- ized client/patient interviews, structured oral examinations, and written examinations. For example, “structured oral examinations” is listed as being useful to assess both the scientific knowledge and methods, and the ethi- cal and legal standards and policy competencies. The interested reader is referred to the actual toolkit for a comprehensive compilation of the assess- ment methods and their suitability for evaluating competence within all competencies across four levels of professional training and development.

Current Trends

Most recently the competencies have been simplified into six “clusters” (May, 2012) based upon feedback from training programs (see http://

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

http://www.apa.org/ed/graduate/benchmarks-evaluation-system.aspx

Introduction12

www.apa.org/ed/graduate/benchmarks-evaluation-system.aspx). The six clusters and their components are listed below (APA, 2012):

Professionalism: • Professional Values and Attitudes • Individual and Cultural Diversity • Ethical, Legal Standards and Policy • Reflective Practice/Self-Assessment/Self-Care

Relational: • Relationships

Science: • Scientific Knowledge and Methods • Research/Evaluation

Application: • Evidence-Based Practice • Assessment • Intervention • Consultation

Education: • Teaching • Supervision

Systems: • Interdisciplinary Systems • Management/Administration • Advocacy

Along with these efforts to simplify the competencies, rating forms have been developed to identify benchmarks of competency across three levels: readiness for practicum, readiness for internship, and readiness for practice (see http://www.apa.org/ed/graduate/guide-benchmarks.pdf, July 2012).

Concluding Remarks

At this point in the competency movement, the initial goals of the 2002 Competency Conference have largely been met: competencies have been

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

http://www.apa.org/ed/graduate/benchmarks-evaluation-system.aspx

http://www.apa.org/ed/graduate/guide-benchmarks.pdf

13Introduction to Competencies in Clinical Psychology

defined, competency benchmarks have been identified, and a toolkit of assessment methods has been compiled. Yet considerable work remains. While the competencies have been identified, only face validity and con- sensual validity have been established among experts in the field. The impact of the established competencies will be greater, for example, if pre- dictive validity can be documented, and the utility and feasibility of prod- ucts such as the Practicum Competencies Outline can be demonstrated. Similarly, progress in this area could provide greater standardization within the field of how competency is instilled and evaluated.

In the following chapters, we provide an introductory survey of the Functional Competencies of assessment and intervention (cognitive-be- havioral, interpersonal therapy, relationship factors, systems-based, and contemporary psychodynamic). While not an independent competency, we discuss case formulation as a critical component of competent inter- vention. We also review the Functional Competencies of consultation; teaching, management, and supervision; and science-base and research. We also explore the Foundational Competencies of relationship compe- tency, ethical and legal challenges, and individual and cultural consider- ations. Finally, while not a distinct Foundational Competency, we include “professional identification” as an important component of being a com- petent professional psychologist, as professional identity encompasses important competencies such as ethics, lifelong learning, and advocacy. To be a competent professional psychologist requires an understanding of what competencies are necessary and the expectation that one must be able to demonstrate competence in these areas. We hope this volume serves to inspire you and further your interest in the various competencies in clinical psychology. If so, we invite you to explore these areas in greater depth in the specialty volumes of this series.

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

This page intentionally left blank

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment

PART II

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

This page intentionally left blank

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

TWO

Assessment Strategies

In this chapter we discuss the important role of psychological assess- ment as a critical competency of the clinical psychologist. Assessment may be defined as a higher-order, detailed, highly complex, and sophis- ticated process of integrating, synthesizing, and deriving meaning about a client from a number and variety of sources. Assessment can be used to infer characteristics and traits about an individual, develop a formal diagnosis, aid in the development of a case conceptualization, create a treatment plan, determine prognosis, make professional recommenda- tions, and answer a referral question. Peterson, Peterson, Abrams and Stricker (1997) describe this competency as an “ongoing, interactive, and inclusive process that serves to describe, conceptualize, character- ize, and predict relevant aspects of a client” (p. 380). Because assess- ment may dramatically affect the lives of those being assessed, clinical psychologists must use great caution when conducting assessments to ensure that they are conducted in a professional, empirical, ethical, and legal manner.

To conduct assessments effectively requires special competencies. These competencies involve (1) understanding of the relevant empirical knowledge base; (2) experience and skill in using specific instruments and tools with given populations; (3) understanding of the psychometric prop- erties of the instruments and methods being used; (4) skill in selecting, administering, scoring, and interpreting instruments; and (5) a thorough grounding in the ethics of assessment.

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment18

Theoretical Orientation

Clinical psychologists often define and identify themselves by allegiance to a specific theoretical orientation. Different theoretical models, of course, may value one assessment domain over another and focus upon specific facets within each domain. For example, while behavioral clinicians place a premium on directly verifiable and observable behavior in defining problems, psychodynamically oriented clinicians see behavior as a sign or symptom of some underlying issue. Assessors operating from differ- ent models will typically emphasize one domain or aspect of a domain as more important in understanding and explaining a person. All told, however, the greatest challenge in psychological assessment is perhaps truly appreciating what the data mean about a given individual within a given context at a given time (Groth-Marnat, 1997). Groth-Marnat (1997) has described the process of assessment as entailing a number of critical components ranging from explicating one’s role, identifying the referral question, selecting appropriate tools to answer the question, acknowledg- ing factors that may adversely affect clinical judgment, recognizing con- textual factors influencing the client, considering ethical/legal issues, and understanding factors that may bias the process and outcome. This pro- cess subsumes the requisite competencies for conducting assessments.

Function of Assessment

According to Freeman, Felgoise, and Davis (2008), assessment as a whole may serve different aims and functions based on whether it serves as a foundation for planning and implementing direct psychological services to a client, answering referral questions of a consultee, or monitoring instrumental or ultimate outcomes of treatment. Clinical psychologists must, then, be competent in using one or more of a variety of techniques to collect information about a client and to use this information to perform a number of clinical tasks. These tasks often include delineating the specific characteristics of a client, making a diagnosis using a formalized classifi- cation system, and predicting some future behavior (Freeman et al., 2008). In clinical practice, any attempt to separate these tasks is purely artificial and arbitrary at best as they mutually affect each other.

DESCRIBING CLIENTS

Providing a formal description of a client’s attributes is often critical. The history of clinical psychology is based on the intensive study of the person, Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

19Assessment Strategies

so capturing the uniqueness of a person is considered essential. When the aim is to understand the essential uniqueness of a person, a comprehen- sive assessment of one individual is all that is necessary.

INDIVIDUAL DIFFERENCES

Clinical psychology is based on the construct of individual differences. Individuals vary in an endless number of ways, and these differences often account for the differences in observable behaviors across individu- als. Without developing an accurate description of a person, diagnosis and prediction would be virtually impossible. Gaining a thorough under- standing of the uniqueness of a person is often rooted in the identification of key areas, including the biological, cognitive, affective, psychological, social, emotional, behavioral, and cultural components of a person. The clinical psychologist may, then, be likened to a highly skilled investigator whose job is to uncover specific aspects of the above domains that account for the behavior of a person.

D IAGNOSIS

Diagnostic classification provides a formal standardized means of com- municating information about an individual. Clinical psychologists must be well versed in diagnostic criteria and the constellation of symptoms that constitute a particular disorder and that differentiate it from other disor- ders (see the American Psychological Association [APA], 1994). The entire process of diagnosis is embedded within a multi-axial system that requires the clinical psychologist to consider a number of important domains. The underlying notion is that a multi-axial system is more likely to compre- hensively capture and describe the uniqueness of a given person.

To competently use any system of diagnosis, the clinical psychologist must be knowledgeable about the specific diagnostic criteria and be able to ask questions that allow a determination of whether specific diagnostic criteria are met or not met in an individual case. There are many advan- tages and disadvantages to this system, not the least of which has to do with failure to capture the unique aspects of an individual that are critical for informing treatment. DiTomasso and Gosch (2002a) have discussed this issue in the context of anxiety disorders and illustrate how in two instances individuals who met diagnostic criteria for social phobia had completely different historical causes that required different treatment targets. Diagnosis itself, then, does not necessarily inform treatment; if anything, it may fail to capture rather important aspects of an individual Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment20

case. Failure to appreciate the differences that uniquely characterize a person with a given diagnosis undermines the very reasons psychological assessments are undertaken.

