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A ngela Savanti was 22 years old, lived at home with her mother, and was employed as a

secretary in a large insurance company. She . . . had had passing periods of “the blues”

before, but her present feelings of despondency were of much greater proportion. She

was troubled by a severe depression and frequent crying spells, which had not lessened

over the past two months. Angela found it hard to concentrate on her job, had great difficulty

falling asleep at night, and had a poor appetite. . . . Her depression had begun after she and

her boyfriend Jerry broke up two months previously.

(Leon, 1984, p. 109)

Her feelings of despondency led Angela Savanti to make an appointment with a therapist at a local counseling center. The first step the clinician took was to learn as much as possible about Angela and her disturbance. Who is she, what is her life like, and what precisely are her symptoms? The answers might help to reveal the causes and probable course of her present dysfunction and suggest what kinds of strategies would be most likely to help her. Treatment could then be tailored to Angela’s needs and particular pattern of abnormal functioning.

In Chapters 1 and 2 you read about how researchers in abnormal psychol- ogy build a general understanding of abnormal functioning. Clinical practitioners apply this broad information in their work, but their main focus when faced with new clients is to gather idiographic, or individual, information about them (Bornstein, 2007). To help persons overcome their problems, clinicians must fully understand them and their particular difficulties. To gather such individual infor- mation, clinicians use the procedures of assessment and diagnosis. Then they are in a position to offer treatment.

jjClinical Assessment: How and Why Does the Client Behave Abnormally? Assessment is simply the collecting of relevant information in an effort to reach a conclusion. It goes on in every realm of life. We make assessments when we decide what cereal to buy or which presidential candidate to vote for. College admissions officers, who have to select the “best” of the students applying to their college, depend on academic records, recommendations, achievement test scores, interviews, and application forms to help them decide (Sackett, Borneman, & Connelly, 2008). Employers, who have to predict which applicants are most likely to be effective workers, collect information from résumés, interviews, references, and perhaps on-the-job observations.

Clinical assessment is used to determine how and why a person is behaving ab- normally and how that person may be helped. It also enables clinicians to evaluate people’s progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques

CLINICAL ASSESSMENT, DIAGNOSIS, AND TREATMENT C H A P T E R :3

TOPIC OVERVIEW Clinical Assessment: How and Why Does the Client Behave Abnormally? Characteristics of Assessment Tools Clinical Interviews Clinical Tests Clinical Observations

Diagnosis: Does the Client’s Syndrome Match a Known Disorder? Classification Systems DSM-IV-TR Is DSM-IV-TR an Effective Classification System? Can Diagnosis and Labeling Cause Harm?

Treatment: How Might the Client Be Helped? Treatment Decisions The Effectiveness of Treatment

Putting It Together: Renewed Respect Collides with Economic Pressure

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and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity.

Characteristics of Assessment Tools All clinicians must follow the same procedures when they use a particular technique of assessment. To standardize a technique is to set up common steps to be followed whenever it is administered. Similarly, clinicians must standardize the way they interpret the results of an assessment tool in order to be able to understand what a particular score means. They may standardize the scores of a test, for example, by first administering it to a group of research participants whose performance will then serve as a common standard, or norm, against which later individual scores can be measured. The group that initially takes the test must be typical of the larger population for whom the test is intended. If an aggressiveness test meant for the public at large were standardized on a group of marines, for example, the resulting “norm” might turn out to be misleadingly high.

Reliability refers to the consistency of assessment measures. A good assessment tool will always yield the same results in the same situation (Weiner & Greene, 2008). An assessment tool has high test–retest reliability, one kind of reliability, if it yields the same results every time it is given to the same people. If a woman’s responses on a particular test indicate that she is generally a heavy drinker, the test should produce the same result when she takes it again a week later. To measure test–retest reliability, participants are tested on two occasions and the two scores are correlated. The higher the correlation (see Chapter 1), the greater the test’s reliability.

An assessment tool shows high interrater (or interjudge) reliability, another kind of reli- ability, if different judges independently agree on how to score and interpret it. True– false and multiple-choice tests yield consistent scores no matter who evaluates them, but other tests require that the evaluator make a judgment. Consider a test that requires the person to draw a copy of a picture, which a judge then rates for accuracy. Different judges may give different ratings to the same drawing.

Finally, an assessment tool must have validity: It must accurately measure what it is supposed to measure (Weiner & Greene, 2008). Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those read- ings are not valid, or accurate.

A given assessment tool may appear to be valid simply because it makes sense and seems reasonable. However, this sort of validity, called face validity, does not by itself mean that the instrument is trustworthy. A test for depres- sion, for example, might include questions about how often a person cries. Because it makes sense that depressed people would cry, these test questions have face validity. It turns out, however, that many people cry a great deal for reasons other than depression, and some extremely depressed people fail to cry at all. Thus an assessment tool should not be used unless it has high predictive validity or concurrent validity (Sackett et al., 2008).

Predictive validity is a tool’s ability to predict future characteristics or behavior. Let’s say that a test has been developed to identify elementary

schoolchildren who are likely to take up cigarette smoking in high school. The test gathers information about the children’s parents—their personal characteristics, smok- ing habits, and attitudes toward smoking—and on that basis identifies high-risk children. To establish the test’s predictive validity, investigators could administer it to a group of elementary school students, wait until they were in high school, and then check to see which children actually did become smokers.

Concurrent validity is the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques. Participants’ scores on a new test designed to measure anxiety, for example, should correlate highly with their scores on other anxiety tests or with their behavior during clinical interviews.

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Unreliable assessments For the first six seasons of the TV show American Idol, the performances of compet- ing singers were assessed by judges Randy Jackson (left), Paula Abdul (center), and Simon Cowell. Typically, Cowell’s assess- ment would be negative, Abdul’s positive, and Jackson’s somewhere in between. Such low interrater reliability may have reflected evaluator bias or defects in the scoring procedure.

•idiographic understanding•An understanding of the behavior of a particular individual.

•assessment•The process of collecting and interpreting relevant information about a client or research participant.

•standardization•The process in which a test is administered to a large group of people whose performance then serves as a standard or norm against which any individual’s score can be measured.

•reliability•A measure of the consis- tency of test or research results.

•validity•The accuracy of a test’s or study’s results; that is, the extent to which the test or study actually measures or shows what it claims.

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Clinical Interviews Most of us feel instinctively that the best way to get to know people is to meet with them face to face. Under these circumstances, we can see them react to what we do and say, observe as well as listen as they answer, and generally get a sense of who they are. A clinical interview is just such a face-to-face encounter (Sommers-Flanagan & Sommers- Flanagan, 2007, 2003). If during a clinical interview a man looks as happy as can be while describing his sadness over the recent death of his mother, the clinician may suspect that the man actually has conflicting emotions about this loss.

Conducting the Interview The interview is often the first contact between client and clinician. Clinicians use it to collect detailed information about the person’s prob- lems and feelings, lifestyle and relationships, and other personal history. They may also ask about the person’s expectations of therapy and motives for seeking it. The clinician who worked with Angela Savanti began with a face-to-face interview:

Angela was dressed neatly when she appeared for her first interview. She was attractive,

but her eyes were puffy and ringed with dark circles. She answered questions and related

information about her life history in a slow, flat tone of voice, which had an impersonal

quality to it. She sat stiffly in her chair. . . .

The client stated that the time period just before she and her boyfriend terminated

their relationship had been one of extreme emotional turmoil. She was not sure whether

she wanted to marry Jerry, and he began to demand that she decide either one way or

the other. Mrs. Savanti [Angela’s mother] did not seem to like Jerry and was very cold and

aloof whenever he came to the house. Angela felt caught in the middle and unable to

make a decision about her future. After several confrontations with Jerry over whether she

would marry him or not, he told her he felt that she would never decide, so he was not

going to see her anymore. . . .

Angela stated that her childhood was a very unhappy period. Her father was seldom

home, and when he was present, her parents fought constantly. . . .

Angela recalled feeling very guilty when Mr. Savanti left. . . . She revealed that when-

ever she thought of her father, she always felt that she had been responsible in some way

for his leaving the family. . . .

Angela described her mother as the “long-suffering type” who said that she had sac-

rificed her life to make her children happy, and the only thing she ever got in return was

grief and unhappiness. . . . When Angela and [her sister] began dating, Mrs. Savanti . . .

would make disparaging remarks about the boys they had been with and about men in

general. . . .

Angela revealed that she had often been troubled with depressed moods. During high

school, if she got a lower grade in a subject than she had expected, her initial response

was one of anger, followed by depression. She began to think that she was not smart

enough to get good grades, and she blamed herself for studying too little. Angela also

became despondent when she got into an argument with her mother or felt that she was

being taken advantage of at work. . . .

The intensity and duration of the [mood change] that she experienced when she broke

up with Jerry were much more severe. She was not sure why she was so depressed, but

she began to feel it was an effort to walk around and go out to work. Talking with others

became difficult. Angela found it hard to concentrate, and she began to forget things she

was supposed to do. . . . She preferred to lie in bed rather than be with anyone, and she

often cried when alone.

(Leon, 1984, pp. 110–115)

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Revealing Interview During World War II, recruits were briefly interviewed and tested by clinicians to determine their fitness for military service. When the famous (and witty) pianist Oscar Levant was asked whether he thought he was capable of killing, he is alleged to have pondered the question for a moment and then replied, “I am not sure about strangers, but friends and family, definitely yes” (Bahrick, 1996). <<

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Spotting Depression Family physicians recognize fewer than one-third of all cases of clinical depression that they encounter among their patients. Most of the undetected cases are mild (Coyne et al., 1995). <<

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70 ://CHAPTER 3

Beyond gathering basic background data of this kind, clinical inter- viewers give special attention to whatever topics they consider most im- portant (Wright & Truax, 2008). Psychodynamic interviewers try to learn about the person’s needs and memories of past events and relationships. Behavioral interviewers try to pinpoint information about the stimuli that trigger responses and their consequences. Cognitive interviewers try to discover assumptions and interpretations that influence the person. Humanistic clinicians ask about the person’s self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments.

