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This research paper serves to provide systematic guidelines for assessing adult inpatients and outpatients. The paper is organized into several sections. First, we examine the rationale for conducting psychological assessment in adult mental health settings.Second,we discuss the foundations and goals of a general approach to psychological assessment in adult mental health settings. Third, we consider various psychological assessment tools. Fourth, we examine the general approach to assessment as well as our recommended approach to psychological assessment in adult mental health settings. Finally, we explore issues relevant to psychological assessment and, in particular, those relevant to assessing inpatients.
Why Conduct Psychological Assessments?
We conceptualize psychological assessment as a problemsolving process in which psychological tests, interviews, and other sources of data function as tools used to answer questions (e.g., to address a referral request) and resolve perplexities (e.g., to assist in differential diagnosis; Maloney & Ward, 1976). The primary purpose of psychological assessments in adult inpatient and outpatient mental health settings is to evaluate patients’cognitions, affect, behaviors, personality traits, strengths, and weaknesses in order to make judgments, diagnoses, predictions, and treatment recommendations concerning the clients (Maruish, 1994).The functional utility of psychological assessments, we believe, lies in the ability to provide information about clients’ symptoms, but also their stable personality characteristics, defensive patterns, identifications, interpersonal styles, selfconcepts, and beliefs (Smith, 1998). Furthermore, comprehensive assessments address the factors that led to the problems and difficulties that presumably led to the referral (Wakefield, 1998). Thus, the general goals of psychological assessment include providing an accurate description of the client’s problems, determining what interpersonal and environmental factors precipitated and are sustaining the problems, and making predictions concerning outcome with or without intervention (Aiken, 2000; Lilienfeld, Wood, & Garb, 2001). In addition, assessments can support or challenge clinical impressions and previous working diagnoses, as well as identifying obstacles to therapy (Appelbaum, 1990; Butcher, 1990; Clarkin & Mattis, 1991; Hurt, Reznikoff, & Clarkin, 1991; Maruish, 1994, 1999).
Finally, assessments can also provide assistance in developing and evaluating the effectiveness of a treatment plan consistent with the client’s personality and external resources, as well as allowing the client to find out more about himself or herself (Butcher, 1990). As clients continue to adapt and deal with their symptoms after their discharge, assessments can guide discharge planning and subsequent treatment of the individual.
General Approach to Psychological Assessment in an Adult Mental Health Setting
Foundations of the General Approach to Psychological Assessment
Psychological assessments must be founded upon specific theoretical premises that guide the assessment process. The history of psychological assessment is quite extensive, resulting in many theoretical stances upon which assessments are based. It is our belief, however, that psychological assessment of adults in mental health settings is based on two founding premises: assessments must be evidence-based and multimodal.
Psychological assessment in mental health settings must be evidence-based. That is, a client’s psychiatric symptoms must be systematically assessed in relation to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American PsychiatricAssociation, 1994) criteria for particular disorders. This criteria analysis is then supplemented with results from empirically validated psychological tests and structured interviews.The client’s responses on these measures are used to indicate likely diagnoses and appropriate treatment implications based on empirical research. Consequently, an evidence-based approach to psychological assessment requires empirical support for any conclusions or recommendations, as opposed to relying solely on clinical impression and judgment.
The evidence-based approach was initially practiced in general medicine and recently has been incorporated in psychology. Evidence-based medicine (EBM) integrates clinical expertise with external evidence based on systematic research, while considering the values and expectations of patients or clients (Gambrill, 1999). Within the medical community, EBM is defined as a set of strategies designed to ensure that the clinicians form opinions and base subsequent decisions on the best available external evidence (Geddes, 1997). Thus, decisions pertaining to the client are made in light of the most up-to-date information available. The steps involved in EBM include a precise definition of the clinical problem, an efficient search for the best available evidence, critical appraisal of the evidence, and integration of the research findings with clinical expertise (Geddes, 1997; Olson, 1996). At each stage of EBM, recent developments in clinical findings and information technology are harnessed and utilized (Geddes, 1997). As physicians have acknowledged that no single authority has comprehensive scientific knowledge, the EBM approach is viewed as an improvement over the authoritative knowledge approach to practicing medicine (Kennell, 1999).
Within the domain of psychological assessment, an evidence-based approach emphasizes the importance of systematic observation and the use of rules of evidence in hypothesis testing. Thus, psychologists base their assessments and diagnoses on the best available evidence (Bensing, 2000). This approach to psychological assessment affords the opportunity to integrate real clinical problems with critical evaluation of the psychiatric research literature (Gilbody, 1996). In essence, an evidence-based approach to psychological assessment is premised on obtaining actuarial evidence from both structured interviews and objective measures that have been empirically supported. Empirical and clinical literature suggests patterns of symptoms that are associated with specific diagnoses and provide treatment implications, thereby enhancing the likelihood of making an accurate diagnosis.
The evidence-based approach is distinct from the more established and popular approach based on clinical judgment. Evidence-based actuarial assessments proceed in accordance with a prespecified routine and are based on empirically derived relations between data and the trait or event of interest (Dawes, Faust, & Meehl, 1989; Wiens, 1991). In contrast, clinical judgment consists of decisions made in the clinician’s mind. In its most polar form, this distinction is analogous to a dimension with objectivity (evidence-based) on one end and subjectivity (clinical impression) at the other end.
The clinicians who base their assessments on clinical judgment highlight the advantages of their technique. First, certain assessment tools, such as unstructured interviews and behavioral observations, cannot be empirically evaluated or subjected to statistical analyses required by the evidence-based model. In fact, clinical judgment is required to evaluate the results of such tools. The results provide clinicians with a plethora of information, including clinical impressions as to the nature of clients’ difficulties and distresses. Second, clinicians’impressions and judgments structure the rest of the assessment and provide a framework around which the client’s symptoms and difficulties are conceptualized and understood. Third, many clinicians contend that their clinical impressions and judgments are rarely disputed by empirical test results. Thus, in the interest of conducting an efficient assessment, they rely solely on their judgment gleaned from information obtained from unstructured interviews. Fourth, some clinicians fear that by basing a diagnosis on empirical findings, they will be treating the client nonoptimally through reliance on actual experience (Meehl, 1973). Furthermore, many clinicians often shun actuarial-based data for fear that the data themselves will involve significant error, thereby leading to misdiagnosis of a client. Consequently, reliance on one’s own experience and judgment rather than actuarial-based data when making diagnoses and treatment recommendations remains a popular method by which clinicians conduct psychological assessments.
