What Clinical Assessment Is, and Why It Matters

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What Clinical Assessment Is, and Why It Matters

Abnormal Psychology · Chapter 10: Psychological Assessment: Tools and TechniquesSection 10.1 · lesson 35 of 9711 min · free with a free account

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In this lesson

A hypothesis-testing process, not a search for a label.

  • Define clinical assessment and the purposes it serves
  • Distinguish a diagnosis from a formulation
  • Name the principal errors of clinical judgment
  • Explain why feedback is itself a clinical intervention

Transcript

Everything said in the video, section by section (1,473 words). Read along, or search it.

Psychological Assessment: Tools and Techniques

What Clinical Assessment Is, and Why It Matters

Two people arrive with the same diagnosis, of the same severity and duration. Should they get the same treatment? The answer is usually no, and this section explains why. Assessment is not a search for the right label. It is a process of generating candidate explanations, and then testing them. We will work through what it is for, and how it proceeds. Where the information comes from, and what each source cannot tell you. The difference between classifying a presentation and explaining it. And the ways clinical judgment fails, which are patterned and well documented. One of those findings is genuinely uncomfortable, and we will state it plainly.

The Definition

Every Word in It Is Doing Work

Clinical assessment is the systematic gathering and integration of information. In order to answer a clinical question. Every part of that is doing work. Systematic distinguishes assessment from an unstructured conversation. What gets asked is chosen, rather than merely arising. Integration distinguishes it from data collection. And the combining is where the clinical skill actually sits. Then a clinical question, which is the part that makes an assessment finite. Here is the point students most often miss. There is no such thing as a complete assessment. So the question has to be identified before the gathering begins. One note first. This material is educational, and is not a basis for diagnosis. Nothing here describes a procedure a reader could carry out.

Purposes

Seven Different Questions, Not Seven Sizes

Assessment serves several distinct purposes, and they are not interchangeable. Describing the presenting problem asks what the person is experiencing, and for how long. Arriving at a diagnosis asks whether this meets criteria for a recognized category. Building a formulation asks why this person has this difficulty now. And what is keeping it going, which is a different question entirely. Planning treatment asks what should be done, in what order, and by whom. Establishing a baseline asks what the starting position is. Monitoring asks whether it is working, and produces a trajectory rather than a reading. And answering a referral asks whether the referrer's question has been established. Each of those is a different question, not a different amount of the same inquiry. Conflating them produces an assessment that serves none of them well.

The Referral

A Question Tied to a Decision

The referral question is the specific question the referring service wants answered. And it shapes everything downstream. Whether collateral information is sought, and what the report finally says. Vague referrals are common, and they cause a specific, predictable failure. A referral reading please assess leaves the clinician to invent a question. And what gets invented is the broadest one available. A general assessment, producing a general report, answering nothing in particular. It is not to conduct a larger assessment. It is to go back and clarify. What decision is waiting on this? What would change depending on the answer? A question tied to a decision is nearly always answerable. One that is not tied to a decision usually cannot be answered at all.

The Process

A Loop, Not a Line Ending in a Report

The process runs from referral through to re-assessment, and it is a loop. Referral establishes the question. Consent and orientation covers what the assessment is for, and what it will involve. Who will see the results, and the limits of confidentiality. That is a substantive stage, and not a formality. A person who does not understand what is happening will supply worse information. Then hypothesis generation, which is the first reasoning point. Targeted testing follows, and notice that this is not simply more testing. It selects methods that would distinguish between the candidate explanations. Integration is the second reasoning point, where it all gets combined into an account. Then feedback, documentation, and re-assessment throughout treatment.

Hypothesis Testing

Go and Look for What Would Show You Wrong

Here is the single most important idea in this section. Assessment is a hypothesis-testing process. Candidate explanations are generated, and information is sought that would separate them. The distinction has a concrete operational test, which you can apply to yourself. Having formed a candidate explanation, ask what you would expect if it were wrong. Then go and look for that. Consider a clinician who thinks a presentation is a mood condition. If they ask only about mood, they will find mood symptoms. A clinician testing the hypothesis asks what else would produce this picture. Notice the asymmetry. The first approach cannot fail. The second one can, and that is exactly what makes it worth doing.

Five Sources

Each One Has a Different Blind Spot

Assessment draws on five sources of information. It is that each source has a characteristic blind spot. Self-report is indispensable, since some things are accessible no other way. And it is limited by what the person has noticed, remembers, and is willing to say. Clinician observation does not depend on report. But it is a short sample of behavior, in an unrepresentative setting. Collateral report supplies what the person cannot see about themselves. And it carries the informant's own perspective and interests. Standardized measures are comparable and quantified, and cover only what they cover. Agreement across sources raises confidence, because their blind spots differ. But disagreement is not a problem to be solved by picking the most credible source. A clinician who decides whom to believe has just discarded a finding.