Interviews can be either unstructured or structured (O’Brien & Tabaczynski, 2007; Rabinowitz et al., 2007). In an unstructured interview, the clinician asks open-ended questions, perhaps as simple as “Would you tell me about yourself ?” The lack of structure allows the interviewer to follow leads and explore relevant topics that could not be anticipated before the interview.

In a structured interview, clinicians ask prepared questions. Some- times they use a published interview schedule—a standard set of ques- tions designed for all interviews. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client’s awareness, orientation with regard

to time and place, attention span, memory, judgment and insight, thought content and processes, mood, and appearance (Palmer, Fiorito, & Tagliareni, 2007). A struc- tured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals.

Although most clinical interviews have both unstructured and structured portions, many clinicians favor one kind over the other. Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by behavioral and cognitive clinicians, who need to pinpoint behaviors, attitudes, or thinking processes that may underlie abnormal behavior (Hersen, 2004).

What Are the Limitations of Clinical Interviews? Although interviews often produce valuable information about people, there are limits to what they can accomplish (Hersen & Thomas, 2007). One problem is that they sometimes lack validity, or accuracy. Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discussing embarrassing topics. Or people may be unable to give an accurate re- port in their interviews. Individuals who suffer from depression, for example, take a pes- simistic view of themselves and may describe themselves as poor workers or inadequate parents when that isn’t the case at all.

Interviewers too may make mistakes in judgments that slant the information they gather. They usually rely too heavily on first impressions, for example, and give too much weight to unfavorable information about a client (Wu & Shi, 2005). Interviewer biases, including gender, race, and age biases, may also influence the interviewers’ inter- pretations of what a client says (Ungar et al., 2006).

Interviews, particularly unstructured ones, may also lack reliability (Wood et al., 2002). People respond differently to different interviewers, providing, for example, less information to a cold interviewer than to a warm and supportive one (Quas et al., 2007). Similarly, a clinician’s race, gender, age, and appearance may influence a client’s responses (Springman, Wherry, & Notaro, 2006).

Because different clinicians can obtain different answers and draw different conclu- sions, even when they ask the same questions of the same person, some researchers believe that interviewing should be discarded as a tool of clinical assessment. As you’ll see, however, the two other kinds of clinical assessment methods also have serious limitations.

•mental status exam•A set of interview questions and observations designed to reveal the degree and nature of a client’s abnormal functioning.

•test•A device for gathering informa- tion about a few aspects of a person’s psychological functioning from which broader information about the person can be inferred.

•projective test•A test consisting of ambiguous material that people interpret or respond to.

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Clinical Assessment, Diagnosis, and Treatment :// 71

Clinical Tests Tests are devices for gathering information about a few aspects of a person’s psycho- logical functioning, from which broader information about the person can be inferred (Gregory, 2004). On the surface, it may look easy to design an effective test. Every month, magazines and websites present new tests that supposedly tell us about our personalities, relationships, sex lives, reactions to stress, or ability to succeed. Such tests might sound convincing, but most of them lack reliability, validity, and standardization. That is, they do not yield consistent, accurate information or say where we stand in comparison with others.

More than 500 clinical tests are currently in use throughout the United States. Cli- nicians use six kinds most often: projective tests, personality inventories, response inventories, psychophysiological tests, neurological and neuropsychological tests, and intelligence tests.

Projective Tests Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as “Draw a person.” Theoretically, when clues and instructions are so general, people will “project” aspects of their personality into the task. Projective tests are used primarily by psycho- dynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning (Tuber et al., 2008; Hojnoski et al., 2006). The most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence- completion tests, and drawings.

RORSCHACH TEST In 1911 Hermann Rorschach, a Swiss psychiatrist, experimented with the use of inkblots in his clinical work. He made thousands of blots by dropping ink on paper and then folding the paper in half to create a symmetrical but wholly accidental design, such as the one shown in Figure 3-1. Rorschach found that everyone saw images in these blots. In addition, the images a viewer saw seemed to correspond in important ways with his or her psychological condition. People diagnosed with schizophrenia, for example, tended to see images that differed from those described by people experienc- ing depression.

Rorschach selected 10 inkblots and published them in 1921 with instructions for their use in assessment. This set was called the Rorschach Psychodynamic Inkblot Test. Ror- schach died just eight months later, at the age of 37, but his work was continued by others, and his inkblots took their place among the most widely used projective tests of the twentieth century.

Clinicians administer the “Rorschach,” as it is commonly called, by presenting one inkblot card at a time and asking respondents what they see, what the inkblot seems to be, or what it reminds them of. In the early years, Rorschach testers paid special atten- tion to the themes and images that the inkblots brought to mind (Weiner & Greene,

Figure 3-1 An inkblot similar to those used in the Rorschach test. In this test, individuals view and react to a total of 10 inkblot images.

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Believe It or Not By a strange coincidence, Hermann Ror- schach’s young schoolmates gave him the nickname Klex, a variant of the German Klecks, which means “inkblot” (Schwartz, 1993). <<

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72 ://CHAPTER 3

2008). Testers now also pay attention to the style of the responses: Do the clients view the design as a whole or see specific details? Do they focus on the blots or on the white spaces between them?

THEMATIC APPERCEPTION TEST The Thematic Apperception Test (TAT) is a pictorial projec- tive test (Tuber et al., 2008; Morgan & Murray, 1935). People who take the TAT are commonly shown 30 black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each card. They must tell what is happen- ing in the picture, what led up to it, what the characters are feeling and thinking, and what the outcome of the situation will be.

Clinicians who use the TAT believe that people always identify with one of the characters on each card. The stories are thought to reflect the individuals’ own circum- stances, needs, and emotions. For example, a female client seems to be revealing her own feelings in this story about the TAT picture shown in Figure 3-2, one of the few TAT pictures permitted for display in textbooks:

This is a woman who has been quite troubled by memories of a mother she was resentful

toward. She has feelings of sorrow for the way she treated her mother, her memories of

her mother plague her. These feelings seem to be increasing as she grows older and sees

her children treating her the same way that she treated her mother.

(Aiken, 1985, p. 372)

SENTENCE-COMPLETION TEST The sentence-completion test, first developed in the 1920s (Payne, 1928), asks people to complete a series of unfinished sentences, such as “I wish . . . ” or “My father . . . .” The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore.

DRAWINGS On the assumption that a drawing tells us something about its creator, cli- nicians often ask clients to draw human figures and talk about them. Evaluations of these drawings are based on the details and shape of the drawing, solidity of the pencil line, location of the drawing on the paper, size of the figures, features of the figures, use of background, and comments made by the respondent during the drawing task. In the Draw-a-Person (DAP) Test, the most popular of the drawing tests, individuals are first told to draw “a person” and then are instructed to draw another person of the opposite sex.

Figure 3-2 A picture used in the Thematic Apperception Test.

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Clinical Assessment, Diagnosis, and Treatment :// 73

WHAT ARE THE MERITS OF PROJECTIVE TESTS? Until the 1950s, projective tests were the most common technique for assessing personality. In recent years, however, clinicians and re- searchers have relied on them largely to gain “supplementary” insights (Huprich, 2006). One reason for this shift is that practitioners who follow the newer models have less use for the tests than psychodynamic clinicians do. Even more importantly, the tests have not consistently shown much reliability or validity (Wood et al., 2002).

In reliability studies, different clinicians have tended to score the same person’s pro- jective test quite differently. Similarly, in validity studies, when clinicians try to describe a client’s personality and feelings on the basis of responses to projective tests, their con- clusions often fail to match the self-report of the client, the view of the psychotherapist, or the picture gathered from an extensive case history (Bornstein, 2007).

Another validity problem is that projective tests are sometimes biased against minor- ity ethnic groups (Costantino, Dana, & Malgady, 2007) (see Table 3-1). For example, people are supposed to identify with the characters in the TAT when they make up stories about them, yet no members of minority groups are in the TAT pictures. In re- sponse to this problem, some clinicians have developed other TAT-like tests with African American or Hispanic figures (Costantino et al., 2007).

Multicultural Hot Spots in Assessment and Diagnosis

Cultural Hot Spot Effect on Assessment or Diagnosis

• Immigrant Client • Dominant-Culture Assessor Homeland culture may differ from current country’s May misread culture-bound reactions as pathology dominant culture

May have left homeland to escape war or oppression May overlook client’s vulnerability to posttraumatic stress

May have weak support systems in this country May overlook client’s heightened vulnerability to stressors

Lifestyle (wealth and occupation) in this country may fall below May overlook client’s sense of loss and frustration lifestyle in homeland

May refuse or be unable to learn dominant language May misunderstand client’s assessment responses, or may overlook or misdiagnose client’s symptoms

• Ethnic-Minority Client • Dominant-Culture Assessor May reject or distrust members of dominant culture, including May experience little rapport with client, or may misinterpret assessor client’s distrust as pathology

May be uncomfortable with dominant culture’s values May view client as unmotivated (e.g., assertiveness, confrontation) and so find it difficult to apply clinician’s recommendations

May manifest stress in culture-bound ways (e.g., somatic May misinterpret symptom patterns symptoms such as stomachaches)

May hold cultural beliefs that seem strange to dominant culture May misinterpret cultural responses as pathology (e.g., belief in communication with dead) (e.g., a delusion)

May be uncomfortable during assessment May overlook and feed into client’s discomfort

• Dominant-Culture Assessor • Ethnic-Minority Client May be unknowledgeable or biased about ethnic minority Cultural differences may be pathologized, or symptoms may culture be overlooked

May nonverbally convey own discomfort to ethnic minority client May become tense and anxious

Sources: Dana, 2005, 2000; Westermeyer, 2004, 2001, 1993; López & Guarnaccia, 2005, 2000; Kirmayer, 2003, 2002, 2001; Sue & Sue, 2003; Tsai et al., 2001; Thakker & Ward, 1998.

table: 3-1

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74 ://CHAPTER 3

Personality Inventories An alternative way to collect information about individu- als is to ask them to assess themselves. The personality inventory asks respondents a wide range of questions about their behavior, beliefs, and feelings. In the typical person- ality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person’s personal- ity and psychological functioning.