Despite the historical popularity of basing assessments on clinical judgments, the validity of such judgments is often low, thereby placing the client at potential risk for underdiagnosis, overdiagnosis, or misdiagnosis (Faust & Ziskin, 1988). Clinical inference and judgment involve probabilistic transitions from clients’observable or reported episodes to their dispositions. Ideally, such inferences should be based upon an extensive actuarial experience providing objective probability statements (Meehl, 1973). However, in reality, this ideal is rarely achieved, because often the conditional probabilities are judged based solely on a clinician’s experience, rather than on empirical findings. Consequently, permitting a weak or moderately strong clinical inference to countervail a well-supported set of actuarial data on patients similar to one’s client will lead to an increase in erroneous clinical decisions (Meehl, 1973).
Faust and Ziskin (1988) also highlighted some of the disadvantages of clinical judgment. For example, they noted that clinicians often overvalue supportive evidence and undervalue evidence contrary to their hypotheses. They stated that clinicians tend to find evidence of abnormality in those they assess, regardless of whether they have any psychopathology. In addition, they argued that clinicians tend not to receive any outcome information about their clients; therefore, they are unable to learn whether their predictions were accurate and their suggestions were helpful. In summary, although the clinical impression approach has some merits, the validity and utility of the evidence-based approach is making this new format the standard for psychological assessment. Indeed, Hersen, Kazdin, and Bellack (1991) suggested that as the extent of the relevant research increases, the use of actuarial procedures will also increase.
Finally, contrary to popular opinion, clinical judgments and evidence-based models do not generate the same conclusions. Meehl (1973) contends that human judgment and statistical predictions concerning diagnosis, prognosis, and decisions based on the same set of information have a less than perfect correlation. Dawes et al. (1989) reviewed research comparing clinical judgment to actuarial judgment.They pointed out that with the same set of data, different actuarial procedures lead to the same conclusion, whereas different human judgments may result in several different conclusions. Moreover, Dawes et al. stated that clinicians’diagnoses can fall prey to self-fulfilling prophecy in that their predictions of diagnoses can influence their decisions about symptom prevalence and, later, diagnosis. Moreover, they noted that the mathematical nature of actuarial procedures ensures that each variable has predictive power and is related to the criterion in question (valid vs. invalid association with the criteria). In contrast, clinicians may deal with a limited and unrepresentative sample of individuals; therefore, they may not be able to determine accurate relations between variables. Furthermore, clinical judgment is prone to human error. Neither procedure, however, is infallible. Therefore, the actuarial procedures should be reassessed periodically.
The approach to psychological assessment in mental health settings should also be multimodal. One assessment tool is not sufficient to tap into complex human processes. Moreover, given that empirical support is critical to the validity of a psychological assessment, it is just as essential that there is concordance among the results from the client’s history, structured interview, self-report, objective tests, and clinical impression. Because the results and interpretations are obtained from several sources, the multimodal approach increases reliability of the information gathered and helps corroborate hypotheses (Hertzman, 1984). Moreover, this approach draws on the strengths of each test and reduces the limitations associated with each test. A multimoda lapproach has the benefit of relying on shared methods and thus minimizing any potential biases associated with specific assessment methods or particular instruments. Finn and Butcher (1991) note that objective tests are imperfect and the results should not be seen as definitive conclusions but, rather, as hypotheses that should be compared with information from other sources.Adiagnosis can be made with more confidence when several independent sources of information converge than when inferences are based on a single source. Moreover, the multimodal approach prevents the influence of a single perspective from biasing the results (Beutler, Wakefield, &Williams, 1994).
Goals of Psychological Assessment
An evidence-based and multimodal approach to psychological assessment enables the clinician to attain the main goals of assessment, namely clarifying diagnosis and providing treatment recommendations. Whereas other authors have emphasized additional assessment goals such as insight into a client’s personality, interpersonal style, and underlying drives, we think that the goals of clarifying diagnosis and guiding treatment are the mainstays of psychological assessment and, in fact, incorporate many of the other goals.
A primary reason for conducting psychological assessments of adults in a mental health setting is to make or clarify a diagnosis based on the client’s presenting symptomatology. This is a common issue when the client presents with symptoms that are common to several diagnoses or when there is a concern that the symptoms of one disorder may be masking the symptoms of another disorder (Olin & Keatinge, 1998). Adhering to an evidence-based multimodal approach ensures that crossvalidated actuarial evidence is obtained, thereby enhancing the validity of the diagnosis and increasing the clinician’s confidence in the diagnosis.
Clinicians are often asked to make a differential diagnosis. However, the either-or implication of differential diagnosis is problematic. Often, clients manifest criteria of several disorders simultaneously, or they may manifest symptoms that do not meet criteria for a specific disorder despite the fact that their behaviors and cognitions are maladaptive (Maloney & Ward, 1976; Westen & Arkowitz-Westen, 1998). Thus, clinicians may find it beneficial to use multiple diagnostic impressions and, if possible, determine which disorder is generating the most distress and requires immediate attention.
Making or clarifying one or more diagnoses can benefit the clinician in many ways. These benefits include the following: enhancing communication between clinicians about clients who share certain features; enhancing communication between a clinician and the client through feedback; helping put the client’s symptoms into a manageable and coherent form for the client; giving the client some understanding of his or her distress; guiding treatment; and enhancing research that, in turn, should feed back into clinical knowledge (Westen, 1998). Nonetheless, difficulties of psychological diagnosis should also be mentioned. Gunderson, Autry, Mosher, and Buchsbaum (1974) summarized the controversy associated with making a diagnosis:
Diagnosis, to be meaningful, must serve a function. Too often its function becomes subservient to the process of choosing a label. Thus, although the intent of diagnosis may be the communication of information in summary form, it may actually convey misinformation if insufficient attention is paid to the complexities and variability of human behavior during the diagnostic process. (p. 22)
According to Kellerman and Burry (1981), diagnosis involves several interconnected features that must be taken into account. These include the potential for shift within any diagnostic formulation, the relationship between the presenting problem and the client’s personality, acute versus chronic dimension of the pathology, the presence of various levels and types of pathology and their interconnections, and the impact of diagnostic features on the development of intervention strategies and prognostic formulations. In essence, the diagnosis of the problem is not a discrete final step but, rather, a process that begins with the referral question and continues through the collecting of data from interviews and test results (Maloney & Ward, 1976). Diagnosis is thus a complex process that incorporates a myriad of potential questions and data.