Simply stated, not all patients with the same diagnosis should be pre- sumed to be the same (Kiesler, 1973). Moreover, studies of the diagnostic assessment process have revealed many important and relevant findings. For instance, Chorpita and his colleagues (Chorpita, Brown, & Barlow, 1998) have reported that diagnostic accuracy for anxiety disorders is affected by a number of variables, including the presence of comorbid problems, the severity level of the disorder being assessed, and the exis- tence of behavioral markers of a disorder. Diagnostic reliability of anxiety disorders suffers when clinicians are confronted with comorbidities, less severe and subclinical variants of disorders, and the absence of behavioral indicators such as maladaptive avoidance patterns. Competent clinical psychologists must always apply careful scrutiny to the assessment pro- cess, but this is especially important in such instances.

PREDICTING BEHAVIOR

Finally, competence in predicting behavior is also important. While there is always error in prediction, clinical psychologists are often required to make some prediction about the behavior of a person. In the context of a specific case, a clinical psychologist may be asked to predict any number of important things that depend in large part on the context of the setting. These settings exert their influence by the nature of the decisions that must be rendered about individuals.

Clinical psychologists are employed in many different settings, includ- ing the private practice sector, inpatient hospitals, medical settings, cor- rectional settings—the list is endless. Such predictions include, but are not limited to, forecasting the potential for risk of suicide; violence against oth- ers; homicidal risk; adjustment to incarceration; recidivism after release from incarceration; suitability of a treatment or treatment program; fit- ness for duty; ability to use discretion in legally carrying a weapon; risk for relapse and the like. More often than not, psychological assessments are used as a vehicle to render high-stakes decisions about individuals, the out- comes of which may result in serious consequences. For this reason, com- petency is necessary to carefully navigate through this difficult terrain.

Perhaps one of the most common tasks confronting clinical psycholo- gists across settings is the prediction of suicide. Rudd and Bryan (2010) have provided a comprehensive overview of the number of factors that Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

21Assessment Strategies

must be carefully weighed in a primary-care context. As is the case in predicting other behaviors, failure to comprehensively address all areas may have grave consequences for the patient as well as the psychologist. Undeniably, when compared to practitioners outside of psychology, assess- ment is a skill that is unique to clinical psychologists.

Assessment as a Skill Unique to Clinical Psychology

Clinical psychologists, as well as those in other specialty areas, routinely conduct assessments. The history of clinical psychology emerged in large part in response to the need for assessment in psychiatric hospitals and military settings. Given their training, psychologists were well positioned to provide these types of services. Psychologists often served in a consulta- tive role to psychiatrists seeking answers to questions related to diagnosis of patients they were treating. Considering the training of psychologists in measurement, psychometrics, and statistical constructs and the absence of such training in psychiatrists and social workers, assessment has proven to be a distinct skill set for psychologists. Yet, today, despite the many ben- efits potentially accrued from assessment, managed-care companies often fail to reimburse for such services.

This unfortunate state of affairs has undermined the distinct skills psy- chologists bring to clinical situations. No other profession places the same emphasis on the use of psychological assessment. Clinical psychologists, through their training in scientific psychology and scientific aspects of professional practice, learn important skills that are critical to competency in this domain. Consideration of APA curriculum requirements under- scores the critical importance of assessment to the definition of clinical psychology, training clinical psychologists, and competently practicing this craft (Groth-Marnat, 1997).

Unlike psychiatrists, social workers, general physicians, and counsel- ors, the training of clinical psychologists is steeped in the relationship between measurement principles, psychological phenomena, and individ- ual differences (Anastasi, 1996; Kline, 2005; Nunnally, 1994). A competent foundation in these areas includes tests and measurements; test theory and construction; statistical and research methods; psychopathology; the psychology of adjustment; the ability to generate, evaluate, and rule in and rule out hypotheses; and the ability to choose and utilize methods to obtain the requisite information (Groth-Marnat, 1997). Psychological assessment is built, in part, on the use of psychological tests. These instru- ments are carefully constructed standardized and objective measures of Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment22

samples of behavior specifically developed to assess individual differences on a psychological construct of interest. However, test scores may be rela- tively meaningless without a comprehensive interview process coupled with behavioral observations (Groth-Marnat, 1997).

The key role of measurement in psychology and science in general is supported by the observation that major developments in psychology have been predated and associated with discoveries in measurement (Nunnally, 1994). The process of psychological assessment, however, is only as good as the quality of the components, many times psychological tests, on which it is built. Competent psychologists recognize the advantages of carefully derived assessments over subjective guesswork. Acceptable psychological tests are relatively objective, are subject to empirical validations, produce quantifiable results, facilitate professional communication, yield economy of time, provide consistent results, and measure what they intend to mea- sure (Nunnally, 1994).

The development of assessment tools in clinical psychology is based in psychological theory, research, rationality, and/or experience (Aiken, 1996, 1997; Kline, 2005). Clinical psychologists have frequently sought new and improved methods for efficiently measuring and assessing constructs of rel- evance to clinical practice and research. These motivations led to the identi- fication and operationalization of important constructs, item development, designing scoring response systems, data-collection strategies, establish- ment of reliability methods, and standards for establishing validity.

Assessment Procedures Unique to Clinical Psychology

There are a variety of assessment procedures that are unique to clini- cal psychology. More or less, each type is designed to provide a snapshot or sample of behavior or behaviors that are constructed to facilitate our understanding of a client. There are a variety of characteristics of psycho- logical tests that are quite distinctive, and competent clinical psycholo- gists possess critical knowledge and skills related to such measures. The competent clinician would be wise, however, to heed the following dictum in guiding clinical practice: “Testing is to assessment as skill is to wisdom” (Richard & Huprich, 2009).

B IOPSYCHOSOCIAL ASSESSMENT

The biopsychosocial model of assessment in the medical community was derived from the original ideas proposed by Engel (1977), who convincingly Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

23Assessment Strategies

argued for a more comprehensive evaluation of patients in medical set- tings. This multimodal assessment approach addresses key components affecting patients, and without consideration of these, one cannot appreci- ate the fullest understanding of the patient and account for the patient’s problems. Belar, Deardorff, and Kelly (1987) provide a thorough elucida- tion of the number and variety of factors that constitute a biopsychoso- cial assessment. Consideration of these key areas and their interaction is essential to competent practice.

When working with patients, clinical psychologists must assume a broad-based perspective in assessment. Failure to do so will likely cause them to ignore important components affecting patients and provide an incomplete picture. It is critical to consider the multifaceted nature of human beings. These domains include the biological or physical, cogni- tive, affective, social, behavioral, environmental/familial, and cultural aspects of the individual, and the many factors included within each domain. Assessment of biopsychosocial factors is in large part based on the growing evidence base delineating the significant role that these fac- tors play in the onset, development, exacerbation, and maintenance of medical problems (DiTomasso, Golden, & Morris, 2010). The advantages of the biopsychosocial model over the traditional biomedical approach are clear, coupled with the diagnostic and predictive utility of psychologi- cal assessments in medical patients (Bruns & Disorbio, 2009; Hutton & Williams, 2001). For example, in the realm of forecasting the outcomes of spinal surgery, a comprehensive review of the literature reveals a host of important factors (psychological symptoms, environmental factors, cog- nitive variables, etc.) associated with negative outcomes.

B IOLOGICAL ASSESSMENT

The evaluation of physiological parameters was not traditionally tied to the role of the clinical psychologist. A number of forces within the field have contributed to the integration of physical measurements into the process of assessment. These forces include the emergence of biofeedback based on the pioneering work of Neal Miller (1975), behavioral medicine and health psychology, neuropsychology, and most recently the profound effects of integrated healthcare models (DiTomasso et al., 2010).

The early work of Miller (1975) opened up new avenues of investigation and a novel paradigm for understanding, testing, and applying concepts related to the role of learning on autonomic processes. Clinical psycholo- gists may employ biofeedback as a primary treatment modality or as an Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment24

auxiliary method to treatment by using electromyography, thermal, and electroencephalography assessments and measuring heart rate, blood pressure, or galvanic skin responses.

Even though dyssynchrony may exist between patient self-reports, bio- logical indicators, and behavior, the use of physiological assessment cou- pled with psychological and behavioral measures can prove helpful to the practicing clinical psychologist.