By far the most widely used personality inventory is the Minnesota Multiphasic Person- ality Inventory (MMPI) (Weiner & Greene, 2008). Two adult versions are available—the original test, published in 1945, and the MMPI-2, a 1989 revision which was itself revised in 2001. A special version of the test for adolescents, the MMPI-A, is also used widely.

The MMPI consists of more than 500 self-statements, to be labeled “true,” “false,” or “cannot say.” The statements cover issues ranging from physical concerns to mood, sexual behaviors, and social activities. Altogether the statements make up 10 clinical scales, on each of which an individual can score from 0 to 120. When people score above 70 on a scale, their functioning on that scale is considered deviant. When the 10 scale scores are considered side by side, a pattern called a profile takes shape, indicating the person’s general personality. The 10 scales on the MMPI measure the following:

Hypochondriasis Items showing abnormal concern with bodily functions (“I have chest pains several times a week.”)

Depression Items showing extreme pessimism and hopelessness (“I often feel hopeless about the future.”)

Hysteria Items suggesting that the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities (“My heart frequently pounds so hard I can feel it.”)

Psychopathic deviate Items showing a repeated and gross disregard for social customs and an emotional shallowness (“My activities and interests are often criticized by others.”)

Masculinity-femininity Items that are thought to separate male and female respondents (“I like to arrange flowers.”)

Paranoia Items that show abnormal suspiciousness and delusions of grandeur or per- secution (“There are evil people trying to influence my mind.”)

Psychasthenia Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness (“I save nearly everything I buy, even after I have no use for it.”)

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About Personality “People’s personalities, like buildings, have various facades, some pleasant to view, some not.” <<

François de La Rochefoucauld, French author

“If it weren’t for caffeine, I’d have no personality whatsoever.” <<

Anonymous

“Dogs got personality. Personality goes a long way.” <<

Quentin Tarantino, Film writer, director

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Clinical Assessment, Diagnosis, and Treatment :// 75

Schizophrenia Items that show bizarre or unusual thoughts or behavior (“Things around me do not seem real.”)

Hypomania Items that show emotional excitement, overactivity, and flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent reason.”)

Social introversion Items that show shyness, little interest in people, and insecurity (“I am easily embarrassed.”)

The MMPI-2, the newer version of the MMPI, contains 567 items—many identical to those in the original, some rewritten to reflect current language (“upset stomach,” for instance, replaces “acid stomach”), and others that are new. Before being adopted, the MMPI-2 was tested on a more diverse group of people than was the original MMPI. Thus scores on the revised test are thought to be more accurate indicators of personality and abnormal functioning (Cox et al., 2009).

The MMPI and other personality inventories have several advantages over projec- tive tests (Wood et al., 2002). Because they are paper-and-pencil (or computerized) tests, they do not take much time to administer, and they are objectively scored. Most of them are standardized, so one person’s scores can be compared to those of many others. Moreover, they often display greater test–retest reliability than projective tests. For example, people who take the MMPI a second time after a period of less than two weeks receive approximately the same scores (Graham, 2006).

Personality inventories also appear to have greater validity, or accuracy, than projec- tive tests (Weiner & Greene, 2008; Lanyon, 2007). However, they can hardly be con- sidered highly valid. When clinicians have used these tests alone, they have not regularly been able to judge a respondent’s personality accurately (Braxton et al., 2007). One problem is that the personality traits that the tests seek to measure cannot be examined directly. How can we fully know a person’s character, emotions, and needs from self- reports alone?

Another problem is that despite the use of more diverse standardization groups by the MMPI-2 designers, this and other personality tests continue to have certain cultural limitations. Responses that indicate a psychological disorder in one culture may be normal responses in another (Butcher et al., 2007; Dana, 2005, 2000). In Puerto Rico, for example, where it is common to practice spiritualism, it would be normal to answer “true” to the MMPI item “Evil spirits possess me at times.” In other populations, that response could indicate psychopathology (Rogler, Malgady, & Rodriguez, 1989).

Despite such limits in validity, personality inventories continue to be popular (Weiner & Greene, 2008). Research indicates that they can help clinicians learn about people’s personal styles and disorders as long as they are used in combination with in- terviews or other assessment tools.

Response Inventories Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning. For example, one such test may measure affect (emotion), another social skills, and still another cognitive processes. Clinicians can use them to de- termine the role such factors play in a person’s disorder.

Affective inventories measure the severity of such emotions as anxiety, depression, and anger (Osman et al., 2008). In one of the most widely used affective inventories, the Beck Depression Inventory, shown in Table 3-2 on the next page, people rate their level of sadness and its effect on their functioning. Social skills inventories, used particularly by behavioral and family-social clinicians, ask respondents to indicate how they would react in a variety of social situations (Wright & Truax, 2008). Cognitive inventories reveal a person’s typical thoughts and assumptions and can uncover counterproductive patterns of thinking (Glass & Merluzzi, 2000). They are, not surprisingly, often used by cognitive therapists and researchers.

Both the number of response inventories and the number of clinicians who use them have increased steadily in the past 25 years (Black, 2005). At the same time, how- ever, these inventories have major limitations. With the notable exceptions of the Beck

•personality inventory•A test designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either character- istic or uncharacteristic of them.

•response inventories•Tests designed to measure a person’s responses in one specific area of functioning,such as affect, social skills, or cognitive processes.

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College Counseling At least 8 percent of all college students seek psychotherapy at their college’s counseling center. The percentage is higher at small, private colleges and pres- tigious schools (Gallagher, 1998). <<

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Depression Inventory and a few others, only some of them have been subjected to care- ful standardization, reliability, and validity procedures (Weis & Smenner, 2007). Often they are created as a need arises, without being tested for accuracy and consistency.

Psychophysiological Tests Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychological problems (Vershuere et al., 2006). This practice began three decades ago after several studies sug- gested that states of anxiety are regularly accompanied by physiological changes, par- ticularly increases in heart rate, body temperature, blood pressure, skin reactions (galvanic skin response), and muscle contraction. The measuring of physiological changes has since played a key role in the assessment of certain psychological disorders.

One psychophysiological test is the polygraph, popularly known as a lie detector (Verschuere et al., 2006). Electrodes attached to various parts of a person’s body detect changes in breathing, perspiration, and heart rate while the individual answers ques- tions. The clinician observes these functions while the person answers “yes” to control questions—questions whose answers are known to be yes, such as “Are your parents both alive?” Then the clinician observes the same physiological functions while the person answers test questions, such as “Did you commit this robbery?” If breathing, perspiration, and heart rate suddenly increase, the person is suspected of lying.

Like other kinds of clinical tests, psychophysiological tests have their drawbacks. Many require expensive equipment that must be carefully tuned and maintained. In ad- dition, psychophysiological measurements can be inaccurate and unreliable. The labora- tory equipment itself—elaborate and sometimes frightening—may arouse a participant’s nervous system and thus change his or her physical responses. Physiological responses may also change when they are measured repeatedly in a single session. Galvanic skin responses, for example, often decrease during repeated testing.

Neurological and Neuropsychological Tests Some problems in personality or behavior are caused primarily by damage to the brain or changes in brain activity. If a psychological dysfunction is to be treated effectively, it is important to know whether its primary cause is a physical abnormality in the brain.

Sample Items from the Beck Depression Inventory

Items Inventory Suicidal ideas 0 I don’t have any thoughts of killing myself.

1 I have thoughts of killing myself but I would not carry them out.

2 I would like to kill myself.

3 I would kill myself if I had the chance.

Work inhibition 0 I can work about as well as before.

1 It takes extra effort to get started at doing something.

2 I have to push myself very hard to do anything.

3 I can’t do any work at all.

Loss of libido 0 I have not noticed any recent change in my interest in sex.

1 I am less interested in sex than I used to be.

2 I am much less interested in sex now.

3 I have lost interest in sex completely.

table: 3-2

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Popular Tests on the Web (Not Validated) Accident Proneness Test <<

Are You an Optimist? Test <<

Risk-Taking Test <<

Sensitivity to Criticism Test <<

Which Beatle Are You? Test <<

Arguing Style Test <<

Jealousy Test <<

Love Diagnostic Test <<

Relationship Satisfaction Test <<

Sensuality Test <<

Commitment Readiness Test <<

Romantic Personality Test <<

Roommate IQ Test <<

Maturity Test <<

How Do You Fight? Test <<

Eye Color Personality Test <<

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A number of techniques may help pinpoint brain abnormalities. Some procedures, such as brain surgery, biopsy, and X ray, have been used for many years. More recently, scientists have developed a number of neurological tests, designed to measure brain structure and activity directly. One neurological test is the electroencephalogram (EEG), which records brain waves, the electrical activity taking place within the brain as a result of neurons firing. In this procedure, electrodes placed on the scalp send brain-wave impulses to a machine that records them.

Other neurological tests actually take “pictures” of brain structure or brain activity. These tests, called neuroimaging, or brain scanning, techniques, include computer- ized axial tomography (CAT scan or CT scan), in which X rays of the brain’s structure are taken at different angles and combined; positron emission tomography (PET scan), a computer-produced motion picture of chemical activity throughout the brain; and magnetic resonance imaging (MRI), a procedure that uses the magnetic property of certain atoms in the brain to create a detailed picture of the brain’s structure.