Diagnoses are dependent on meeting DSM-IV criteria for Axis I and Axis II disorders, because the DSM-IV is currently the gold standard by which to diagnose psychopathology and personality disorders. It is an operational system in which each diagnosis must be met by a necessary and sufficient number of criteria that must occur on multiple dimensions (Hertzman, 1984).
Unfortunately, there are problems inherent in making a diagnosis based on the DSM-IV, because the DSM-IV itself has certain limitations. First, it is based on a medical model and does not consider underlying processes (i.e., it is concerned only with the signs and associations of the disorder) and overall manifestations of disorders. Second, it does not address etiological contributions to disorders and how they affect the manifestation and outcome of disorders. Third, the Axis I and Axis II disorder criteria represent a consensual opinion of a committee of experts that labeled a particular pattern of symptoms a disorder. Traditionally, the committee’s decision to assign a certain cluster of symptoms to a diagnosable condition has been based on the presence and frequency of symptoms, an empirical analysis of the symptoms’ social significance, and the specificity of the symptomatic response to various classes of drugs (Beutler et al., 1994).Thus, the process of developing DSM-IV diagnoses lacked the very characteristic valued in the assessment process: relying on empirical evidence and ensuring the collection of data from a variety of sources. Fourth, the DSM-IV is categorical in nature, requiring a specified number of criteria to meet a diagnosis, even though human nature, mental illness, and mental health are distributed dimensionally.
There are numerous limitations to such a categorical approach in which mental disorders are divided into types based on criteria sets with defining features. It becomes restricted in its clinical utility when diagnostic classes are heterogeneous, when there are unclear boundaries between classes, and when the different classes are not mutually exclusive (DSM-IV-TR; American Psychiatric Association, 2000). In addition, the DSM-IV categories have overlapping boundaries, resulting in multiple diagnoses and the problem of comorbidity (Barron, 1998). Moreover, a categorical approach does not provide as powerful predictions about etiology, pathology, prognosis, and treatment as a dimensional approach (Gunderson, Links, & Reich, 1991). Fifth, the DSM-IV is skewed toward the nomothetic end of the spectrum, resulting in static diagnoses whose operational definitions may be inaccurate, unsupported by research findings, and camouflaging questionable construct validity (Barron, 1998). Other criticisms of the DSM-IV include excessive focus on reliability at the expense of validity, arbitrary cutoff points, proliferation of personality disorders, and questionable validity of the personality disorder clusters (Blatt & Levy, 1998).
The American Psychiatric Association has attempted to make the DSM-IV more empirical, accessible, reliable, and useful (Nathan, 1998), as well as to create an optimal balance between a respect for historical tradition, compatibility with the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10; World Health Organization, 1992), evidence from reviews of the literature, analysis of data sets, results of field trials, and consensus of the field (DSM-IV-TR; American Psychiatric Association, 2000). Furthermore, many diagnostic categories are supported by empirical literature (i.e., data from DSM field trials). In summary, the DSM-IV is a descriptive classificatory system, ostensibly unbound to a specific theory of development, personality organization, etiology, or theoretical approach (Barron, 1998). Moreover, it is an official nomenclature that is applicable in a wide number of contexts, can be used by clinicians and researchers from various theoretical orientations, and has been used across psychological settings. The DSM-IV also attempts to address the heterogeneity of clinical presentation of symptoms by adopting a polythetic approach. That is, clients must present with a subset of items from a list of criteria in order to meet a diagnosis. In addition, the DSM-IV includes several axes to take social, medical, and economic factors into account. These merits of the DSM-IV, particularly in the absence of another comprehensive diagnostic system, suggest that assessment of psychological disorders should adhere to this multiaxial system.
The potential problem with the DSM is that it undergoes periodic revision; thus, the clinician relying on this diagnostic system would seem to be continually chasing a moving target or construct. However, except for the changes made from DSM-II to DSM-III, this system does not undergo substantial structural changes with each new version. Moreover, most tests, for example, the MMPI-2, cover most symptoms associated with a variety of syndromes. The changes in DSM from version to version usually involved carving sets of symptoms into different syndromes. Thus, the omnibus inventories designed to assess a variety of psychiatric symptoms are not necessarily affected by these changes, because the fundamental symptoms of most disorders remain captured.
Guide for Treatment
A second and equally important goal of psychological assessments of adults in a mental health setting is to offer a guide for treatment by developing an individualized treatment plan for the client (and family). A psychological assessment offers the opportunity to link symptomatology, personality attributes, and other information with certain treatment modalities or therapeutic targets. Therefore, giving treatment recommendations allows psychologists to proceed past the level of diagnosis and provide suggestions about how to deal with the diagnosed disorder. In fact, diagnosis has most utility when it can be related to treatment. Ideally, an outline of treatment recommendations should include plans to immediately deal with the client’s acute symptoms, as well as long-term treatment plans that address the client’s chronic symptoms, personality features, coping mechanisms, and interpersonal problems, and stressors within the client’s environment (Hertzman, 1984). Moreover, treatment recommendations must provide suggested changes as well as methods for implementing these changes (Maloney & Ward, 1976). In short, treatment recommendations should include short-term and long-term goals, procedures to reach the goals, possible obstacles to treatment, and prognosis of the client.
The process of diagnostic clarification, often the first and primary goal of psychological assessment, often serves as a guide to treatment. Certain treatment protocols are suggested by way of the diagnosis, whereas other treatments may be excluded by virtue of failing to meet criteria for a certain disorder (Hertzman, 1984). However, treatment planning is complicated, because the relationship between diagnosis and treatment is not always simple. Due to the nature of psychiatric difficulties, a client’s symptomatology may result from multiple causal pathways, thereby contributing to imprecise treatment (Clarkin & Mattis, 1991). Nonetheless, diagnosis can provide important useful information.