THE CLINICAL INTERVIEW

Perhaps no other means of gathering and synthesizing information from clients is more critical than the clinical interview. The clinical interview may be considered a formalized professional interaction between a clinical psychologist and client that provides a context or backdrop within which other information about the client can be understood. While criticized for its subjectivity and related reliability and validity issues, the clinical inter- view remains a mainstay in the toolbox of the seasoned and competent prac- titioner. When implemented carefully and used effectively, it provides a rich source of information not otherwise available to the clinical psychologist.

Consider the hypothetical situation in which an interview is used exclu- sively as a basis for psychological assessment. Relying upon an interview alone has many disadvantages. The quality of the information derived from a clinical interview is likely to be a direct function of the individual conducting the interview, the rapport built between the participants, the expertise of the interviewer, the specific questions asked, the manner in which questions are posed, and the comprehensiveness and scope of the interview (Groth-Marnat, 1997; Summerfeldt & Antony, 2002).

By their very nature clinical interviews lack important features such as standardization, exact content, objectivity, scoring, and norms. While interviews are time-intensive, they do provide opportunities for things that most psychological tests preclude. Clinical interviews provide a great deal of latitude for seeking out meanings, probing and delving into fur- ther detail, and exploring a variety of important areas including, but not limited to, the thoughts, attitudes, beliefs, perceptions, and behaviors of the client. Most importantly, an interview allows the client to tell his or her own story and share idiosyncrasies. The psychologist gets the chance to directly observe the behavior and reactions of the client; this often keys the clinician into important discrepancies between verbal and nonverbal behaviors. For reasons already described, in conducting an assessment, relying solely on an interview can be problematic. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

25Assessment Strategies

Exclusive reliance on psychological tests, however, would be just as dis- advantageous for obvious reasons. While providing a great deal of useful information about a client, the data may overshadow important subtleties of the person that warrant consideration and that may beg for adjusting the meaning and interpretation of the derived data, providing a system of checks and balances. As Groth-Marnat (1997) has aptly noted, “Without interview data, most psychological tests are meaningless” (p. 67).

Overall, clinical interviews, while varying between interviewers and clients, are intended to achieve certain objectives. The traditional unstruc- tured interview will likely remain a core, essential ingredient of a com- petently conducted psychological assessment. It essentially defines the interpersonal, rapport-building, and hypothesis-testing components of assessment. The marked observed variability in the reliability and valid- ity of the clinical interview (Groth-Marnat, 1997), however, behooves the clinical psychologist to carefully consider and compensate for those fac- tors that may undermine its usefulness. The interview provides a basis for observing the client’s behavior firsthand, experiencing how the client relates, using one’s reactions to the client as a means of understanding others’ reactions to the client, understanding how the client processes information, validating the client’s concerns, and the like. However, most importantly, it is the primary vehicle for formulating testable hypotheses to be validated by other independent information, including psychiatric and medical records, psychosocial history, reports of significant others and peers, and psychological test data.

Competent clinical psychologists approach the interview as a fallible process, subject to the questions the assessor chooses to ask (information variance) and the criteria one employs and integrates (criterion variance), to establish the existence of problems (Groth-Marnat, 1997; Summerfeldt & Antony, 2002; ). The competent clinician practices assessment from a perspective that recognizes the contribution of both assessor and asses- see in potentially undermining the stability and accuracy of diagnostic and related conclusions. Professional and ethical practice presupposes an awareness of these factors, with a keen eye toward evaluating the likely influence and impact of each within a given context.

Groth-Marnat (1997) has warned clinicians about a number of critical threats for consideration. In the realm of the assessor, this list includes halo effects, primacy effects (initial impressions), confirmatory biases, base rates, the role of salient characteristics, a focus on trait as opposed to situ- ational determinants of behavior, and theoretical orientation. The list of client factors includes cognitive distortions, outright deceit, fixed ideation, Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment26

frank delusions, confabulatory processes, and inaccuracies tied to mem- ory decay. Taken together, the interaction of one or more of these factors across participants may bias the assessment process through the selection of certain hypotheses, exclusion of other viable hypotheses, choosing one line of questioning over some other, and inaccurately weighing the relative importance of selected information, thereby completely threatening the reliability and validity of clinical judgments. To overcome its limitations, clinical psychologists have standardized the interview process.

Structured Clinical Interviews The challenge confronting clinical psycholo- gists in arriving at diagnoses of mental disorders is well established. The impetus to develop structured and semistructured interviews actually emerged in large part from the disillusionment with traditional unstructured approaches. These approaches routinely yielded not only lack of congruence in assigned diagnosis but interdiagnostic agreement statistics that did not exceed minimum levels that would be expected on the basis of chance alone (Summerfeldt & Antony, 2002).

Structured interviews vary on a number of dimensions, including the skill required to appropriately administer them, the degree of structure of the questions, and the goals (overall functioning or given diagnoses) (Groth-Marnat, 1997). Regardless of these differences, efforts were then naturally directed toward developing approaches that would improve diag- nostic reliability and validity. Improving reliability, for instance, necessi- tated a method that overcame sources of variation that had an adverse impact on the diagnostic process itself. As Summerfeldt and Antony (2002) have emphasized, content, form, and the sequence of questions are important in achieving diagnostic reliability and accuracy.

Careful consideration of the main sources of problems contributing to traditional open-ended interviews fueled the development of structured interviews. These problems were captured and corrected by addressing what was being asked, who was being asked, who was asking, and how the information was integrated. Through a process of standardization, structured interviews control for variability related to the exact questions included in the interview, the manner in which interviewees are asked to respond, how questions are asked by the interviewer, and criteria for decision-making (Groth-Marnat, 1997).

Yet even with structured interviews, careful considerations must be made when choosing one for use in the clinical setting. Clinical psycholo- gists must address a number of important factors, such as the number of diagnoses to be considered in a given context, the stability of the diagnostic Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

27Assessment Strategies

information yielded, and the degree to which the measure validity reflects the diagnosis in question (Summerfeldt & Antony, 2002). These factors reciprocally influence each other and affect the decision to choose a given structured interview.

The competent clinical psychologist must carefully weigh these issues. The question relating to the number of diagnoses to consider in a specific context has its roots in the very nature of the patients seen in clinical prac- tice and practical considerations. In clinical research studies, structured interviews are used to rule out extraneous sources of diagnostic variabil- ity and to ultimately identify relatively homogenous groups of participants who share the same diagnosis, recognizing the existence of the patient uni- formity myth (Kiesler, 1973). In the interest of achieving sound research methodology, clinical psychology researchers often seek to minimize indi- vidual differences. In clinical practice, however, psychologists have the opposite goal: the clinician is interested in describing the unique aspects of the client, and this usually entails consideration of multiple diagnoses and traits, with an emphasis on what makes an individual different. How else might one then truly capture the unique essence of a client?

In either case, however, issues of practicality prevail, for to consider all possible diagnoses in the DSM system would present a daunting task for any professional in terms of time, effort, and cost. While there is a positive relationship between the number of diagnoses one wishes to assess and the number of questions to be asked, there is an inverse relationship between the breadth of diagnostic coverage sought and the amount of detailed infor- mation one acquires about each possible diagnosis (Summerfeldt & Antony, 2002). While reconciling these issues is necessary, this task is fraught with many other problems as well. For example, in summarizing the psycho- metric status of structured interviews, Groth-Marnat (1997) has concluded that clinicians are more consistent in their clinical decisions when judging presence or absence of minimally inferential and directly observable attri- butes of less complicated cases. Nonetheless, competent clinicians must make important decisions about selecting specific structured interviews.

In choosing a structured diagnostic interview for clinical use, the com- petent clinician would be wise to consider a number of factors. These fac- tors, conveniently summarized by Summerfeldt and Antony (2002), fall into several distinct areas: diagnoses included and disorder characteristics (e.g., severity); adequacy for populations of interest; reliability and valid- ity characteristics; logistical issues; administration and scoring require- ments; and availability of formalized sources of information for assistance (e.g., technical manual). Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment28

The reliability and validity of diagnostic interviews are critical char- acteristics worth highlighting here. Reliability refers to the stability of the diagnoses derived from these interviews by the same clinician over time (test–retest) and between clinicians (interrater reliability), and the overall homogeneity and internal consistency of the item pool. Validity refers to the extent to which these systems measure what they have been designed to measure. Types of validity of relevance include content validity (adequacy to which the content of the interviews represents the universe of the content domain); construct validity (degree to which the diagnosis is in fact a measure of the construct); and criterion-related (predictive and concurrent validity in that the diagnoses derived should be capable of differentiating patients from other patients with different diagnoses in the present or in the future on some criterion of interest). Validity studies have been hampered by the lack of an objective, inde- pendent criterion standard, as found in judgments by psychiatrists that could hardly considered as such (Groth-Marnat, 1997). Nonetheless, there appears to be benefit from providing more structure to the inter- view process.