A more recent version of the MRI, functional magnetic resonance imaging ( fMRI), converts MRI pictures of brain structures into detailed pictures of neuron activity, thus offering a picture of the functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer than PET scan images, the fMRI has generated enormous enthusiasm among brain researchers since it was first developed in 1990.

Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more

In movies, criminals being grilled by the police reveal their guilt by sweating, shaking, cursing, or twitching. When they are hooked up to a polygraph (a lie detector), the needles bounce all over the paper. This image has been with us since World War I, when some clinicians developed the theory that people who are telling lies display systemic changes in their breathing, perspiration, and heart rate (Marston, 1917).

The danger of relying on polygraph tests is that, according to researchers, they do not work as well as we would like (Iacono, 2008; Vrij, 2004). The public did not pay much attention to this incon- venient fact until the mid-1980s, when the American Psychological Association of- ficially reported that polygraphs were often inaccurate and the United States Congress voted to restrict their use in criminal prose- cution and employment screening (Krapohl, 2002). Research indicates that 8 out of 100 truths, on average, are called lies in polygraph testing (Raskin & Honts, 2002; MacLaren, 2001). Imagine, then, how many innocent people might be convicted

of crimes if polygraph findings were taken as valid evidence in criminal trials.

Given such findings, polygraphs are less trusted and less popular today than they once were. For example, few courts now admit results from such tests as evi- dence of criminal guilt (Daniels, 2002). Polygraph testing has by no means dis-

appeared, however. The FBI uses it exten- sively; parole boards and probation offices routinely use it to help decide whether to release convicted offenders; and in public- sector hiring (such as for police officers), the use of polygraph screening may actually be on the increase (Kokish et al., 2005).

A CLOSER LOOK

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Polygraph, a test that lies?

The Truth, the Whole Truth, and Nothing but the Truth

•psychophysiological test•A test that measures physical responses (such as heart rate and muscle tension) as possi- ble indicators of psychological problems.

•neurological test•A test that directly measures brain structure or activity.

•neuroimaging techniques• Neuro- logical tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain scans.

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revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks and interpret abnormal performances as an indicator of underlying brain problems (Axelrod & Wall, 2007). Brain damage is especially likely to affect visual perception, memory, and visual-motor coordination, so neuropsychological tests focus particularly on these areas. The famous Bender Visual-Motor Gestalt Test, for example, consists of nine cards, each displaying a simple geometrical design. Patients look at the designs one at a time and copy each one on a piece of paper. Later they try to redraw the designs from memory. Notable errors in accuracy after age 12 are thought to reflect organic brain impairment. Clinicians often use a battery, or series, of neuro- psychological tests, each targeting a specific skill area (Reitan & Wolfson, 2005, 1996).

New kid on the block The fMRI is a scanning procedure that has excited researchers in recent years because it produces extraordinarily clear images of both brain structure and brain function. The scans shown here reveal which areas of the brain are active when a person is thinking about performing a gesture (left) and which are active when the person is actually performing the gesture (right).

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Traditional scanning The most widely used neuroimaging techniques in clinical practice—the MRI, CAT, and PET scans— take pictures of the living brain. The machinery for each of these techniques is imposing, much like the MRI machine shown at right. However, the scans produced by the machines are very different. Here, an MRI scan (above left) reveals a large tumor, colored in orange; a CAT scan (above center) reveals a mass of blood within the brain; and a PET scan (above right) shows which areas of the brain are active (those colored in red, orange, and yellow) when an individual is stimulated.

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Clinical Assessment, Diagnosis, and Treatment :// 79

Intelligence Tests An early definition of intelligence described it as “the capacity to judge well, to reason well, and to comprehend well” (Binet & Simon, 1916, p. 192). Because intelligence is an inferred quality rather than a specific physical process, it can be measured only indirectly. In 1905 French psychologist Alfred Binet and his associate Theodore Simon produced an intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills. The general score derived from this and later intelligence tests is termed an intelligence quotient, or IQ. There are now more than 100 intelligence tests available. As you will see in Chapter 14, intelligence tests play a key role in the diagnosis of mental retardation, but they can also help clinicians identify other problems.

Intelligence tests . . . are for sale on eBay Inc.’s online auction site, and the test maker is worried they will be misused.

The series of Wechsler intelligence tests, made by San Antonio-based Harcourt Assessment, Inc., are supposed to be sold to and administered by only clinical psychologists and trained professionals.

Given more than a million times a year nationwide, accord- ing to Harcourt, the intelligence tests often are among numerous tests ordered by prosecutors and defense attorneys to determine the mental competence of criminal defendants. A low IQ, for ex- ample, can be used to argue leniency in sentencing.

Schools use the tests to determine whether to place a student in a special program, whether for gifted or struggling students. Harcourt officials say they fear the tests for sale on eBay will be misused for coaching by lawyers or parents.

But eBay has denied their request to restrict the sale of the tests. EBay officials say there is nothing illegal about selling the tests, and it cannot monitor every possible misuse of items sold through its network of 248 million buyers and sellers. Company spokesman Hani Durzy said eBay does prohibit the sale of items that are illegal in some states, even if they’re legal in others. And it prohibits the sale of some legal items, like teacher editions of textbooks, as matter of public good. With regard to the Harcourt tests, he said, however, “at this point, this is our response.”

Five of the tests were listed for sale . . . for about $175 to $900. The latest edition of the adult test, which retails for $939, was offered on eBay for $249.99.

“In order for it to maintain its integrity, there needs to be limited availability,” said Harcourt spokesman Russell Schweiss. . . . “Misinterpreting the results [of questions and tasks on the tests], even without malicious intent, could lead to mistakes in assess- ing a child’s intelligence,” said Aurelio Prifitera, the president of Harcourt’s clinical division. . . .

Schweiss said Harcourt was still considering how to respond to eBay’s refusal. It has taken out a full-page ad in The National Psychologist magazine, asking clinicians and test publishers to contact eBay to express their concern, he said.

Jack King, communications director for the National Associa- tion of Criminal Defense Lawyers, said it would be very difficult to fake the results of an IQ test because cognitive and psycho- logical tests are usually given as part of a battery of tests, and in most cases, there is a profile of scores that would be considered normal for certain disabilities or disorders. “Just flunking the test is not likely to be determinative of anything, and a person can always be tested again and again,” he said. In any event, “it would be unethical to suggest to the client that they try to fudge a psychological test.”

Copyright © 2007. Reprinted by permission.

Tests, eBay, and the Public Good BY MICHELLE ROBERTS, ASSOCIATED PRESS, DECEMBER 18, 2007

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The Wechsler Adult Intelligence Scale-Revised (WAIS-R) This widely used intelligence test has 11 subtests, which cover such areas as factual information, memory, vocabulary, arithmetic, design, and eye-hand coordination.

•neuropsychological test•A test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.

•intelligence test•A test designed to measure a person’s intellectual ability.

•intelligence quotient (IQ)•An overall score derived from intelligence tests.

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Intelligence tests are among the most carefully produced of all clinical tests (Kellerman & Burry, 2007; Williams et al., 2007). Because they have been standardized on large groups of people, clinicians have a good idea how each individual’s score compares with the performance of the population at large. These tests have also shown very high reliability: People who repeat the same IQ test years later receive approximately the same score. Finally, the major IQ tests appear to have fairly high validity: children’s IQ scores often correlate with their performance in school, for example.

Nevertheless, intelligence tests have some key shortcomings. Factors that have nothing to do with intelligence, such as low motivation or high anxiety, can greatly influence test performance (Gregory, 2004). In addition, IQ tests may contain cultural biases in their language or tasks that place people of one background at an advantage over those of another (Ford, 2008; Edwards & Oakland, 2006). Similarly, members of some minority groups may have little experience with this kind of test, or they may be uncomfortable with test examiners of a majority ethnic background. Either way, their performances may suffer.

Clinical Observations In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe clients in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self-monitoring, clients are instructed to observe themselves.

Naturalistic and Analog Observations Naturalistic clinical observations usu- ally take place in homes, schools, institutions such as hospitals and prisons, or community settings. Most of them focus on parent-child, sibling-child, or teacher-child interactions

and on fearful, aggressive, or disruptive behavior (Murdock et al., 2005). Often such observations are made by participant observers, key persons in the client’s environment, and reported to the clinician.

When naturalistic observations are not practical, clinicians may resort to analog observations, often aided by special equipment such as a videotape recorder or one-way mirror (Haynes, 2001). Analog observations often have focused on children interacting with their parents, married couples attempt- ing to settle a disagreement, speech-anxious people giving a speech, and fearful people approaching an object they find frightening.

Although much can be learned from actually witnessing behavior, clin- ical observations have certain disadvantages (Connor-Greene, 2007; Pine, 2005). For one thing, they are not always reliable. It is possible for various clinicians who observe the same person to focus on different aspects of behavior, assess the person differently, and arrive at different conclusions. Careful training of observers and the use of observer checklists can help reduce this problem.

Similarly, observers may make errors that affect the validity, or accuracy, of their observations (Aiken & Groth-Marnat, 2006). The observer may suffer from overload and be unable to see or record all of the important be- haviors and events. Or the observer may experience observer drift, a steady decline in accuracy as a result of fatigue or of a gradual unintentional change in the standards used when an observation continues for a long period of time. Another possible problem is observer bias—the observer’s judgments may be influenced by information and expectations he or she already has about the person (Markin & Kivlighan, 2007).

A client’s reactivity may also limit the validity of clinical observations; that is, his or her behavior may be affected by the very presence of the

An ideal observation Using a one-way mirror, a clinical observer is able to view a mother inter acting with her child without distracting the duo or influenc- ing their behaviors.

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Clinical Assessment, Diagnosis, and Treatment :// 81

observer (Kamphaus & Frick, 2002). If schoolchildren are aware that someone special is watching them, for example, they may change their usual classroom behavior, perhaps in the hope of creating a good impression.