Although diagnosis is often a first step in the treatment planning process, the ability to offer treatment recommendations must go beyond diagnosis and assess a variety of qualities and variables that best describe the client (Halleck, 1991). Treatment planning should take into account information about symptom severity, stage of problem resolution, general personality attributes, interpersonal style, coping mechanisms, and patient resistance. Further sources of information include the client’s psychiatric and medical history, psychological mindedness,currentlevelsofstress,motivationlevels,andhistory of prior treatments, as well as physical condition, age, sex, intelligence, education, occupational status, and family situation (Halleck, 1991). This information is relevant to treatment planning in two ways. First, demographic variables and a history of prior treatments can dictate or modify current treatment modalities. Second, other variables might help formulate certain etiological models that can in turn guide treatment (Halleck, 1991). Thus, information from various sources obtained in a psychological assessment can be integrated to provide treatment recommendations as well as to predict the prognosis of the client and expected effects of treatment.
In addition, Clarkin and Hurt (1988) listed several areas of patient functioning that must be evaluated to adequately inform treatment planning. These include patient symptoms, personality traits (strengths and weaknesses) and disorders, cognitive abilities and functioning, patient psychodynamics, patient variables that enable the patient to engage in various kinds of treatments, environmental demands, and general therapeutic enabling factors (Clarkin & Hurt, 1988). In particular, patient enabling factors refer to patient dimensions that are important for treatment planning and engaging in particular forms of psychological intervention (Clarkin & Mattis, 1991). For example, the patient’s defensive structure, coping style, interpersonal sensitivity, and basic tendencies and characteristics adaptations may dictate the most appropriate psychological intervention (Beutler & Clarkin, 1990; Harkness & Lilienfeld, 1997).
Psychological tests have been widely used to guide treatment. Unfortunately, the information they provide is not necessarily useful in guiding the choice of specific therapeutic modality. However, test scores can guide treatment recommendations. For example, symptom severity, stage of client resolution, recurrent interpersonal themes, level of resistance to treatment, and coping styles can be obtained from various psychological tests, and all serve as indicators for the focus and prognosis of psychotherapeutic procedures (Beutler et al., 1994). In particular, clients’ scores on the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity scales offer predictions about treatment based on factors such as compliance, level of insight, current psychological status, risk of premature termination of therapy, and level of motivation. Both individual scores and profiles of scores on the content and clinical scales, as well as endorsement of critical items, can also be used for treatment planning, including determining needs to be met, issues with which to deal, and structure and style of therapy (Greene & Clopton, 1994). Similarly, the Personality Assessment Inventory (PAI; Morey, 1991) can also guide treatment recommendations by providing information about a client’s level of functional impairment, potential for self-harm, risk of danger to others, chemical dependency, traumatic stress reaction, and likelihood of need for medication (Morey & Henry, 1994). Furthermore, the PAI contains a number of scales that serve as either positive or negative indicators of potential for psychotherapy. Positive indicators include level of perceived distress, positive attitude toward treatment, capacity to utilize psychotherapy, availability of social supports, and ability to form a therapeutic alliance. These suitability indicators should then be weighed against negative indicators, including having disorganized thought processes, being nonpsychologically minded, and being characterologically unsuited for therapy (Morey & Henry, 1984).
Psychological Assessment Tools
Types of Psychological Assessment Tools
Clinicians should generally not rely on only one data source, scale, or set of test results to infer the nature of a client’s psychological status. Any diagnosis or treatment recommendation should be based on a configuration of impressions from client history, other clinical data, and the results of several tests. Following is a list of various types of assessment tools that can guide the psychological assessment when used in collaboration with other sources of data.
Clinical interviews provide comprehensive and detailed analysis of clients’past and current psychological symptomatology. Furthermore, they offer insight into clients’ personality features, coping styles, interpersonal styles, and behaviors. Interviews help the clinician generate and evaluate hypotheses and then select appropriate psychological tests to clarify diagnostic impressions. Consequently, clinical interviews play a central role in the assessment process. Interviews can be unstructured, semistructured, or structured. Unstructured interviews are often conducted to obtain a clinical impression (person-centered) view of the client, build rapport, clarify symptomatology, and test for discrepancies between self- and other reports. They allow for greater depth and insight into the nature of the client’s problems, behaviors, and other modes of functioning. Interpretation of the client’s responses relies primarily on the expertise of the clinician. In contrast, semistructured and structured interviews are often scored and interpreted against normative (variable-focused) data. Thus, they provide the potential for greater objectivity and less bias in interpretation. Examples of semistructured and structured interviews include the Structured Clinical Interview for DSM-IV Axis I (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1995) and Axis II disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997), and the Diagnostic Interview for Personality Disorders (DIPD; Zanarini, Frankenburg, Chauncey, & Gunderson, 1987). A primary advantage of such diagnostic interviews is that the questions ensure that certain criteria are directly questioned, such as whether a syndrome has persisted for a minimum period of time (DSM-IV-TR; American Psychiatric Association, 2000). Thus, diagnosis follows directly from the results.
Whereas interviews often provide a plethora of information and help with both diagnostic clarification and treatment recommendation, their clinical utility is reduced by limitations typically associated with such techniques. For example, results of interviews are solely based on the client’s selfreport and are, therefore, subject to client overreporting, underreporting, or memory distortions. Moreover, the dynamics of directly interviewing clients engender potential biases in clients’ responses, as a result of their need to present themselves favorably to the clinician or as a plea for help. Thus, interviews should be supplemented with objective tests in order to assess client reporting style and confirm diagnosis.
We advocate the use of objective tests primarily in three ways: (a) to assess the frequency and intensity of psychiatric symptoms; (b) to determine a clinical diagnosis; and (c) to assess enduring traits that predict future behaviors, symptoms, or treatment implications. Objective tests vary in the degree of expertise required to accurately evaluate and interpret the results. These tests may have fixed, precise scoring standards and may be scored manually or by computer, or require interpretation by the clinician (Aiken, 2000). Many of these tests are often based on certain criterion groups of people with known symptoms or characteristics, so that the selection of the test items suggests these symptoms.