There are currently a number of commonly available structured and semi-structured interviews for Axis I, Axis II, and specific disorders. For a comprehensive review and discussion of some of these instruments, the reader is referred to Groth-Marnat (1997) and Summerfeldt and Antony (2002). Two examples of structured interview scales include: the Anxiety Disorders Interview Schedule–Revised (ADIS-IV) (DiNardo, Brown & Barlow, 1994) and the Eating Disorders Examination (EDE) (Fairburn, Cooper, & O’Connor, 2008), The emergence of an interesting, alternative approach to assessment is found in behavioral assessment.

Behavioral Assessment Behavioral assessment refers to a distinctive, empirically based assessment paradigm that has its roots in behavior therapy (Ascher & Esposito, 2005). This model grew out of dissatisfac- tion with traditional trait-based models of assessment that relied heavily on inference as opposed to directly observable and verifiable data; viewed the symptoms as emerging from some nonobservable underlying causative agent (e.g., unresolved conflict); and asserted that assessment data must be generalized to some criterion in the life of the client. In behavioral assess- ment there is minimal inference, direct observation, and verifiable data, and the test setting and the criteria are identical. Bellack and Hersen (1998) defined several critical and distinguishing components of behavioral assessment in that it is an empirical, multimodal, and after multimethod, Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

29Assessment Strategies

multi-informant approach that places a premium on the specification of observable behavior and time-related causal factors.

The overarching goal of behavioral assessment is twofold: to provide a solid foundation for clinical decision-making and to facilitate the develop- ment and implementation of interventions for altering behavior (Haynes, Leisen & Blaine, 1997; Haynes & Williams, 2003). The process of behav- ioral assessment yields critical information for the clinical psychologist by carefully describing the problematic target behavior of the client; the situations under which it is reliably observed to occur; the frequency, intensity, and/or duration of the behavior; and the impact of the behavior on the client and his or her environment through what is contingently gained, avoided, or escaped as a result (Bellack & Hersen, 1998; DiTomasso & Gilman, 2005).

As DiTomasso and Gilman (2005) have noted, using a broad-based def- inition of behavior and sharing assumptions of the behavioral approach, behavioral assessment emphasizes (1) the primary role of learning in the precipitation, development, and maintenance of maladaptive behaviors; (2) the importance of directly observable and verifiable behaviors; (3) the value of a here-and-now, present-focused orientation; (4) the belief that the target behavior is the problem as opposed to some presumed underly- ing source; (5) learning as a key explanatory and therapeutic mechanism; and (6) fostering effective behavior change through a process of learning to replace problematic behaviors with incompatible, adaptive behaviors. Behavioral assessment may be combined with traditional forms of assess- ment to enhance the clinical picture of the client and to facilitate treat- ment planning.

To implement behavioral assessment effectively, the clinical psycholo- gist must approach the assessment process with a number of key points in mind; to do otherwise undermines the process. We provide a fairly com- prehensive list of recommendations described in detail below (Bellack & Hersen, 1998; DiTomasso & Colameco, 1982; DiTomasso & Gilman, 2005). These recommendations are based on the unique assumptions and char- acteristics of behaviorally based assessment processes. Behavioral assessors must carefully and precisely specify the target behavior in question, opera- tionalize it in observable descriptions, facilitate its detection, differentiate it from other behaviors, and provide reliable recording. Observation oppor- tunities are planned and scheduled (e.g., time sampling or event sampling) in such a manner as to obtain representative observations across a num- ber and variety of situations. Multiple methods may be employed that are based on the specific problem and the nature of the problematic behavior. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment30

Relevant dimensions such as frequency, intensity, and duration of behav- iors are most often obtained in the natural environment and are collected by independent trained observers, the client, or other individuals in the client’s natural environment. Moreover, reliance on different informants is utilized to provide perspectives from multiple sources, each employing behavioral assessment tools in which he or she has been adequately trained regarding when and how to collect the information.

In behavioral assessment, behavior is broadly construed to include more than the client’s overt behavior, including cognitions, emotions, and physiological parameters, with the intent of making the typically unob- servable more observable. Even when standardized self-report measures are employed, such as behavioral rating scales, they comprise explicitly defined behavioral descriptors that represent an adequate sampling of the universe of the content domain that defines the construct of interest. Also, specific stimulus conditions that represent circumstances under which the target behavior occurs must be identified. An analysis of differential situa- tions under which the problem behavior is manifested may provide impor- tant clues to subtle precipitants. One must also identify comprehensive time-related and associated causal factors. These data include antecedent conditions; target behaviors; and client thoughts, images, and feelings as well as important consequential events that may be critical in reinforcing and maintaining the target behaviors (Sturmey, 2007). Here, the assessor is focused on what the client gains from the target behavior as well as what aversive circumstances the client is able to avoid or escape. In addition, one must collect repeated measurements as a function of time extending from baseline throughout treatment, with one or more follow-up points at periodic times.

In describing this process, DiTomasso and Gilman (2005) have noted that

Assessment is therefore not a one-shot deal. Rather, the clinician obtains a series of integrated snapshots of the targets across a variety of relevant contexts . . . Baseline information provides a measure of the severity of the problem, useful information for performing a functional analysis, and a criterion against which to measure treatment efficacy. Ongoing data obtained during treatment further inform the case conceptualization, either supporting the selection of the treatment or necessitating the reanalysis of the problem and selection of another treatment . . . Follow-up data provide a measure of the stability of the behavior change. (p. 63) Co py ri gh t © 2 01 3. O xf or d Un iv er si ty P re ss . Al l ri gh ts r es er ve d. M ay n ot b e re pr od uc ed i n an y fo rm w it ho ut p er mi ss io n fr om t he p ub li sh er , ex ce pt f ai r us es p er mi tt ed u nd er

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

31Assessment Strategies

Finally, scheduling of observations must be planned in such a manner as to avoid the risk of bias and must be designed to provide a cost-effective means of gathering representative data. Careful consideration of factors influencing the reliability of observations must be addressed, such as interobserver agreement, reactive effects of observations, and efforts to ensure the integrity of reliability checks. Implementation of these guide- lines is likely to provide competent behavioral assessment.

Cognitive Assessment Clinical psychology practitioners are frequently called upon to conduct cognitive assessments. Included within this domain are a number of characteristics that affect the functioning in the everyday lives of our clients. Freeman and colleagues (2008) have described several critical areas of focus in this domain, including “attention, perception, memory, schemas, learning (intelligence, achievement, aptitudes), cogni- tive development, creativity, language, problem-solving, decision-making and judgment” (p. 150).

Intelligence consists of a variety of different abilities that are necessary in order to sustain existence and progress within the environment within which a person exists (Anastasi, 1996). Sternberg and Detterman (1986) have provided a consensus definition of intelligence as “the capacity to learn from experience, using meta-cognitive processes to enhance learn- ing, and the ability to adapt to the surrounding environment which may require different adaptations within different social and cultural contexts” (p. 469). Common examples of intelligence tests include the Wechsler Scales, the Kaufman Scales, and the Stanford-Binet.

The assessment of intellectual functioning has its roots in the early works of Binet and Wechsler and is one key area in which clinical psychol- ogists continue to seek to document and understand individual differ- ences in intellectual capacity. Over the course of its history, in reviewing a number of definitions of intelligence, Groth-Marnat (1997) has noted that intelligence, understood from psychometric, neurobiological, devel- opmental, and information-processing perspectives, encompasses ability in five critical areas: thinking abstractly, learning from one’s experience, problem-solving capacity, adjustment to novel circumstances, and using one’s abilities to attain a desirable objective.