Finally, clinical observations may lack cross-situational validity. A child who behaves aggressively in school is not necessarily aggressive at home or with friends after school. Because behavior is often specific to particular situations, observations in one setting cannot always be applied to other settings (Kagan, 2007).

Self-Monitoring As you saw earlier, personality and response inventories are tests in which persons report their own behaviors, feelings, or cognitions. In a related assessment procedure, self-monitoring, people observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time (Wright & Truax, 2008). How frequently, for instance, does a drug user have an urge for drugs or a head- ache sufferer have a headache? Self-monitoring is especially useful in assessing behavior that occurs so infrequently that it is unlikely to be seen during other kinds of observa- tions. It is also useful for behaviors that occur so frequently that any other method of observing them in detail would be impossible—for example, smoking, drinking, or other drug use (Tucker et al., 2007). Finally, self-monitoring may be the only way to observe and measure private thoughts or perceptions.

Like all other clinical assessment procedures, however, self-monitoring has drawbacks (Wright & Truax, 2008). Here too validity is often a problem. People do not always man- age or try to record their observations accurately. Furthermore, when people monitor themselves, they may change their behaviors unintentionally (Otten, 2004). Smokers, for example, often smoke fewer cigarettes than usual when they are monitoring themselves, and teachers give more positive and fewer negative comments to their students.

SUMMING UP Clinical Assessment

Clinical practitioners are interested primarily in gathering individual information about their clients. They seek an understanding of the specific nature and origins of a client’s problems through clinical assessment.

Most clinical assessment methods fall into three general categories: clinical interviews, tests, and observations. A clinical interview may be either unstructured or structured. Types of clinical tests include projective, personality, response, psycho- physiological, neurological, neuropsychological, and intelligence tests. Types of ob- servation include naturalistic observation, analog observation, and self-monitoring. To be useful, assessment tools must be standardized, reliable, and valid. Each of the methods in current use falls short on at least some of these characteristics.

jjDiagnosis: Does the Client’s Syndrome Match a Known Disorder? Clinicians use the information from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client’s disturbance, a construction sometimes known as a clinical picture (Kellerman & Burry, 2007). Clini- cal pictures also may be influenced to a degree by the clinician’s theoretical orientation (Garb, 2006). The psychologist who worked with Angela Savanti held a cognitive- behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Angela’s expectations, assumptions, and interpretations:

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Smart Labels In a study conducted in the 1960s, two psychologists told teachers which of their students had high IQs and which had low IQs (Rosenthal & Jacobson, 1968). Sub- sequently, the students identified as smart performed significantly better than the ones identified with a low IQ. The only problem was that the IQ scores told to the teachers had been faked. The students performed better strictly as a function of teacher expectations. <<

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What Is a Nervous Breakdown? The term “nervous breakdown” is used by laypersons, not clinicians. Most people use it to refer to a sudden psychological disturbance that incapacitates a person, perhaps requiring hospitalization. Some people use the term simply to connote the onset of any psychological disorder (Padwa, 1996). <<

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Angela was rarely reinforced for any of her accomplishments at school, but she gained

her mother’s negative attention for what Mrs. Savanti judged to be poor performance at

school or at home. Mrs. Savanti repeatedly told her daughter that she was incompetent,

and any mishaps that happened to her were her own fault. . . . When Mr. Savanti de-

serted the family, Angela’s first response was that somehow she was responsible. From

her mother’s past behavior, Angela had learned to expect that in some way she would be

blamed. At the time that Angela broke up with her boyfriend, she did not blame Jerry for

his behavior, but interpreted this event as a failing solely on her part. As a result, her level

of self-esteem was lowered still more.

The type of marital relationship that Angela saw her mother and father model re-

mained her concept of what married life is like. She generalized from her observations of

her parents’ discordant interactions to an expectation of the type of behavior that she

and Jerry would ultimately engage in. . . .

Angela’s uncertainties intensified when she was deprived of the major source of grati-

fication she had, her relationship with Jerry. Despite the fact that she was overwhelmed

with doubts about whether to marry him or not, she had gained a great deal of pleasure

through being with Jerry. Whatever feelings she had been able to express, she had shared

with him and no one else. Angela labeled Jerry’s termination of their relationship as proof

that she was not worthy of another person’s interest. She viewed her present unhappiness

as likely to continue, and she attributed it to some failing on her part. As a result, she be-

came quite depressed.

(Leon, 1984, pp. 123–125)

With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis—that is, a determination that a person’s psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client’s pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person’s problem and the treatments that are likely to be helpful.

Classification Systems The principle behind diagnosis is straightforward. When certain symptoms occur to- gether regularly—a cluster of symptoms is called a syndrome—and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder. If people display this particular pattern of symptoms, diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system.

In 1883 Emil Kraepelin developed the first modern classification system for abnor- mal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic and Statistical Manual of Mental Disorders (DSM), the classification system currently written by the American Psychiatric Association (APA, 2000). The DSM is the most widely used classification system in the United States. Most other countries use a system called the International Classification of Diseases (ICD), developed by the World Health Organization. The DSM has been changed significantly over time. The current edition, called the DSM-IV Text Revision (DSM-IV-TR), includes a combination of classifica- tion changes produced in 1994 (when it was called DSM-IV) and in 2000 (when it became DSM-IV-TR).

•diagnosis•A determination that a person’s problems reflect a particular disorder.

•syndrome•A cluster of symptoms that usually occur together.

•classification system•A list of disorders, along with descriptions of symptoms and guidelines for making appropriate diagnoses.

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By the Numbers 1 Number of categories of psychologi-

cal dysfunctioning listed in the 1840 U.S. census (“idiocy/insanity”) <<

7 Number of categories listed in the 1880 census <<

60 Number of categories listed in DSM-I in 1952 <<

400 Number of categories listed in DSM- IV-TR today <<

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DSM-IV-TR DSM-IV-TR lists approximately 400 mental disorders (see Figure 3-3). Each entry describes the criteria for diagnos- ing the disorder and its key clinical features. The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by text information (that is, background information) such as research findings; age, culture, or gender trends; and each disorder’s prevalence, risk, course, complications, predispos- ing factors, and family patterns.

DSM-IV-TR requires clinicians to evaluate a client’s condition on five separate axes, or branches of information, when making a diagnosis. First, they must decide whether the person is displaying one or more of the disorders found on Axis I, an extensive list of clinical syndromes that typi- cally cause significant impairment. Some of the most frequently diagnosed disorders listed on this axis are the anxiety disorders and mood disorders, problems you will read about later.

Anxiety disorders People with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder), anxiety centered on a specific situation or object (phobias), periods of panic (panic disorder), persistent thoughts or repetitive behaviors or both (obsessive-compulsive disorder), or lingering anxiety reactions to un- usually traumatic events (acute stress disorder and posttraumatic stress disorder).

Mood disorders People with mood disorders feel excessively sad or elated for long periods of time. These disorders include major depressive disorder and bipolar disorders (in which episodes of mania alternate with episodes of depression).

Next, diagnosticians must decide whether the person is displaying one of the dis- orders listed on Axis II, which includes long-standing problems that are frequently overlooked in the presence of the disorders on Axis I. There are only two groups of Axis II disorders, mental retardation and personality disorders. You will also read about these patterns in later chapters.

Mental retardation People with this disorder display significantly subaverage intellec- tual functioning and poor adaptive functioning by 18 years of age.

Personality disorders People with these disorders display a very rigid maladaptive pat- tern of inner experience and outward behavior that has continued for many years. People with antisocial personality disorder, for example, persistently disregard and violate the rights of others. People with dependent personality disorder are persistently depen- dent on others, clinging, obedient, and very afraid of separation.

Although people usually receive a diagnosis from either Axis I or Axis II, they may receive diagnoses from both axes. Angela Savanti would first receive a diagnosis of major depressive disorder from Axis I (a mood disorder). Let’s suppose that the clinician judged that Angela also displayed a life history of dependent behavior. She might then also receive an Axis II diagnosis of dependent personality disorder.

The remaining axes of DSM-IV-TR guide diagnosticians in reporting other fac- tors. Axis III asks for information concerning relevant general medical conditions from which the person is currently suffering. Axis IV asks about special psychosocial or environmental problems the person is facing, such as school or housing problems. And Axis V requires the diagnostician to make a global assessment of functioning (GAF ), that is, to rate the person’s psychological, social, and occupational functioning overall.

If Angela Savanti had diabetes, for example, the clinician might include that under Axis III information. Angela’s recent breakup with her boyfriend would be noted on

53.6% No disorders

17.3% Three or more disorders

18.7% One disorder

10.4% Two disorders

Figure 3-3 How many people in the United States qualify for a DSM diagnosis during their lives? Almost half, according to one survey. Some of them even experience two or more different disorders, an occurrence known as comorbidity. (Adapted from Kessler et al., 2005.)

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In Their Words “I became insane, with long intervals of horrible sanity.” <<

Edgar Allen Poe

“I can calculate the motion of heavenly bodies but not the madness of people.” <<

Sir Isaac Newton

“Insanity—a perfectly rational adjustment to an insane world.” <<

R. D. Laing

“The distance between insanity and genius is measured only by success.” <<

James Bond in Tomorrow Never Dies

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Axis IV. And because she seemed fairly dysfunctional at the time of diagnosis, Angela’s GAF would probably be around 55 on Axis V, indicating a moderate level of dysfunction. The complete diagnosis for Angela Savanti would then be:

Axis I: Major depressive disorder

Axis II: Dependent personality disorder

Axis III: Diabetes

Axis IV: Problem related to the social environment (termination of engagement)

Axis V: GAF = 55 (current)

Is DSM-IV-TR an Effective Classification System? A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were at best moderately reliable (Spiegel, 2005; Malik & Beutler, 2002). In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, indepen- dently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement.