The self-report modality of this form of assessment has several advantages; namely, empirical validity, brevity, low cost, and generalized utility among various settings. As well, many of the objective tests are empirically based and have been extensively researched, providing a sound basis on which to evaluate their reliability and validity along with other psychometric criteria. Moreover, the respondent completing these tests is the person who is actually experiencing the psychological symptoms.Thus, the client is directly expressing his or her actual experience and state of distress. However, disadvantages of this modality also include client bias, conscious or unconscious distortion of responses (although most objective tests have scales designed to assess such response distortion), and the inflexibility of the tests to alter the types of questions depending on the client’s responses. Consequently, objective tests should be used to supplement, not supplant, interview and behavioral observation data.
Projective tests, in general, are unstructured, disguised, and global. Although certain administration and scoring systems allow for the quantification of response scoring, extensive training is required. Furthermore, psychologists often disagree about the interpretations of clients’ responses. Unfortunately, most projective tests fail to meet conventional standards of reliability and validity (Aiken, 2000; Lilienfeld et al., 2001). Possible obstacles to the clinical utility of these tests include low validity coefficients of the instruments, the influence of situational factors on client’s responses, and clinician subjectivity in scoring and interpreting responses. Thus, the lack of objectivity in scoring and the paucity of representative normative data on projective tests, in our opinion, limit their use with an adult clinical population. Their use is also limited because projective tests may require more time to administer, score, and interpret than many objective psychological tests, and the assessment procedure is usually under strict time constraints.
It is important to note that both objective and projective tests, by themselves, are typically insufficient in answering referral questions, making differential diagnoses, or deciding upon treatment recommendations. These three tasks can only be effectively performed if the clinician develops a conceptual model of the client based on a hypothetical deductive reasoning approach (Maloney & Ward, 1976) and if the clinician utilizes multiple assessment tools, including tests, interviews, and other sources of data. Clinicians seem to be polarized as to whether they should use projective tests or rely solely on objective measures. It is our opinion that within the EBM, projective tests are not appropriate.
The use of unstructured interviews (and even structured interviews) introduces clinical judgment into the assessment process, thereby allowing for both expertise and greater flexibility in clarifying and delving into areas that can provide relevant information in the assessment. However, clinician bias can never be eliminated, and clinician skills may affect interpretation. Thus, to adhere to the evidence-based muiltimodal approach to assessment, clinicians should use other assessment tools to evaluate and confirm their clinical judgments.
Choosing the Tests to Use
In order to choose which tests to use, clinicians must be familiar with the effectiveness and efficiency of the tests that could help answer the referral question (Olin & Keatinge, 1998). Furthermore, clinicians should select tests that, together, measure a variety of dimensions and are of importance for making treatment recommendations (Beutler et al., 1994).
Four major considerations important in selecting which tests to administer are the test’s psychometric properties, clinical utility, client factors, and clinician variables (Olin & Keatinge, 1998). The first two speak to the ability of the psychological tests to answer the referral question based on an evidenced-based approach, whereas the latter two consider factors such as client ethnicity, age, level of education, functional capacity, motivation, and clinician experience, all of which may confound test results or interpretation. One must also take into account the client’s ability to speak the language in which the tests are written. For example, if the client speaks Italian and is being assessed in an English-speaking setting, the clinician can utilize versions of some self-report questionnaires that have been translated into Italian and later validated. It may also be necessary to use a translator and modified versions of interviews and other self-report questionnaires. Furthermore, the client’s ability to remain focused for extended periods of time must be taken into account. In addition, the length of time required to complete the test must be considered. The utility of the results must be weighed against the time to administer the test and to score and interpret the results.
During the assessment, the clinician may decide to add, eliminate, or modify some tests if the client appears to have a limited attention span or cognitive ability or to be functionally illiterate. In addition, the emphasis of the assessment may change depending on the symptoms the client describes and the clinician’s impression. The assessment tools might change accordingly. Finally, a number of tests contain validity scales that measure inconsistent responding, response biases, exaggeration of psychopathology, and feigning of memory or of cognitive deficits. Consequently, the clinician should pay careful attention to the validity scales included in tests such as the MMPI-2 and the PAI. These tests allow the clinician to determine whether the client is presenting an accurate picture of his or her symptoms. If the results of the validity scales indicate that the clinician should be concerned about the validity of the results, the clinician can follow up with specific measures to test for the exaggeration of psychological symptoms and cognitive deficits. For example, if malingering is suspected, tests specifically designed to assess symptom overreporting, such as the Structured Interview of Reported Symptoms (Rogers, Bagby, & Dickens, 1992) can assess the extent to which the client is intentionally overreporting symptoms to attain secondary gains from the diagnosis.
Choosing the Number of Tests
Although the multimodal approach to assessment encourages the use of more than one test, it does not specify the exactnumber of tests clinicians should use. The clinician must prevent the assessment from becoming too cumbersome yet still obtain enough information to provide an empirically supported diagnosis. Those tests selected should assess for the presence of the primary disorder or problem as well as other disorders that either share similar essential features or typically co-occur (Olin & Keatinge, 1998). Although it is less time-consuming and costly to use fewer tests, taking a multimodal approach and using several objective tests allows for cross-validation, assessment of a client’s responses to different situations, identification of previously unrecognized problems, and provision of a more comprehensive evaluation (Olin & Keatinge). There may be instances in which a focal assessment is more appropriate than a comprehensive one. However, given fewer time and financial restraints, a comprehensive assessment is usually considered better practice. On a note of caution, clinicians can give too many tests, which can result in interpreting chance effects as real (O’Neill, 1993).
In summary, employing a variety of assessment tests in a systematic sample of situations, while being aware of the possibility of bias in test selection and interpretation, as well as knowing the degree of generalizability of test findings, will help reduce misinterpretations and overgeneralizations and provide a more comprehensive analysis of the client’s functioning, thereby enhancing the clinical utility of psychological assessment (Aiken, 2000).
Integration and Interpretation of Tests
After each of the test results has been discerned, it is important to interpret and integrate the results. Although each test presents a discrete analysis of the client’s psychological functioning, the results must be logically and coherently related to other test results and to the individual as a whole. The results of any test should be cross-referenced with other test results, interview findings, current behaviors, and client history to search for convergence of symptoms, personality traits, coping and interpersonal styles, environmental situations, and any other pertinent information that will guide diagnosis and treatment recommendations. Discrepancies between results can also provide valuable information.