Undoubtedly, the Wechsler scales are the most frequently used tools for assessing intelligence in children, adolescents, and adults. This is in large part attributable to the history of clinical and empirical work associated with these scales (Benson, Hulac, & Kranzler, 2010), which has established them as the “gold standard” (Stanos, 2004). While intelligence comprises Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment32

an overall global capacity affecting an individual’s behavior on the whole, it is itself a product of qualitatively distinct abilities (Psychological Corporation, 1997). Intellectual assessment is yet another skill unique to the clinical psychologist.

Achievement measures the extent of knowledge an individual pos- sesses within a specific content domain. Common individually admin- istered achievement tests include the Wechsler Individual Achievement Test, the Woodcock Johnson, and the Wide Range Achievement Test. In general, achievement tests measure what a person has acquired in areas such as reading, arithmetic, spelling, and writing (Richard & Huprich, 2009). Aptitude tests measure homogeneous components of ability (Anastasi, 1996). There are also numerous measures of musical, clerical, and mechanical aptitudes. Assessing memory, a key ingredient for learn- ing, encompasses an active and passive component, working memory and short-term memory, that reflect the information-processing capacity of a person (Psychological Corporation, 1997). One of the most well-known measures here is the Wechsler Memory Scales.

Clinical psychologists conduct cognitive assessments for any of a multi- tude of reasons, which invariably result from concerns that generate a refer- ral question. Such assessments may be used to establish baseline functioning, track changes in functioning over time, explain failures to attain devel- opmental milestones, document the adverse impact of an external insult (e.g., traumatic brain injury), or identify the effects of an internal malignant (e.g., brain tumor) or naturally occurring developmental process (e.g., aging process) (Freeman et al., 2008). The challenge for clinical psychologists is to make sense out of the vast array of information gleaned from a variety of different measures of cognitive ability, how these attributes characterize the uniqueness of the individual client, how they affect the functioning of the individual on a daily basis, and how they are likely to affect the future adap- tation of the person. Of particular importance is explaining and predicting how specific factors and events within the social, psychological, medical/ biological, and environmental realms have coalesced to have an adverse impact on the client and how they may be expected to forecast his or her capacity to handle certain experiences in the future.

The work of the competent clinical psychologist is evidenced by a thorough, reliable, and valid interpretation that parsimoniously explains the problems confronting an individual at a given time within a given context of living. Of course, to do so successfully and precisely requires not only the ability to competently generate hypotheses but also to systematically test and rule out these potential explanations Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

33Assessment Strategies

by considering the multitude of factors in context. Whatever the case, however, competent clinical cognitive assessment presupposes a thor- ough understanding of the unique processes being evaluated; a sound grasp of the empirical literature related to each process; advanced skill in selecting, administering, scoring, and interpreting such measures; experience with a population of interest; and, ultimately, skills in mean- ingfully synthesizing data.

In sum, clinical psychologists in clinical, educational, medical, and legal settings are frequently called upon to assess the cognitive capacities of clients and patients. To do so competently requires a thorough under- standing of available scales, their psychometric properties, administration skills, scoring, and interpretation.

Personality Assessment One of the mainstays of clinical psychology prac- tice is the assessment of personality. Personality may be defined as stable and long-standing patterns of thinking, perceiving, and behaving that characterize an individual’s transactions with the environment. More spe- cifically, Millon, Grossman, Millon, Meragher, and Ramnath (2004) have described personality as deeply rooted traits that find their expression in all areas of functioning. The assessment of personality is a high-level skill that usually entails the selection, administration, scoring, and interpreta- tion of a variety of different devices designed to tap one or more areas of personality functioning. Over the course of time, numerous measures of personality emerging from different schools of thought have been devel- oped and studied; they generally fall into one of two domains, projective and objective measures.

The use of projective drawings and incomplete sentence blanks has a long and hallowed tradition in clinical psychology, not to mention con- troversy. Examples include the Rorschach, the Thematic Apperception Test, the House Tree Person Test, and Projective Drawings. On the whole, projectives are based on a number of implicit assumptions about person- ality and its measurement. Most assuredly, the Rorschach is the strik- ing example of the projectives (Groth-Marnat, 1997; Richard & Huprich, 2009). It remains one of the most frequently used tests in clinical practice, in graduate training programs in clinical psychology, and in clinical psy- chology internships. While the central tenet underlying this methodol- ogy is surprisingly simple, the scoring and interpretation is anything but so. Questions about validity and reliability continue to this day, but as Groth-Marnat (1997) has indicated, while validity findings are more vari- able, in general reliability and validity are adequate. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment34

The Thematic Apperception Test, a projective test originally developed by Murray, requires clients to observe a series of structured cards depicting ambiguous situations; the client is asked to explain what is occurring, the thoughts and feelings of the main character, what led up to the situation portrayed, and the outcome (Groth-Marnat, 1997). While the procedure can be very useful in providing information about clients, controversy over reliability and validity persist.

The objective measurement of personality entails the use of stan- dardized objective self-report items that load on scales assessing various aspects of personality. These scales are derived by developing, calibrating, and testing a pool of items that make up various subscales; individuals respond with a “true” or “false” or some other Likert-type scaling proce- dure. Inherent within the design of these types of measures is that groups of items are clustered together statistically to provide reliable and valid measures of various attributes. One of the greatest strengths of these mea- sures is that the scoring of the items requires no human judgment or infer- ence on the part of the examiner (Nichols, 2001).

Included among these measures are the Minnesota Multiphasic Personality Inventory (MMPI), the California Psychological Inventory, and the Millon Clinical Multi-Axial Inventory III. Perhaps the best-known, most widely recognized, and most frequently utilized test of personality and emotional adjustment is the MMPI. It represents the standardized use of objectively presented items that load on one or more scales reflect- ing critical aspects of personality functioning and psychopathology. This instrument has a long and rich tradition of empirical and clinical his- tory attesting to its usefulness in clinical psychology circles. In the hands of a competent clinician, the MMPI is a powerful tool for assessing and understanding personality and necessitates a thorough consideration of the impact of demographic factors on the meaning of the scores. Nichols (2001) has outlined several important parameters related to competent use of the MMPI.

Family Systems Assessment The family systems approach has a number of distinct assessment tools associated with it that emphasize important factors related to family functioning. Given the complexity, volatility, and changeability of family systems, family assessment presents many chal- lenges (Skinner, Steinhauer, & Sitarenios, 2000) to the clinical psycholo- gist. As noted by Butler (2008), “Family diagrams visually record the facts of functioning across at least three generations of the multigenerational family . . . facts of functioning are factual information about such things Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

35Assessment Strategies

as physical problems, emotional symptoms, and educational achieve- ment placed on family diagrams . . . [and] are assumed to reflect the emo- tional processes within the family” (p. 171). Butler (2008) has thoroughly described the method for interpreting data obtained from these measures. Later, the widely used family genogram was introduced, serving a key function in the work of McGoldrick, Gerson, and Shellenberger (1999), who emphasized the context of the family. As pointed out by Butler (2008), assessment through the genogram includes a consideration of the follow- ing variables: the structure of the family, its constituents, the marriage, sib- ling birth, spacing of the offspring, the life-cycle stage, cross-generational patterns, and parts played and functions served by family members.

Family functioning and patterns of transaction are often targets of inter- est for clinical psychologists working within family systems. Systematic assessment of critical areas of family functioning and related constructs is important in identifying important targets. One of the best-known and most comprehensive models of family treatment is the McMaster Approach. The assessment model derived from this approach is based on several critical assumptions, as described by Miller, Ryan, Keitner, Bishop, and Epstein (2000).

Miller et al. (2000) describe and define six areas of family functioning: the ability to solve problems, patterns and quality of relaying information to each other, engagement in functional tasks, the amount and degree of appropriate responses to expressed feelings, the extent of involvement of members with each other, and the means and extent to which influence is exerted over the behavior of its members. In addition to these dimen- sions, this model proposes that how members interact with each other influences the extent to which a family is functional or dysfunctional, necessitating change in the latter instance. Examples of assessment tools derived from this model include the Family Assessment Device (Epstein, Baldwin, & Bishop, 1983), the McMaster Clinical Rating Scale (Miller, Bishop, Epstein, & Keitner, 1994), and the McMaster Structured Interview for Family Functioning (Bishop, Epstein, Keitner, Miller, & Zlotnick, 1980).