DSM-IV-TR appears to have greater reliability than the early DSMs (Keenan et al., 2007; Lyneham, Abbott, & Rapee, 2007). Its framers conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. They then developed a number of new diagnostic criteria and categories and ran field trials to make sure that the new criteria and categories were in fact reliable. Nevertheless, research indicates that DSM-IV-TR does contain certain reliability problems (Black, 2005; Beutler & Malik, 2002). Many clinicians, for example, have difficulty distinguish- ing one kind of anxiety disorder from another. The disorder of a particular client may be classified as generalized anxiety disorder by one clinician, agoraphobia (fear of traveling outside of one’s home) by another, and social phobia (fear of social situations) by yet another.

The validity of a classification system is the accuracy of the information that its di- agnostic categories provide. Categories are of most use to clinicians, for example, when

The power of labeling When looking at this late-nineteenth- century photograph of a baseball team at the State Homeopathic Asylum for the Insane in Middletown, New York, most observers assume that the players are patients. As a result, they tend to “see” depression or confusion in the players’ faces and posture. In fact, the players are members of the asylum staff.

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Bands with Psychological Labels Bad Brains <<

Clinic <<

Placebo <<

The Dissociatives <<

Fear Factory <<

Mood Elevator <<

Neurosis <<

Disturbed <<

10,000 Maniacs <<

Grupo Mania <<

Suicidal Tendencies <<

Xanax 25 <<

The Insane Clown Posse <<

Unsane <<

Therapy? <<

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Clinical Assessment, Diagnosis, and Treatment :// 85

they demonstrate predictive validity—that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or exces- sive sleep. When clinicians give Angela Savanti a diagnosis of major depressive disorder, they expect that she may eventually develop sleep problems even if none are present now. In addition, they expect her to respond to treatments that are effective for other depressed persons. The more often such predictions are accurate, the greater a category’s predictive validity.

DSM-IV-TR’s framers tried to ensure the validity of their new version of the DSM by again conducting extensive reviews of research and running many field studies. As a result, its criteria and categories appear to have stronger validity than those of the earlier versions of the DSM (Reeb, 2000). Yet, again, many of today’s clinical theorists argue that at least some of the criteria and categories in DSM-IV-TR are based on weak research and that others reflect gender or racial bias (Löwe et al., 2008; Vieta & Phillips, 2007).

Beyond these concerns about the reliability and validity of certain categories, a growing number of clinical theorists believe that two fundamental problems weaken the current edition of the DSM (Widiger, 2007). One problem is DSM-IV-TR’s basic

As you have seen, clinicians try to combat psychological dis- orders, either by preventive efforts or, if those fail, through assessment, diagnosis, and effective treatment. Unfortunately, today there are also other—more sinister—forces operat- ing that run counter to the work of mental health professionals. Among the most common are so-called dark sites on the Internet—sites with the goal of promoting behaviors that the clinical community, and most of society, consider abnormal and destructive. Pro-anorexia sites and suicide sites are two examples.

Pro-Anorexia Sites The Eating Disorders Association reports that there are more than 500 pro-anorexia Internet sites with names such as “Dying to Be Thin” and “Starving for Perfection” (Catan, 2007). Users of these sites ex- change tips on how they can starve them- selves and disguise their weight loss from family, friends, and doctors. The sites also offer support and feedback about starva- tion diets. One site of this kind sponsors a contest, “The Great Ana Competition,” and awards a diploma to the girl who consumes the fewest calories in a two- week period (Catan, 2007). Another site

endorses what it calls the Pro-Anorexia Ten Commandments—assertions such as “Being thin is more important than being healthy” and “Thou shall not eat without feeling guilty” (Barrett, 2000).

Suicide Sites Suicide sites are another Internet phenom- enon. Suicide forums and chat rooms vary in their messages, but they pose clear risks to depressed or impressionable users. Some pro-suicide websites celebrate former users who have committed suicide; others help set up appointments for joint or partner sui- cides; and several offer specific instructions about suicide methods and locations and writing suicide notes (Becker & Schmidt, 2004).

During a two-month period in 2008, for example, 30 people committed suicide across Japan, all of them involving the use of detergent mixtures that produce a deadly hydrogen sulfide gas—a technique repeatedly described and encouraged on Internet suicide sites (CNN, 2008). A 31-year-old man took his life in a car using a mixture of detergent and bath salts, a 42-year-old woman killed herself in her bathroom using toilet cleaner and bath powder, and a

14-year-old girl mixed laundry detergent with cleanser to commit suicide in her apartment. Such detergent mixtures release powerful fumes that can also endanger in- nocent bystanders, so almost all of those who killed themselves in this way hung warning signs at the locations of their suicide saying “Stay Away” or “Poisonous Gas Being Emitted”—warnings apparently also suggested on the Internet suicide sites.

Many individuals worry that Internet sui- cide sites place vulnerable people at great risk, and they have called for the banning of these sites. Others argue, however, that de- spite their dangers,the sites represent basic freedoms that should not be violated—free- dom of speech, for example, and perhaps even the freedom to do oneself harm.

PSYCH WATCH

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86 ://CHAPTER 3

assumption that clinical disorders are qualitatively different from normal behavior. Per- haps this assumption is incorrect. It may be, for example, that the feelings of dejection occasionally experienced by everyone differ from clinical depression in degree only. If certain psychological disorders actually differ from normal behavior in degree rather than kind, many of today’s criteria and categories are, at the very least, misleading.

A related criticism centers on DSM-IV-TR’s use of discrete diagnostic categories, with each category of pathology considered to be separate from all the others. Some crit- ics believe that certain of its categories reflect, in fact, variations of a single, fundamental dimension of functioning rather than separate disorders. Let’s consider the dimension of negative emotionality, for example. Perhaps this dimension should be used when describ- ing abnormal patterns. When one individual’s negative emotionality is extreme and maladaptive, it may take on an appearance of high anxiety. Alternatively, another person’s negative emotionality may take on the appearance of depression. In short, rather than distinguish two kinds of disorders—an anxiety disorder versus a depressive disorder—it may be that the classification should list each pattern as a variation of a key dimension, negative emotionality. In support of this dimensional argument, research has often found high anxiety levels among clinically depressed people and high depression levels among clinically anxious people. If the dimensional view is appropriate, DSM-IV-TR is, once again, misleading clinicians when it asks them to determine whether persons are display- ing an anxiety disorder or a mood disorder.

Given such concerns, there is little doubt that DSM-V, the next edition of DSM, will include some key changes. A DSM-V task force has been assembled and is actively con- sidering a range of issues and research findings, and indications are that classifications of the anxiety disorders and the personality disorders are particularly likely to see changes in DSM-V (Regier et al., 2009), as you will see in Chapters 4 and 13. The new clas- sification system will not, however, be completed until 2012 or later (Garber, 2008).

Can Diagnosis and Labeling Cause Harm? Even with trustworthy assessment data and reliable and valid clas- sification categories, clinicians will sometimes arrive at a wrong conclusion (Rohrer, 2005). Like all human beings, they are flawed information processors. Studies show that they are overly influ- enced by information gathered early in the assessment process (Dawes, Faust, & Meehl, 2002; Meehl, 1996, 1960). They some- times pay too much attention to certain sources of information, such as a parent’s report about a child, and too little to others, such as the child’s point of view (McCoy, 1976). Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status, to name just a few (Vasquez, 2007). Given the limitations of assessment tools, assessors, and classifica- tion systems, it is small wonder that studies sometimes uncover

shocking errors in diagnosis, especially in hospitals (Caetano & Babor, 2007). Beyond the potential for misdiagnosis, the very act of classifying people can lead to

unintended results. As you read in Chapter 2, for example, many family-social theorists believe that diagnostic labels can become self-fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be viewed and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Spagnolo, Murphy, & Librera, 2008; Corrigan, 2007). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time.

Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classification and diagnosis are critical to understanding and treating people in distress.

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Insensitive labeling Recognizing that glib labels can contribute to negative stereotypes and to the stig- matization of people with psychological disorders, a few years ago mental health advocacy groups protested the produc- tion of “Crazy for You” bears, a new line of Vermont Teddy Bears. The teddy bear company subsequently agreed to cease the production and sale of those bears.

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Clinical Assessment, Diagnosis, and Treatment :// 87

jjTreatment: How Might the Client Be Helped? Over the course of 10 months, Angela Savanti was treated for depression and related symp- toms. She improved considerably during that time, as the following report describes:

Angela’s depression eased as she began to make progress in therapy. A few months before

the termination of treatment, she and Jerry resumed dating. Angela discussed with Jerry

her greater comfort in expressing her feelings and her hope that Jerry would also become

more expressive with her. They discussed the reasons why Angela was ambivalent about

getting married, and they began to talk again about the possibility of marriage. Jerry, how-

ever, was not making demands for a decision by a certain date, and Angela felt that she

was not as frightened about marriage as she previously had been. . . .

Psychotherapy provided Angela with the opportunity to learn to express her feelings to

the persons she was interacting with, and this was quite helpful to her. Most important,

she was able to generalize from some of the learning experiences in therapy and modify

her behavior in her renewed relationship with Jerry. Angela still had much progress to make

in terms of changing the characteristic ways she interacted with others, but she had al-

ready made a number of important steps in a potentially happier direction.

(Leon, 1984, pp. 118, 125)

Clearly, treatment helped Angela, and by its conclusion she was a happier, more func- tional person than the woman who had first sought help 10 months earlier. But how did her therapist decide on the treatment program that proved to be so helpful?

Treatment Decisions Angela’s therapist began, like all therapists, with assessment information and diagnostic decisions. Knowing the specific details and background of Angela’s problem (idiographic data) and combining this individual information with broad information about the na- ture and treatment of depression, the clinician arrived at a treatment plan for her.

Yet therapists may be influenced by additional factors when they make treatment decisions. Their treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy (Sharf, 2008). As therapists apply a favored model in case after case, they become more and more familiar with its principles and treatment techniques and tend to use them in work with still other clients.