Test interpretation involves integrating all the information from the various test results into a cohesive and plausible account. Proficient integration of the tests should explain the presenting problem, answer the referral question, and offer additional information to clarify diagnoses and guide treatment. Integrating psychological assessment results should also provide empirical support for the clinician’s hypothetico-deductive reasoning skills, since integration of the tests strengthens some hypotheses and invalidates others. Essentially, analysis of test results and integration and interpretation of the tests enable the clinician to make inferences and, ultimately, decisions concerning the most appropriate care for the client.
O’Neill (1993) described three levels of test interpretation that can help the clinician gain insight into the nature of the client’s psychological status. First, the concrete level involves interpretation that is limited to the subtest and subscale scores and does not draw conclusions beyond the scores. Level two, the mechanical level, is concerned with the pattern of subscales and subtests, particularly significant differences between scores. Level three, the individualized level, involves interpreting the test results in the context of a larger picture, incorporating specific details that are particularly characteristic of the client. This last level offers the best clinical interpretation of the client and helps guide treatment goals.
In general, the primary goal of test integration is to discover what O’Neill terms the “internal connection” (1993), that is, to use the test results in conjunction with the client’s behavior and history to arrive at an understanding of the client’s current state of psychological functioning. Furthermore, integrating the test results helps the clinician make objective observations, infer internal psychological states, make generalized descriptions about the client’s behavior and functioning, and give probable explanations for the client’s psychological difficulties.
Assessment Procedure in Adult Mental Health Settings: The Generalapproach
A psychological assessment within an adult inpatient setting can be of intermediate or extensive depth. The range of information required, the sampling of a number of areas of a client’s life, series of psychological tests, and multiple sources of information, all systematically collected and interpreted, testify to the breadth and complexity of psychological assessment in such a setting. This, in turn, generates a plethora of information and recommendations. Olin and Keatinge (1998) have proposed an 11-step model for the assessment procedure: (a) determine the information needed to answer the referral question(s), (b) identify who is to be involved, (c) obtain informed consent and releases, (d) collect and examine medical records, (e) identify what is to be measured, (f) identify and select appropriate measures, (g) administer assessment and modify as needed, (h) score measures and analyze and interpret results, (i) seek consultation if necessary, (j) write the report, and (k) provide feedback to appropriate parties.
The Referral Question
Referral questions are the foundation of any psychological assessment. They provide the rationale for conducting an assessment and dictate the types of questions to ask and the selection of psychological tests to be employed. The referral question acts as a base around which all other information revolves, and it guides the entire assessment process, from the choice of tests and test interpretation to diagnosis and treatment recommendations. Typically, as the examiner starts to clarify the referral question, the process of collecting and interpreting data and formulating hypotheses has already begun (Maloney & Ward, 1976). In essence, the referral question sets the focus of the assessment, which in turn shapes the information gathered. The assessment process thus involves linking the information with the problem (referral question) by a configural web of explanations (O’Neill, 1993).
The nature of the referral question is dependent on the severity and complexity of the client’s psychological symptoms and personality, as well as the goals and theoretical orientation of the referring physician or other mental health professional. The clinician must take into account who made the referral and tailor the report to that person’s discipline and level of expertise. Moreover, the potential use of the test results (e.g., disability insurance, workplace competency) must be clarified and given careful consideration. Too often, the referral question is relatively brief and vague, and it may necessitate contacting the immediate referral source to determine its nature. It is recommended that the referral form for psychological evaluation include explicit questions about the reasons, purpose, and potential uses of the test and whether or not the patient consented to testing for such purposes.
Although psychological assessment can address a variety of referral questions, there are several questions that psychologists commonly encounter in assessing mental health inpatients. The following are examples of typical referral questions: Clarify a previous working diagnosis or the referring physician’s impression of the client; differentiate the client’s symptom presentation; identify the cause of the client’s symptoms; and determine what characterological features may be interfering with the client’s ability to engage in treatment.
Unfortunately, psychologists may receive inappropriate referral questions to which the assessment is unable to provide clear answers. In these situations the clinician must be aware of the limitations of psychological tests and clearly communicate these limitations to the referral source. Regardless of the nature and specificity of the referral question, an effective psychological assessment should take a generic approach to any question and comprehensibly perform four generalfunctions: diagnostic clarification of Axis I; diagnostic clarification of Axis II, description of personality dimensions, or both; description of the client’s coping mechanisms and interpersonal styles; and treatment recommendations.
Sources of Information
Like any detective work, a psychological assessment involves amassing preliminary information that will further guide the nature of the assessment. Preliminary information about the client’s history and current psychological state can be obtained from many sources. Often, the clients themselves are asked to provide this information, because it is helpful to understand their impressions of their history and current problems. This general information is typically gained using an unstructured interview format. However, clients may have memory distortions or biases and may wish to portray themselves in an overly positive or negative manner. Medical records should also be examined, because they contain pertinent information regarding clients’psychiatric histories, medications, previous treatments, and working diagnoses. Furthermore, discussions with the clients’ past and current mental health professionals may provide additional insight. Sometimes it is advisable to obtain information from family members or close friends of the clients. This is particularly useful if the clinician suspects that the clients are not portraying themselves in an accurate manner and if the clinician desires insight into the clients’ interactions in other environments. However, individuals close to the client may also have their own biases and motives that must be considered.
In general, it is advisable that the psychologist obtain preliminary information from both the client and the medical and general (mental and physical) health care community (usually through a review of the medical records) in order to increase the reliability of the client’s symptom presentation, obtain a more comprehensive picture of the client, and determine whether there are any discrepancies that should be addressed during the assessment.
Chronology of Psychological Symptoms
First and foremost, the psychologist should record the client’s chief complaint, including current signs and symptoms of presentation. Equally important is recording symptom chronology, which includes symptom onset and progress, as well as changes in behavior, emotional state, mentation, and personality from the time the client was last considered well until the current assessment (Halleck, 1991; Hertzman, 1984). This should be followed by noting the relevant preceding events, the length and severity of the problem, precipitants and effects, patterns of recurrence, and past psychological treatments (Halleck, 1991; Hertzman, 1984). In addition, a history of the client’s previous hospitalizations and medications should be obtained. Moreover, assessing the client’s current life situation, including family, living and working environment, and stressors, and how these aspects contribute to the client’s symptomatology, will help clarify the manner in which the client’s symptoms developed and are being maintained.