Based on the Process Model of Family Functioning, Skinner and col- leagues (2000) provide an interesting framework for conducting fam- ily assessment focusing on the ability of the family to negotiate typical, expected, and unexpected tasks challenging families. The Family Assessment Measure (FAM) is an unusual measure that is used to compile data on an overall measure of general family functioning, relationships between dyads within the family, and the perception of family members Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment36

about their own functioning within the family. Comparisons across these domains can yield a clinically rich picture of the family.

Two other interesting models of assessment include the Beaver Systems Model of Family Functioning (Beavers & Hampson, 2000) and the Circumplex Model of Marital and Family Systems (Olson, 2000). Briefly, the Beaver Model emphasizes two important factors—competence (flexibility and adaptation) and style of interacting—which are combined to yield nine pos- sible descriptors, three of which are considered functional (optimal, adequate, and mid-range group 3 families) and six clearly dysfunctional (mid-range groups 4 and 5, groups 6 and 7 borderline families, and groups 8 and 9 severely dysfunctional families) in need of treatment. The Circumplex Model (Olson, 2000) emphasizes three important dimensions considered by many to be vital to family functioning: cohesion, flexibility, and communication.

Gottman and Notarius (2002) provided a thorough review of empirical data on marital research and recommended the need for more research in what they considered five key areas. Comparisons of what behaviors differ- entiate distressed and nondistressed couples in vivo has much to offer from an assessment perspective (Van Windenfelt, 1995). Detecting and attend- ing to observable regular and repetitive patterns of communicating and interacting reveals predictable sequences of interaction that constitute dys- function and lead to dissatisfaction. Avoiding the all-too-common focus on pathological factors and seeking evidence for strengths such as emotional support, positive feelings, and intimate behaviors is important. Gottman and colleagues (2002) have pointed toward the relative absence of positive affect as opposed to the presence of negative affect that ultimately predicted divorce. Assessment of personality characteristics of partners is also likely to yield important information that influences styles of thinking, emoting, behaving, communicating, and relating in partners. Assessing the impact of stressors outside of the relationship per se and how these stressors creep into the relationship must be considered. Finally, the important role of marital cognitions, in the form of perceptual biases and selective attention as tapped through the Oral History Interview, was supported by Carr è re, Buehlman, Gottman, Coan, and Ruckstuhl (2000). Another important framework for assessment stems from Gottman’s Sound Marital House (Gottman et al., 2002), containing components that represent the building blocks for constructing and maintaining an effective marital relationship.

Self-Monitoring Self-monitoring is a behavioral assessment technique designed to yield self-observed information in which the client is actively and collaboratively employed as a data collector (DiTomasso & Colameco, Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

37Assessment Strategies

1982; DiTomasso & Gilman, 2005). The targets of this data-collection pro- cess usually include any number of a variety of facets of the client and his or her environment. Clinical psychologists, especially those from the cognitive-behavioral tradition, employ client self-monitoring as an important tool that yields clinically useful information. This information directly informs the clinical decision-making process and serves as a tool for treatment planning. The logic behind self-monitoring is that through a standardized procedure clients can provide valid and reliable information related to their behavior, broadly defined of course. Antecedent and con- sequential conditions serve respectively as occasions for the emission of target behaviors as well as contingent reinforcers that serve to strengthen and maintain problematic behaviors. As is true with behavioral assess- ment data in general, self-observations may be recorded in vivo, in vitro, or during analog tasks and can easily be incorporated into an assessment battery.

Commonly, self-monitored data may include information on day, time, situation, thoughts, images, feelings, symptoms, behaviors, and conse- quences. An inherent aspect of this process in the analysis of these data is the association between each of these facets and potential causal relation- ships in conducting a thorough functional analysis (DiTomasso & Gilman, 2005; Sturmey, 2007). There are a multitude of possible self-monitoring devices available for clinical use, the design of which depends in large part on what exactly is being measured. Self-monitoring tools include things such as a food intake diary (Brownell, 2000), headache chart, mood diary (Beck, 1995; Burns, 1980), smoking chart, and the like. Each device includes specific measures of relevance to the problem at hand.

As outlined by DiTomasso and Colameco (1982), there appear to be a number of practical considerations for clinical psychologists when planning to competently employ a self-monitoring approach to assessment. Clients must be educated about self-monitoring, its importance and clinical utility, the critical importance of producing valid and reliable data, and exactly how to use the technique. The clinician must also carefully and precisely specify the objective components of the behavior to be recorded, communi- cate this definition to the client, and guide the patient in practice using the procedure. The clinician must weigh the practical considerations in using the strategy against the amount of information to be yielded. Inordinately complicated procedures that require a great deal of time, cost, energy, and inconvenience for the client may undermine data gathering. Also, histori- cal and related changes in the client or his or her environment must be considered lest they be confused with changes associated with treatment. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment38

Clinicians need to emphasize the need to collect self-observations over a wide variety of situations that occur naturally in the client’s environment, or when necessary, even arrange a situation in which the response should occur (e.g., arranging for a social phobic to initiate a social encounter with a stranger in a public place). The clinician must highlight the importance of obtaining valid and reliable self-observed data from the client and rein- force the client’s efforts at doing so. Caution is urged in ensuring that the client is not rewarded for producing data that only suggest improvement.

The psychologist should educate the client about the impact of reactiv- ity effects on the behavior being observed, stress the importance of accu- racy, and capitalize whenever possible on the therapeutic, albeit transient, benefits of self-observation to enhance the client’s motivation and efficacy for change (Shelton & Rosen, 1980). Whenever feasible, the assessor should consider invoking the assistance of someone in the client’s environment as an unobtrusive, random reliability checker. As a means of improving the accuracy of self-recordings, early research in this area supported the prac- tice of informing self-observers that reliability will be checked, but not disclosing when the checks would occur (Lipinski & Nelson, 1974; Reid, 1970). Awareness of the potentially biasing impact of expectancy on global evaluations of a problem must also be considered. Research in behavioral assessment has ruled out the impact of expectancy biases when specific, behavioral observations are self-monitored or observed by others (Kent, O’Leary, Diament, & Dietz, 1974; Lipinski & Nelson, 1974; Redfield & Paul, 1976). Finally, clinicians should plan on obtaining repeated measurements of self-observed data that ideally span the time from baseline, throughout treatment, and ultimately at several follow-up points.

In summary, clinical psychologists have a number and variety of assess- ment methods at their disposal. Competent clinical assessment entails using a multimodal approach in synthesizing information from a variety of reliable and valid sources. These assessment data provide a foundation for determining a diagnosis and developing a case formulation.

Relationship Between Assessment, Diagnosis, and Case Formulation

Assessment, diagnosis, and case conceptualization are interdependent in a stepwise fashion, with diagnosis and formulation built upon assess- ment. We would propose that diagnosis and conceptualization are as only as good as the assessment from which they are derived. As noted previ- ously, the quality, value, and clinical utility of psychological assessment itself hinges on a variety of factors related to the characteristics of the Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

39Assessment Strategies

assessor, the assessment process, the methods chosen, the tools selected, their psychometric properties, the problems being assessed, the setting in which assessment is conducted, the explicit purpose of the evaluation, as well as characteristics of the assessment. Potential biases, reliability issues, and validity concerns loom large and in turn can directly affect related processes. For these reasons the assessment process can have a dramatic impact on the diagnoses assigned as well as the conceptualization of a case. We would suggest that valid, reliable psychological assessment coupled with competent clinical judgment is a prerequisite to accurate diagnosis and case formulation.

Clinical judgment errors in terms of questions asked or not asked and the manner in which clinical information is synthesized can markedly affect the diagnostic process. There is reason to believe that the diagnostic process can be improved by standardizing the diagnostic process through a more structured format. However, blind allegiance to one form of assess- ment can certainly undermine and overlook other essential information that may serve to qualify the diagnoses assigned.

One important consideration in diagnosis is the concept of an essen- tial criterion (Zimmerman, 1994) that must be met in order for a patient to qualify for a given diagnosis. For example, while depressed mood is an essential ingredient of a mood disorder, recurrent unexpected anxiety attacks accompanied by sympathetic arousal and fear of the symptoms themselves are important determinants of a panic disorder diagnosis. However, competent clinicians realize that differential diagnosis requires consideration of other factors that may serve to mimic a psychological disturbance—hypothyroidism in depression and pheochromocytoma in panic, for example. Among a host of factors, the overlap in diagnostic criteria of psychological disorders, comorbidity, level of clinical severity, ability to report symptoms, and cultural factors further serve to cloud the picture and provide challenges to clinicians.