Current research may also play a role. Most clinicians say that they value research as a guide to practice (Beutler et al., 1995). However, not all of them actually read research

SUMMING UP Diagnosis

After collecting assessment information, clinicians form a clinical picture and decide upon a diagnosis. The diagnosis is chosen from a classification system. The system used most widely in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The most recent version of the DSM, known as DSM-IV-TR, lists approximately 400 disorders and includes five axes. The reliability and validity of this edition continue to be criticized by a number of clinical theorists.

Even with trustworthy assessment data and reliable and valid classification categories, clinicians will not always arrive at the correct conclusion. Moreover, the prejudices that labels arouse may be damaging to the person who is diagnosed.

BETWEEN THE LINES

Cutting Financial Ties Before being appointed to the DSM-V task force, clinical researchers were required to pledge to limit their total annual in- come from pharmaceutical companies to $10,000 (Garber, 2008). The reason? To avoid a conflict of interest. When a psy- chological problem is formally declared a disorder, companies that develop a drug for that problem typically experience huge increases in sales. <<

BETWEEN THE LINES

The Stigma Continues 67% Percentage of Americans who

would not tell their employer that they were seeking mental health treatment <<

51% Americans who would hesitate to see a psychotherapist if a diagno- sis were required <<

41% Americans who believe they should be able to handle psychological problems on their own <<

37% Americans who would be reluctant to seek treatment because of con- fidentiality concerns <<

33% Americans who would not seek counseling for fear of being labeled “mentally ill” << (Opinion Research Corporation, 2004)

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88 ://CHAPTER 3

Culture-Bound Abnormality

Such disorders remind us that the classifica- tions and diagnoses applied in one culture may not always be appropriate in another.

Susto, a disorder found among mem- bers of Indian tribes in Central and South America and Hispanic natives of the Andean highlands of Peru, Bolivia, and Colombia, is most likely to occur in infants and young children. The symptoms are ex- treme anxiety, excitability, and depression, along with loss of weight, weakness, and rapid heartbeat. The culture holds that this disorder is caused by contact with super- natural beings or with frightening strangers or by bad air from cemeteries.

People affected with amok, a disorder found in Malaysia, the Philippines, Java, and some parts of Africa, jump around violently, yell loudly, grab knives or other weapons, and attack any people and objects they encounter. Within the culture, amok is thought to be caused by stress, severe shortage of sleep, alcohol consump- tion, and extreme heat.

Red Bear sits up wild-eyed, his body drenched in sweat, every muscle tensed. The horror of the dream is still with him; he is choked with fear. Fighting waves of nausea, he stares at his young wife lying asleep on the far side of the wigwam, illuminated by the dying embers.

His troubles began several days before, when he came back from a hunting expedition empty-handed. Ashamed of his failure, he fell prey to a deep, lingering depression. . . . The signs of windigo were all there: depression, lack of appetite, nausea, sleeplessness and, now, the dream. Indeed, there could be no mistake.

He had dreamed of the windigo—the monster with a heart of ice—and the dream sealed his doom. Cold- ness gripped his own heart. The ice monster had entered his body and possessed him. He himself had become a windigo, and he could do nothing to avert his fate.

Suddenly, the form of Red Bear’s sleeping wife begins to change. He no longer sees a woman, but a deer. His eyes flame. Silently, he draws his knife from under the blanket and moves stealthily toward the motionless figure. . . . A powerful desire to eat raw flesh consumes him.

With the body of the “deer” at his feet, Red Bear raises the knife high, preparing the strike. Unexpectedly, the deer screams and twists away. But the knife flashes down, again and again. Too late, Red Bear’s kinsmen rush into the wigwam. . . . [T]hey drag him outside into the cold night air and swiftly kill him.

(LINDHOLM & LINDHOLM, 1981, P. 52)

Red Bear was suffering from windigo, a disorder once common among Algonquin Indian hunters. They believed in a super- natural monster that ate human beings and had the power to bewitch them and turn them into cannibals. Red Bear was among the few afflicted hunters who actually did kill and eat members of their households.

Windigo is but one of numerous un- usual mental disorders discovered around the world, each unique to a particular culture, each apparently growing from that culture’s pressures, history, institutions, and ideas (Flaskerud, 2009; Draguns, 2006).

Koro is a pattern of anxiety found in Southeast Asia in which a man suddenly becomes intensely fearful that his penis will withdraw into his abdomen and that he will die as a result. Cultural lore holds that the disorder is caused by an imbalance of “yin” and “yang,” two natural forces believed to be the fundamental components of life. Accepted forms of treatment include having the individual keep a firm hold on his penis until the fear passes, often with the assistance of family members or friends, and clamping the penis to a wooden box.

Latah is a disorder found in Malaysia. Certain circumstances (hearing someone say “snake” or being tickled, for example) trigger a fright reaction that is marked by repeating the words and acts of other people, uttering obscenities, and doing the opposite of what others ask.

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Do Western abnormalities follow? A culture clash is on display as this woman with a head scarf walks past a Western billboard upon leaving a metro stop in Turkey (religious Muslim women cover their hair). The spread of Western values, fashions, and ads to eastern European and Asian countries has been accompanied by a rise in anorexia nervosa and other psy- chological disorders that once seemed to be found strictly in Western society.

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Clinical Assessment, Diagnosis, and Treatment :// 89

To help clinicians become more familiar with and apply research findings, there is

an ever-growing movement in the United States, the United Kingdom, and elsewhere called empirically supported, or evidence-based, treatment (Pope & Wedding, 2008; Nathan & Gorman, 2007). Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such informa- tion to clinicians. Critics of the movement worry that such efforts have thus far been simplistic, biased, and, at times, misleading (Weinberger & Rasco, 2007; Mahrer, 2005; Westen et al., 2005). However, the empirically supported treatment movement has been gaining momentum in recent years.

The Effectiveness of Treatment Altogether, more than 400 forms of therapy are currently practiced in the clinical field (Corsini, 2008). Naturally, the most important question to ask about each of them is whether it does what it is supposed to do. Does a particular treatment really help people overcome their psychological problems? On the surface, the question may seem simple. In fact, it is one of the most difficult questions for clinical researchers to answer.

The first problem is how to define “success.” If, as Angela’s therapist suggests, she still has much progress to make at the conclusion of therapy, should her recovery be considered successful? The second problem is how to measure improvement (Markin & Kivlighan, 2007; Luborsky, 2004). Should researchers give equal weight to the reports of clients, friends, relatives, therapists, and teachers? Should they use rating scales, inven- tories, therapy insights, observations, or some other measure?

Perhaps the biggest problem in determining the effectiveness of treatment is the variety and complexity of the treatments currently in use. People differ in their problems, personal styles, and motivations for therapy. Therapists differ in skill, experience, orienta- tion, and personality. And therapies differ in theory, format, and setting. Because an indi- vidual’s progress is influenced by all these factors and more, the findings of a particular study will not always apply to other clients and therapists.

Proper research procedures address some of these problems. By using control groups, random assignment, matched research participants, and the like, clinicians can draw certain conclusions about various therapies. Even in studies that are well designed, how- ever, the variety and complexity of treatment limit the conclusions that can be reached (Kazdin, 2006, 2004, 1994).

Despite these difficulties, the job of evaluating therapies must be done, and clinical researchers have plowed ahead with it. Investigators have, in fact, conducted thousands of

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•empirically supported treatment• A movement in the clinical field that seeks to identify which therapies have received clear research support for each disorder, to develop corresponding treat- ment guidelines, and to spread such information to clinicians. Also known as evidence-based treatment.

BETWEEN THE LINES

Famous Movie Clinicians Dr. Steele (Changeling, 2008) <<

Drs. Jaffe and Vauban (I Heart Huckabees, 2004) <<

Dr. Rosen (A Beautiful Mind, 2001) <<

Dr. Crowe (The Sixth Sense, 1999) <<

Dr. McGuire (Good Will Hunting, 1997) <<

Dr. Lecter (The Silence of the Lambs, 1991; Hannibal, 2001; and Red Dragon, 2002) <<

Dr. Marvin (What About Bob?, 1991) <<

Dr. Sayer (Awakenings, 1990) <<

Dr. Sobel (Analyze This, 1999; and Analyze That, 2002) <<

Dr. Livingston (Agnes of God, 1985) <<

Dr. Berger (Ordinary People, 1980) <<

Dr. Dysart (Equus, 1977) <<

Nurse Ratched (One Flew over the Cuckoo’s Nest, 1975) <<

Dr. Swinford (David and Lisa, 1962) <<

Dr. Petersen (Spellbound, 1945) <<

Dr. Murchison (Spellbound, 1945) <<

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90 ://CHAPTER 3

therapy outcome studies, studies that measure the effects of various treatments. The studies typically ask one of three questions: (1) Is therapy in general effective? (2) Are particular therapies generally effective? (3) Are particular therapies effective for particular problems?

Is Therapy Generally Effective? Studies suggest that therapy often is more help- ful than no treatment or than placebos. A pioneering review examined 375 controlled studies, covering a total of almost 25,000 people seen in a wide assortment of therapies (Smith, Glass, & Miller, 1980; Smith & Glass, 1977). The reviewers combined the findings of these studies by using a special statistical technique called meta-analysis. According to this analysis, the average person who received treatment was better off than 75 percent of the untreated persons (see Figure 3-4). Other meta-analyses have found similar relation- ships between treatment and improvement (Bickman, 2005).

Some clinicians have concerned themselves with an important related question: Can therapy be harmful? A number of studies suggest that more than 5 percent of patients actually seem to get worse because of therapy (Nolan et al., 2004; Lambert & Bergin, 1994). Their symptoms may become more intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy (Lambert et al., 1986; Hadley & Strupp, 1976).