Overall Client History
Obtaining information pertaining to the client’s developmental, family, emotional, academic, vocational, social, economic, legal, cultural, and medical history is also an essential feature of psychological assessment. Such information provides an understanding of the subtleties of the client’s problems and the context in which they exist. Furthermore, this information can help inform diagnosis, identify and clarify stressors, and guide treatment.
Developmental and family history should include attainment of developmental milestones, relationships among family members, history of childhood abuse, and a family history of mental illness. Social history should contain information about past and current friendships, intimate relationships, sexual history, religious participation, social support, and hobbies and activities.Abasic appraisal of the client’s academic and vocational history should include details about the client’s problematic academic areas, special education, grades (including courses failed or skipped), best and worst subjects, highest level of education completed, school behavior, extracurricular activities, attendance, occupational history, current occupational status, and relationships with coworkers and employers. A legal history pertains to any difficulties the client has had with the law, and an economic history relates to the client’s financial status and stability. With respect to cultural history, information should be obtained about the client’s feelings of closeness, distance, or alienation from his or her cultural group and about the beliefs and meanings associated with the culture. Finally, a medical history should cover previous head injuries, serious accidents or illnesses, surgeries, past and current medical problems, and medications (Halleck, 1991; Hertzman, 1984; Olin & Keatinge, 1998). This list is by no means extensive but, rather, provides a guideline for discovering information that may be pertinent to the client’s current psychological state.
Mental Status Examination
Additional preliminary information should be obtained by conducting a Mental Status Exam (MSE). The MSE originated from medical interviews and is now commonly part of psychological assessments. It is a summary of the client’s current emotional and cognitive states and provides information about the client’s current level of functioning and severity of impairment. Information obtained from the MSE is vital in that it describes the client’s level of functioning at the time of testing. Key sections in the MSE include the following: appearance, mood, affect, behavior and activity, intellectual functioning, language, orientation, memory, attention, thought processes (form and content), perception, dangerousness (including suicidal and homicidal ideation), degree of impulse control, insight, judgment, and emotional state (Aiken, 2000; Halleck, 1991; Hertzman, 1984; Olin & Keatinge, 1998). The presence of normal and the absence of abnormal processes should be noted, as well as any observations of unusual, strange, or significant thoughts, emotions, or behaviors.
Clarification of Axis I Diagnoses
Diagnostic clarification of an Axis I condition organizes the presenting symptomatology into a framework in which the nature, severity, and extent of the client’s problems can be understood and addressed. Many clinicians depend on the medical chart and clinical interview to make Axis I diagnoses. However, the ideal practice is to use a multimodal approach and rely on several sources of information, including the medical chart, unstructured interview, structured clinical interviews, and psychological tests. Reliable diagnosis must always rest on clear operational or behavioral criteria that can be assessed by the clinician.
Interviews Used to Clarify Axis I Diagnoses
It is useful to begin an assessment with an unstructured interview as a means of surveying the client’s past experiences and chief complaints. The art of an unstructured psychological interview is being able to extract relevant information without interrupting the client’s flow of thoughts (Hertzman, 1984). This should be followed by semistructured or structured interviews that systematically assess whether the client’s symptoms meet the criteria for any Axis I disorders. One widely used interview is the SCID-I/P. The SCID-I/P assesses the presence and lifetime occurrence of current disorders, as well as severity and chronology of symptoms. An important point to note is that the SCID-I/P requires the use of some clinical judgment, because conflicting sources of information and open-ended responses must be evaluated, extrapolated, and coded based on the client’s responses (Rubinson & Asnis, 1989).
Psychological Tests Used to Clarify Axis I Diagnoses
The information gathered from the interviews should be supplemented by the results of both omnibus and specific psychological tests. Examples of omnibus tests of general symptom impairment include such inventories as the MMPI-2 and the PAI. In particular, the MMPI-2 and PAI provide actuarialbased clinical hypotheses forAxis I disorders.Although there are a variety of other tests used to examine the presence of Axis I disorders, we will focus on the MMPI-2 because it is the instrument that is most widely used. As indicated earlier, we believe that projective tests are not appropriate for an evidenced-based approach for psychological evaluation, particularly in psychiatric diagnosis, and we do not recommend their use. Consequently, we do not review their use in this section. We realize, however, that many clinicians do use them and have confidence in their validity and reliability.
The MMPI-2 is often used to clarify coexisting diagnoses, validate the clinical impression of a client from the structured interviews, assess emotional functioning, and obtain information about the client’s level of psychopathology. The MMPI-2 demonstrates good reliability and validity and provides rapid diagnostic information as well as information about the client’s emotional and personality functioning (Olin & Keatinge, 1998). In particular, the 10 clinical scales are actuarially based, because they were developed to identify patients with specific psychiatric disorders. In addition, a client’s profile pattern provides information about the individual’s overall psychological structure. For example, configural interpretation of clients’ code types can inform a clinician about clients’moods, cognitions, interpersonal relations, and other problem areas, as well as their symptoms and personality characteristics (Greene, 2000). Similar information can be obtained from the content scales and the recently developed Psychopathology Five personality scales (PSY-5; Harkness, McNulty, & Ben-Porath, 1995). All of this information is then used to formulate a diagnostic impression. Furthermore, the MMPI-2 profiles and specific scales provide recommendations for treatment. As well, the MMPI-2 contains various critical items that provide insight into the nature and intensity of clients’symptoms. In particular, items dealing with suicidal ideation and psychotic features highlight issues that must be further considered and evaluated. Garb (1984) and Finn and Butcher (1991) reviewed assessment literature and concluded that the MMPI-2 has incremental validity when added to an interview.
Clinicians should make themselves aware of measures that assess specific symptoms. In fact, there is practically a test designed for every disorder or psychological difficulty. These tests may provide incremental validity or consensual validity to omnibus tests. Examples of such specific tests are the StateTrait Anxiety Inventory (Spielberger, 1983), the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), the Hamilton Anxiety Rating Scale (Hamilton, 1959), the Posttraumatic Stress Disorder Symptom Scale (Foa, Riggs, Dancu, & Rothbaum, 1993), the Trauma Symptom Inventory (TSI; Briere, 1995), the Maudsley Obsessional-Compulsive Inventory (Hodgson & Rachman, 1977), the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Hamilton Rating Scale for Depression (Hamilton, 1960), the Suicide Risk Assessment Scale (Motto, 1985), and the Alcohol Use Inventory (Wanberg, Horn, & Foster, 1977). However, the clinician must consider the efficiency of using specific measures given that many omnibus tests are able to assess a variety of specific disorders and psychological difficulties.