Psychological assessment is also critical for case formulation. It is difficult to imagine a clinically useful case conceptualization that does not rely on psychological assessment of some sort. There are a variety of case conceptu- alization formats discussed in this book, and each relies on the use of psy- chological data. Improperly conducted assessments provide flawed data that may serve to fuel one conceptualization over another. As Needleman (2005) has noted, the conceptualization itself is actually a product of the synthesis of “empirically validated or theoretically-derived assessment methods; col- laboration with clients; and clinical judgment” (p. 98). An inaccurate con- ceptualization may then be used to support a problematic treatment plan. Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment40

Models emerging from diverse theoretical orientations obviously include and emphasize and prefer some factors over others, evidenced by the obser- vations made, hypotheses derived, and assessment strategies employed. To illustrate the relationship between assessment and case formulation we will use the example of cognitive-behavioral case conceptualization.

Needleman (2005), employing components of his own model (Needleman, 1999) as well as that of Persons (1989), has provided an exhaustive list of components of case conceptualization that mutually influence each other, including a comprehensive list of client problems; related precipi- tating stressors; diagnostic data; core underlying beliefs and conditional beliefs; information-processing strategies; coping strategies; maladaptive thoughts, feelings, and behavioral responses to current environmental triggers; client positive characteristics; and a variety of mechanisms that serve to sustain problems. Each of these critical components is clearly influenced by the technical characteristics of the data-gathering strate- gies, the openness and willingness of the assessor to consider competing hypotheses, as well as the integrity of the model from which the conceptu- alization is derived (Needleman, 2005).

While competent psychological assessment presupposes knowledge and skills in selecting, administering, scoring, integrating, and interpreting data gathered from psychological approaches, other factors warrant con- sideration as well. Careful consideration of the host of factors that essen- tially define assessment, the characteristics of the processes themselves that can undermine and bias it, and an attitude of scientific skepticism, scrutiny, and self-awareness are crucial.

Finally, the ethical practice of assessment entails a number of critical components. A foundational ethical competence in assessment dictates that clinical psychologists are responsible for possessing a sound basis for their interpretations; use assessment strategies appropriately; obtain informed consent; release test data prudently; demonstrate knowledge of the host of factors that may influence test performance; exhibit care in interpretation; prevent the use of assessments by those unqualified to do so; base all findings on current test data and tests; and exhibit caution in the use of test services, explain the results of assessment, and keep test materials secure (APA, 2002).

Benchmark Competencies for Assessment

In attaining and maintaining competence in assessment, there are a num- ber of benchmark competencies to be achieved as one moves forward Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

41Assessment Strategies

from entry into a graduate program to readiness for practicum experi- ences, to readiness for beginning internship, and to ultimate completion of the doctorate and being prepared to begin practice. The Competency Benchmarks Work Group (Fouad et al., 2009) proposed assessment as a functional competency comprising several components. The components of competency development in assessment include knowledge of prin- ciples of measurement and psychometrics, understanding of methods of evaluation, choosing appropriate measures that provide answers to ques- tions, diagnostic skills, ability to formulate and recommend, and ability to communicate the results of the assessment process.

Assessing Competence in Assessment

Kaslow and colleagues (2009) recommend a host of relevant methods for psychologists to self-assess in the assessment domain. The recommended methods vary as a function of the component being assessed. We present some general recommendations based on their work. “Very useful” meth- ods and “useful” methods include the following: annual reviews, con- sumer surveys, objective structured clinical examinations, performance ratings, portfolios, record reviews, simulations, standardized patients, oral exams, written exams, and 360-degree evaluations. Competent psy- chologists welcome information about their knowledge and skill in the assessment realm and seek to utilize a variety of methods to document, sustain, and expand their competence in the realm of practice.

Concluding Remarks

Assessment competence will remain a critical aspect of the role of the clin- ical psychologist and one that distinguishes clinical psychology practice from other specialists outside of psychology. Clinical psychologists who seek to provide assessment services must be prepared to meet the chal- lenges confronting them in the daily practice of their craft. Effectiveness in assessment presupposes the possession of critical knowledge, skills, and attitudes. Achievement, maintenance, and expansion of competen- cies at various stages of professional development in this domain require focused self-assessment planning based on one or more evaluation tools and actions to consolidate competence.

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

THREE

Case Formulation Models

A 35-year-old healthy female patient is referred by her primary care phy- sician to a clinical psychologist for problems related to panic and fear of having a heart attack. During the past year she has experienced a vari- ety of interpersonal stressors, including witnessing the unexpected death of her father. Since that time the client reports several instances of panic attacks each day; they come on suddenly, appear out of the blue, and peak quickly. She has had over 30 visits to the emergency room of her local hospital as well as numerous visits to her physician. Three key compo- nents of her panic attacks are shortness of breath, accelerated heart rate, and chest pain. Despite repeated medical reassurance and a clean bill of health, she firmly believes that she will suddenly stop breathing and die from a heart attack. She has a deep sense of vulnerability encapsulated in the catastrophic belief that something terrible will happen to her at any moment. As a result she feels unsafe when home alone or outside of the house and has stopped all physical exercise and use of caffeine. Her clini- cal psychologist is challenged with conceptualizing the onset and mainte- nance of her problem and developing an effective treatment plan to resolve her concerns.

As implied by the foregoing case, an important distinguishing com- petency of the specialist in clinical psychology is the ability to conduct a comprehensive and intensive assessment of a client. The ability to gather, synthesize, and interpret information from a variety of reliable and valid sources is paramount to the effective process of assessment, diagnosis, and treatment. One critical area of competence in clinical psychology, then, lies in the process known as case formulation or conceptualization. Fouad Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

43Case Formulation Models

and colleagues (2009) view the ability to conceptualize cases as one of six pivotal components of the Functional Competency of assessment. Eells (1997) has defined case formulation in this manner: “Case formulation is essentially a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral prob- lems . . . It should serve as a blue-print guiding treatment, as a marker for change, and as a structure enabling the therapist to understand the patient better” (pp. 1–2). The clinical psychologist must, then, be able to develop a clear and coherent model that accounts for the problems and symptoms of the individual presenting for care.

Case conceptualization is a higher-level activity that requires the inte- gration and synthesis of collected information or data about an individual from a theoretical model that forms the basis for explaining and predict- ing the behavior of this individual. The ultimate product is a clinically useful and theoretically informed model that adequately captures and thoroughly accounts for the essence of an individual’s complaints and forms some cogent, overarching explanation. Ideally, this model provides a foundation for understanding the client’s presentation (Nezu, Nezu, & Lombardo, 2004).

Case conceptualization represents a process that is theoretically bound, meaning that different theoretical orientations posit specific constructs about which the clinician must be knowledgeable. In this sense, compe- tence in formulating an individual case necessitates a firm grounding in a given model of psychopathology and treatment (see Hollon & Dimidjian, 2009). Each model has its own set of constructs that are theoretically tied in a formalized manner to explain the problems of a client. Each formula- tion model, then, places primary emphasis on one or more key constructs and may minimize, ignore, or downplay constructs that are central to other models. In any case, the clinical psychologist needs a guide for han- dling problems that emerge in practice, managing treatment decisions, and applying theoretical constructs in a practical context. Case formula- tion fulfills this need.

Currently, there exist a number of case formulation models, each asso- ciated with a given theoretical perspective. Eells (1997) has elucidated how specific models of case formulation are inherently tied to a clinician’s assumptions about the causes of psychopathology, the adoption of either a categorical or continuum perspective of abnormality, and what essen- tially is seen as constituting mental health and dysfunction. Some com- mon case conceptualization models include Psychodynamic (Luborsky, 1976), Functional Analytic (Sturmey, 2007), Behavioral (Wolpe & Turkat, Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment44

1985), and Cognitive-Behavioral (Beck, 1995; Kuyken, Padesky & Dudley, 2009; Needleman, 1999; Nezu et al., 2004; Persons, 1989). Before provid- ing a brief description of each model, we present a more general review of the goals and functions of case formulation. These goals and functions provide important information about the development and application of a case formulation model in a competent manner. Most importantly, the competent clinical psychologist is keenly aware of the many advantages that case formulation provides in the clinical context.