Are Particular Therapies Generally Effective? The studies you have read about so far have lumped all therapies together to consider their general effectiveness. Many researchers, however, consider it wrong to treat all therapies alike. Some critics suggest that these studies are operating under a uniformity myth—a false belief that all therapies are equivalent despite differences in the therapists’ training, experience, theo- retical orientations, and personalities (Good & Brooks, 2005; Kiesler, 1995, 1966).

Thus, an alternative approach examines the effectiveness of particular therapies (Bickman, 2005). Most research of this kind shows each of the major forms of therapy to be superior to no treatment or to placebo treatment (Prochaska & Norcross, 2006). A number of other studies have compared particular therapies with one another and found that no one form of therapy generally stands out over all others (Luborsky et al., 2003, 2002, 1975).

If different kinds of therapy have similar successes, might they have something in common? A rapprochement movement has tried to identify a set of common strate- gies that may run through the work of all effective therapists, regardless of the clinicians’ particular orientation (Portnoy, 2008; Castonguay & Beutler, 2006). Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their cli- ents are interacting, and try to promote self-mastery in their clients. In short, effective therapists of any type may practice more similarly than they preach.

Are Particular Therapies Effective for Particular Problems? People with different disorders may respond differently to the various forms of therapy (Corsini, 2008). In an oft-quoted statement, influential clinical theorist Gordon Paul said decades

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Figure 3-4 Does therapy help? Combining participants and results from hundreds of studies, investigators have determined that the average person who receives psychotherapy experiences greater improvement than do 75 percent of all untreated people with similar problems. (Adapted from Prochaska & Norcross, 2003; Lambert et al., 1993; Smith et al., 1980.)

BETWEEN THE LINES

What Is the Difference between Treatment Efficacy and Treatment Effectiveness? Many writers use the terms “treatment efficacy” and “treatment effectiveness” interchangeably. Technically, however, efficacy research determines whether a treatment can work under ideal condi- tions (for example, with therapists who are given special training for the study), while effectiveness research examines whether a treatment works well in the real world (for example, as offered by practicing therapists). <<

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Clinical Assessment, Diagnosis, and Treatment :// 91

ago that the most appropriate question regarding the effectiveness of therapy may be “What specific treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (Paul, 1967, p. 111). Researchers have investigated how effective particular therapies are at treating particular disorders, and they often have found sizable differences among the various therapies. Behavioral therapies, for example, appear to be the most ef- fective of all in treating phobias (Wilson, 2008), whereas drug therapy is the single most effective treatment for schizophrenia (Awad & Voruganti, 2007).

As you read previously, studies also show that some clinical problems may respond better to combined approaches (de Maat et al., 2007; TADS, 2007). Drug therapy is sometimes combined with certain forms of psychotherapy, for example, to treat depression. In fact, it is now common for clients to be seen by two therapists—one of them a psychopharmacologist, a psychiatrist who primarily prescribes medications, and the other a psychologist, social worker, or other therapist who conducts psychotherapy.

Obviously, knowledge of how particular therapies fare with particular disorders can help therapists and clients alike make better decisions about treatment (Clinton et al., 2007; Beutler, 2002, 2000) (see Figure 3-5). Thus this is a question to which this book will keep returning as it examines the various disorders.

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SUMMING UP Treatment

The treatment decisions of therapists may be influenced by assessment information, the diagnosis, the clinician’s theoretical orientation and familiarity with research, and the field’s state of knowledge.

Determining the effectiveness of treatment is difficult. Nevertheless, therapy outcome studies have led to three general conclusions: (1) People in therapy usually are better off than people with similar problems who receive no treatment, (2) the various therapies do not appear to differ dramatically in their general effectiveness, and (3) certain therapies or combinations of therapies do appear to be more effec- tive than others for certain disorders.

•rapprochement movement•An effort to identify a set of common strat- egies that run through the work of all effective therapists.

•psychopharmacologist•A psychiatrist who primarily prescribes medications.

PUTTING IT... together Renewed Respect Collides with Economic Pressure In Chapter 2 you read that today’s leading models of abnormal behavior often differ widely in their assumptions, conclusions, and treatments. It should not surprise you, then, that clinicians also differ considerably in their approaches to assessment and diag- nosis. Yet when all is said and done, no assessment technique stands out as superior to the rest. Each of the hundreds of available tools has major limitations, and each produces at best an incomplete picture of how a person is functioning and why.

In short, the present state of assessment and diagnosis argues against relying exclu- sively on any one approach. As a result, more and more clinicians now use batteries of assessment tools in their work (Iverson et al., 2007). Such batteries already are providing invaluable guidance in the assessment of Alzheimer’s disease and certain other disorders that are particularly difficult to diagnose, as you shall see later.

Attitudes toward clinical assessment have shifted back and forth over the past several decades. Before the 1950s, assessment was a highly regarded part of clinical practice. As

Figure 3-5 Who seeks therapy? According to surveys conducted in the United States, people who are middle-aged, female, from Western states, and highly educated are the most likely to have been in therapy at some point in their lives. (Adapted from Fetto, 2002.)

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92 ://CHAPTER 3

the number of clinical models grew during the 1960s and 1970s, however, followers of each model favored certain tools over others, and the practice of assessment became fragmented. Meanwhile, research began to reveal that a number of tools were inaccurate or inconsistent. In this atmosphere, many clinicians lost confidence in and abandoned systematic assessment and diagnosis.

Today, however, respect for assessment and diagnosis is on the rise once again. One reason for this renewal of interest is the development of more precise diagnostic criteria, as presented in DSM-IV-TR. Another is the drive by researchers for more rigorous tests to help them select appropriate participants for clinical studies. Still another factor is the clinical field’s growing awareness that certain disorders can be properly identified only after careful assessment procedures.

Along with heightened respect for assessment and diagnosis has come increased research. Indeed, today’s researchers are carefully examining every major kind of assess- ment tool—from projective tests to personality inventories. This work is helping many clinicians perform their work with more accuracy and consistency—welcome news for people with psychological problems.

Ironically, just as today’s clinicians and researchers are rediscovering systematic assess- ment, rising costs and economic factors seem to be discouraging the use of assessment tools. In particular, managed care insurance plans, which emphasize lower costs and shorter treatments, often refuse to provide coverage for extensive clinical testing or observations (Wood et al., 2002). Which of these forces will ultimately have a greater in- fluence on clinical assessment and diagnosis—promising research or economic pressure? Only time will tell.

1. How would you grade the tests you take in school? That is, how reliable and valid are they? What about the tests you see on the Web or in maga- zines? pp. 68, 71, 76

2. Just about everybody has heard of and knows about the Rorschach, even though the test has limited reli- ability and validity. How might you explain the fame and popularity of this test throughout Western society? pp. 71–72, 73

3. How might IQ scores be misused by school officials, parents, or other individuals? Why do you think our society is so preoccupied with the concept of intelligence and with IQ scores? pp. 79–80

4. Many people argue for a “people first” approach to clinical l abeling. For example, they recommend using the phrase “a person with schizophre- nia” rather than “a schizophrenic.”

Why might this approach to labeling be preferable? p. 86

5. A newspaper columnist has observed, “Newspapers usually take great care not to mention the race or religion of those accused of violent crimes. But how many times have you seen the sentence, ‘He had a history of men- tal illness’?” What does this double standard suggest about the status and rights of people with psychological disorders? p. 86

CRITICAL THOUGHTSC

idiographic understanding, p. 67 assessment, p. 67 standardization, p. 68 reliability, p. 68 validity, p. 68 clinical interview, p. 69 mental status exam, p. 70 test, p. 71

projective test, p. 71 Rorschach test, p. 71 Thematic Apperception Test (TAT), p. 72 personality inventory, p. 74 MMPI, p. 74 response inventories, p. 75 psychophysiological test, p. 76 neurological tests, p. 77

EEG, CAT, PET, MRI, fMRI, p. 77 neuroimaging techniques, p. 77 neuropsychological test, p. 78 battery, p. 78 intelligence test, p. 79 intelligence quotient (IQ), p. 79 naturalistic obsesrvation, p. 80 analog observation, p. 80

KEY TERMSK

BETWEEN THE LINES

The Dodo Bird Effect The finding that no one form of therapy is generally more effective than any other form was first observed decades ago. It was soon named the “Dodo Bird Effect” by psychologist Saul Rosenzweig, after the Dodo Bird in Alice in Wonderland, who famously said, “Everybody has won and all must have prizes.” <<

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Clinical Assessment, Diagnosis, and Treatment :// 93

self-monitoring, p. 81 diagnosis, p. 82 syndrome, p. 82

classification system, p. 82 DSM-IV-TR, p. 83 empirically supported treatment, p. 89

therapy outcome study, p. 90 rapprochement movement, p. 90 psychopharmacololgist, p. 91

1. What forms of reliability and valid- ity should clinical assessment tools display? p. 68

2. What are the strengths and weaknesses of structured and unstructured interviews? p. 70

3. What are the strengths and weak- nesses of projective tests (p. 73), personality inventories (p. 75), and other kinds of clinical tests (pp. 75–80)?

4. List and describe today’s leading projective tests. pp. 71–72

5. What are the key features of the MMPI? pp. 74–75

6. How do clinicians determine whether psychological problems are linked to brain damage? pp. 76–78

7. Describe the ways in which clini- cians may make observations of clients’ behaviors. pp. 80–81

8. What is the purpose of clinical diagnoses? pp. 81–82

9. Describe DSM-IV-TR. What prob- lems may accompany the use of classification systems and the process of clinical diagnosis? pp. 83–86

10. According to therapy outcome studies, how effective is therapy? pp. 89–91

QUICK QUIZ What forms of rel ity should clinical display? p. 68 Wh h

QUICK QU ity and valid-

essment tools

d

cyberstudy <<>> SEARCH

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▲ Chapter 3 Video Cases DSM-IV-TR Categories: Bias against Females? Assessing Psychopathy “Brain Fingerprinting”: Detecting Hidden Thoughts

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