Two Products

One Classifies; the Other Explains

A diagnosis classifies. A formulation explains. Those are different products. A diagnosis assigns a presentation to a category, on the basis of stated criteria. A formulation is an account of why this person has this difficulty now. A diagnosis is nomothetic. It is about a class of people. A formulation is idiographic. It is about this person. A diagnosis is relatively fixed once criteria are met. A formulation is revised whenever new information arrives. Two people with the same diagnosis may have almost nothing else in common. So an assessment produces both, and for complementary reasons. The diagnosis connects the person to evidence gathered on groups. The formulation determines what is actually done for them.

The Four Ps

Where the Clinical Work Actually Sits

A formulation is conventionally organized under four headings, called the four Ps. Predisposing factors are vulnerabilities present before onset. Precipitating factors are what triggered the difficulty at this particular point. Perpetuating factors are what is maintaining it now. Those are clinically the most important, because they are what treatment targets. And protective factors are the strengths and resources supporting recovery. Predisposing and precipitating factors explain how the difficulty arose. Perpetuating factors determine what is done about it. A precipitant is usually not modifiable in itself. The difficulty as a response to circumstances, rather than a personal failing. And one more thing. An absence of protective factors is itself a target.

Same Diagnosis

Two Composites, Two Different Plans

Two composites, with the diagnosis deliberately held constant. Aditi is twenty-nine. Low mood, loss of interest, poor concentration, early waking. Five months. Onset followed the end of a long relationship. And she describes a long-standing pattern of blaming herself when things go wrong. She has withdrawn from a sports club she previously attended twice a week. Michael is thirty-one, with the same features, severity, and duration. His onset followed the loss of his job when the site closed. He has arrears and an insecure tenancy. Now compare the perpetuating factors, because that is where the plans diverge. Aditi's are psychological and behavioral, and both are directly treatable. Michael's principal perpetuating factors are material and physiological. Deliver Aditi's treatment to him first and you target factors that are not the drivers. Same diagnosis. Different plans. Because plans follow from perpetuating factors.

Judgment

Four Patterned Failures, and an Uncomfortable Finding

Assessment depends on judgment, and judgment fails in patterned ways. Confirmation bias is seeking information that supports a hypothesis already formed. Anchoring is the first information received exerting disproportionate influence. Availability is judging something more likely because instances come to mind easily. And then the illusion of confidence, which is the most unsettling of the four. Confidence in a judgment increases with the amount of information gathered. Accuracy does not increase correspondingly. Now the general research finding, and it should be stated plainly rather than softened. Reviewed repeatedly since Paul Meehl's work in nineteen fifty-four. Structured approaches generally outperform unstructured clinical judgment. Judgment is still necessary, though, and not for defensive reasons. Structured tools exist only for questions someone has built one for.

Ethics And After

Feedback Is an Intervention, and Assessment Does Not End

Four ethical requirements govern all of this. Informed consent means the person understands what the assessment is for. What it involves, who receives the results, and that they may decline. Consent given without that understanding is not consent. Confidentiality and its limits are stated at the outset, not invoked afterwards. Competence means practitioners use only what they are trained and qualified to use. And results must be communicated understandably. Now feedback, which is routinely treated as an administrative step. It is not. It is a clinical intervention in its own right. An assessment is several hours of someone attending closely to a person's life. It is also the point at which errors surface. One last idea. A formulation is a hypothesis that treatment tests. If targeting the perpetuating factors produces no change, they were probably the wrong ones.

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FAQ

Questions students ask us

About What Clinical Assessment Is, and Why It Matters

What is clinical assessment in psychology?
Clinical assessment is the systematic gathering and integration of information to answer a specific clinical question. It can serve several distinct purposes: describing the problem, reaching a diagnosis, building a formulation, planning treatment, setting a baseline, monitoring progress, and answering a referral. Because no assessment can ever be complete, the question has to be identified first, and the process works best as hypothesis testing, looking for evidence that would show a candidate explanation is wrong.
What is the difference between a diagnosis and a case formulation?
A diagnosis classifies a presentation into a category based on stated criteria, while a formulation explains why this particular person has this difficulty now. A diagnosis is nomothetic, about a class of people, and stays relatively fixed once criteria are met. A formulation is idiographic, about one person, and is revised as new information arrives. The diagnosis links the person to group research, while the formulation guides what is actually done.
What are the four Ps of case formulation?
The four Ps are predisposing, precipitating, perpetuating, and protective factors. Predisposing factors are vulnerabilities present before onset, precipitating factors triggered the difficulty at this point, perpetuating factors keep it going now, and protective factors are strengths that support recovery. Perpetuating factors matter most clinically because treatment targets them, which is why two people with the same diagnosis can need very different treatment plans.
What are the most common errors in clinical judgment?
Common errors in clinical judgment include confirmation bias, anchoring, availability, and overconfidence. Confirmation bias is seeking information that supports an existing hypothesis, anchoring gives first impressions too much weight, and availability treats easily recalled cases as more likely. Confidence also rises with the amount of information gathered while accuracy does not. Since Paul Meehl's 1954 work, research has generally found that structured approaches outperform unstructured clinical judgment.

About the Abnormal Psychology course

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Abnormal Psychology (Psychology 180) carries a NCCRS credit recommendation for 3 semester credits. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.
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