Goals and Functions of Case Formulation

The goals and functions of case conceptualization underscore the need for the clinical psychologist to possess a number of important competencies. Generally, a sound formulation model provides a theoretical framework that allows the practitioner to explain and predict a client’s behavior, over- comes the limitations of diagnostic systems, and enhances the therapeutic relationship. Moreover, among others, a formulation serves as a basis for psychoeducation, overcoming practical problems, and enhancing treat- ment effectiveness. The very process of formulation itself, then, highlights the need for requisite knowledge and skills in a number of areas.

In a sense case conceptualization may be construed as a theoretically based template that the competent clinical psychologist may fit over the details gathered about an individual client, organizing the information in a clinically relevant and meaningful manner. This template helps to guide the clinician in searching for and gathering critical information that facil- itates a thorough understanding of the client, thereby guiding the clinical psychologist in this process. This ever-evolving process is responsive to the ongoing collection of assessment information that is self-correcting in a continuous manner. The conceptualization is tailor-fitted to the indi- vidual patient. Clinical psychologists must be careful to avoid forming conceptualizations that attend only to confirmatory data and ignore dis- confirming information. Ultimately, through a model, the clinician must accurately and meaningfully synthesize and integrate the thoughts, feel- ings, behaviors, beliefs, and symptoms of the client.

A formulation model must also meet the goal of providing a thorough understanding of the patient’s problems (Persons, 1989). In this sense, it must possess both an explanatory and predictive capacity. In employ- ing a given model the competent clinical psychologist must ask how well the model explains or accounts for the current problems and symptoms of the client. Likewise, the model must also be able to predict the future Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

45Case Formulation Models

behavior of the client. Explaining behavior, however, is far easier than pre- dicting it. Some theoretical models may be more successful in attempting to understand behavior but less successful in reliably and validly predict- ing it. Whatever the case, the point is that the model chosen by the clinical psychologist in any given case may influence the successful treatment of the client (see Barber & Crits-Christoph, 1993).

In competently employing a conceptualization model, the psychologist seeks to understand the unique characteristics of the client. The compe- tent psychologist realizes that no two clients who share the same diagno- sis are truly alike (Kiesler, 1973). Case conceptualization helps to account for individual differences between clients and how similar problems may emerge from different causes (Needleman, 1999). Formulation, therefore, enables the psychologist to overcome the significant limitations associated with the available diagnostic system and to capture the unique idiosyn- crasies of the client (Needleman, 1999). A critical challenge in treatment planning for any clinician is comprehensively capturing and understand- ing the unique essence of a client, over and above whether a client meets a minimum number of criteria necessary to warrant a given diagnosis. The DSM-IV diagnostic system, for example, has been criticized by some behaviorally oriented practitioners on these grounds. DiTomasso and Gosch (2002b) have noted that a problem with structural classification resides in the notion that behaviors defining the diagnostic criteria across patients may actually result from unique causes based on learning expe- riences that ultimately must be addressed to adequately design tailored interventions.

Nevertheless, the DSM system, while not perfect, is essentially evidence-based and is a standard tool used by all clinical psychologists, who must be competent in its use for case conceptualization. A concep- tualization model of a client, therefore, underscores the need for bridging the gap between a diagnostic label, the distinct characteristics of the cli- ent, and effective treatment planning. It provides a mechanism for appre- ciating the individual client working with a given clinician in a unique therapeutic context and consequentially offers numerous benefits regard- ing the therapeutic relationship.

The competent clinical psychologist is capable of using the formulation model to inform the therapeutic relationship. The information gleaned from the conceptualization is likely to be useful in facilitating the collabo- ration between the client and therapist (Persons, 1989; Needleman, 1999) and may increase the quality of the therapeutic alliance. Considering that the working alliance comprises the agreement on the goals and tasks of Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

Functional Competency: Assessment46

therapy and the bond between client and psychologist (Horvath & Bedi, 2002), it is understandable how a formulation may be helpful in fostering a more effective alliance. The profound importance of the therapeutic alli- ance (Duncan, Miler, Wampold, & Hubble, 2010) is supported by an exten- sive body of research (see Chapter 11). Competent psychologists are able to build effective therapeutic relationships (Duncan, Miler, Wampold, & Hubble, 2010; Norcross, 2002), which are characterized by elements such as perceived warmth, empathy, understanding, respect, and congruence. These characteristics are more likely to be facilitated by a thorough under- standing of the client embedded within a sound formulation model.

The formulation may also provide a number of other advantages. It may provide a list of factors that may not only potentially rupture a therapeutic alliance but repair one as well. Second, it may help to explain a client’s reaction to the therapist or even a therapist’s reactions to a client. Finally, it may assist the clinician by providing a means for explaining the repeated experiences of the client both inside and outside of the consulting room. In any given instance, these factors may profoundly influence the course and outcome of treatment. Competent clinicians are not only attuned to these factors but are skilled in gleaning relevant information from these experiences and using them in the service of the client.

Case conceptualizations may also serve an important function in assist- ing clinical psychologists to navigate their way through complex clinical situations. For example, by helping to prioritize a client’s problem list, the model may allow the clinician to determine how and whether progress on some problems would have a theoretical basis for generalizing to other problems. As an important bridge between theory and practice, the for- mulation of a patient may also provide a more systematic approach to han- dling patient problems in the clinical context, including alliance ruptures, anger, and unexpected reactions or events. By helping to address unfore- seen issues that typically develop in the therapeutic context (Persons, 1989) and issues that are largely ignored by theories (Persons, 1989), the competent clinical psychologist is in a better position to handle problems (e.g., transference and countertransference reactions, resistance). The con- ceptualization may mediate its effects by helping the clinician to generate hypotheses, handle practical problems, develop useful solutions, inform clinical decisions, tailor the treatment to the client, provide parsimonious explanations for problem behaviors, and improve clinical decision-making (Nezu et al., 2004).

In this age of evidence-based treatments, transporting effective treat- ments into the consulting room, while no easy task, is critical. A number Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .

47Case Formulation Models

of factors may impede generalization from the randomized clinical trial to the client in the office. An accurate formulation may enhance the impact of treatment and provide a basis for extrapolation from standardized treatment protocols (Needleman, 1999) by guiding the clinical psycholo- gist in customizing the treatment to the patient. As Nezu et al. (2004) put it, “One size does not fit all” (p. 5). The implication here is that the empiri- cal basis of treatments is not a “cookbook” approach, which is all too often an unjustified criticism of manualized treatment protocols. A competent psychologist understands that case conceptualization provides the vehicle for flexibility (Kendall, Chu, Gifford, Hayes, & Nauta, 1998) that is the key for clinical application and effectiveness. Indeed, some treatment manu- als, such as interpersonal psychotherapy for binge eating disorder, dictate formulating a case conceptualization. A similar point may be made about treating major depression through cognitive therapy, problem-solving therapy, or interpersonal therapy.

Case conceptualizations are particularly useful in promoting a client’s understanding of his or her problems (Needleman, 1999). In developing a formulation, the competent clinical psychologist engages the client, obtains feedback about goodness of fit, and alters the model to maximize the fit for the client. Clients who have an understanding of their problems may be better able to accept the need for treatment, develop enhanced motivation for treatment (Needleman, 1999), view the treatment as more credible, be more likely to assimilate treatment into their lives, and adhere to treatment recommendations. A thorough understanding of the cli- ent’s problem may also help to identify treatment barriers and obstacles (Persons, 1989). Finally, helping the client to appreciate that a problem is treatable may help to instill a sense of hopefulness (Needleman, 1999). A competent psychologist harnesses the benefits of fostering the client’s understanding of his or her problems and uses them to maximize out- come in the treatment of the client. Kuyken and colleagues (2009) report how case conceptualization offers a variety of additional benefits that are likely to have an impact on the therapeutic process and outcomes. They identified several functions of the case conceptualization, which we sum- marize below.

A case conceptualization provides a vehicle for synthesizing the client’s experience with existing theoretical models and research data (Kuyken et al., 2009). In this sense the client’s problem is tied and connected to an existing model of personality, psychopathology, and behavior change. In doing so, the psychologist has a frame of reference for systematically orga- nizing his or her thinking about the client. This function makes therapy Co

U. S. o r ap pl ic ab le c op yr

ig ht l aw .