Clarification of Axis II Diagnoses
Clients in an adult mental health setting may present with characterological features that are contributing to, and possibly even magnifying, the current state of psychological distress. If these features are severe and are interfering in a client’s daily life, they constitute a personality disorder.AcomorbidAxis II disorder also becomes a focus of intervention or a moderating variable in the treatment of anAxis I disorder.
It is important to note that current research suggests that Axis II diagnoses are not usually helpful in explaining presenting symptomatology or in providing mental health care professionals with information that will help guide the treatment of the client. Furthermore, comorbidity of personality disorders is a frequent occurrence and thus both an empirical and clinical dilemma. Nonetheless, knowing about the presence of an Axis II disorder may, in some cases, be useful.
Personality psychopathology is typically clarified in the adult clinical setting by identifying Axis II disorders. Certain so-called normal personality traits that should also be assessed include the client’s degree of likability, dependency, passivity, aggressiveness, attention-seeking, controllingness, and exploitativeness, as well as personal values and thoughts about himself or herself and others (Halleck, 1991). Extreme dimensions of these traits tend to be maladaptive and often constitute criteria for personality disorders that can be assessed using psychological tests for personality psychopathology. As is the case with Axis I disorders, medical charts, unstructured and structured clinical interviews, and psychological tests should be used to determine the presence of a personality disorder.
Interviews Used to Clarify Axis II Diagnoses
There are several structured and semistructured interviews that assess personality disorders, personality pathology, or both, according to the DSM-IV criteria. These include such instruments as the SCID-II (First et al., 1997), DIPD (Zanarini et al., 1987), the Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1995), and the Personality Disorder Interview-IV (PDI-IV; Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995). Interviews are particularly useful to clarify personality disorder diagnoses, because this format allows clinicians to discern the chronology of clients’ symptoms and the effect these symptoms have made on their interpersonal relationships and their daily functioning and to determine how clients’characterological patterns are currently affecting their psychological functioning.
Psychological Tests Used to Clarify Axis II Diagnoses
Similar to Axis I diagnoses, various self-report measures designed to assess Axis II disorders exist, including the Personality Diagnostic Questionnaire-4+ (PDQ-4 + ; Hyler, 1994), the SCID-II Personality Questionnaire (SCID-II-PQ; First et al., 1997), and the Wisconsin Personality Disorders Inventory (Klein et al., 1993). In addition, omnibus tests, such as the MMPI-2 and PAI, contain sets of scales that directly assess the Axis II disorders (Somwaru & Ben-Porath, 1994) or provide actuarial-based diagnostic suggestions for Axis II disorder psychopathology, for example, the MMPI-2 and the PAI. The Millon Clinical Multiaxial Inventory (MCMI-III; Millon, 1993) also has scales specifically designed to assess DSM-IVAxis II disorders, although Millon’s conceptualization of these disorders differs slightly from DSM-IV (Millon, 1981).
Other self-report measures exist that measure personality psychopathology traits other than those in DSM-IV. Many of these measures are the direct outcome of different dimensional models of personality psychopathology, developed to address the well-known limitations of the DSM, Axis II categorical system. These include the Dimensional Assessment of Personality Psychopathology (DAPP; Livesley, 1998); the Schedule for Non-AdaptiveandAdaptivePersonality(SNAP;Clark,1993); the Personality Psychopathology Five (PSY-5; Harkness et al., 1995), which are measured with a set of MMPI-2 scales (Harkness et al., 1995); and the Temperament and Character Inventory (TCI; Cloninger, Przybeck, Svrakic, & Wetzel, 1994). Another alternative to the Axis II system has been to apply existing measures of so-called normal dimensions of personality to personality pathology, with extreme scores representing clinically significant personality pathology when accompanied by psychological distress. Most prominent, in this regard,istheFive-FactorModelofPersonality(FFM;Costa& McCrae, 1992), which has garnered considerable empirical support and is thought by many researchers to be the best alternative to theAxis II system (Widiger, 1998). The revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992) measures the domains and facets of this model.
Assessment Procedure in Adult Mental Health Settings: The Recommended Approach
Our recommended approach to psychological assessment in adult mental health settings is not intended to be the sole method of assessment. Rather, it is presented as a model that adheres to the foundations and goals of psychological assessment. It is an approach that is both evidence-based and multimodal, thereby allowing for accurate and valid diagnostic clarification and treatment recommendations. It is also important to note that our assessment approach adheres to a multidimensional approach. Whenever possible, we incorporate clients’biological, developmental, adaptational, and ecological histories in our case conceptualizations.
In addition, it is important to note that with the increasing cost of health care and the trend toward shorter hospital stays, the psychological assessment procedure must be efficient. We strive to contact the client or caregiver and begin testing within two days of receiving the referral. Furthermore, the report is usually written and presented to the referring physician within two to four working days following testing (this is especially the case for inpatient assessment, where longer hospitalizations are costly). Nonetheless, we recognize the importance of ensuring that the assessment process is thorough.
Review of Referral and Preliminary Information
Upon receiving a referral, we review it and proceed with attaining extensive preliminary information. This process includes contacting the referral source (typically a psychiatrist) to gather information and clarify the referral question, if necessary. Next, we review the client’s medical record so as to have clearer insight into the nature of the client’s problems and to guide the assessment process by determining the assessment tools that are necessary and sufficient to answer the referral question.
Before beginning any psychological assessment, we first explain the process to the client, including who requested the assessment, what is expected of the client, and what the client can hope to gain by participating. We also insure that the patient clearly understands the reason for the referral, often paraphrasing the referral question posed by the referral source and obtain verbal informed consent to use the results from the assessment to address the specific reasons for the referral. Patients are then given the opportunity to pose any of their questions. We then follow with an unstructured clinical interview. Often these two steps allow us to build rapport with the client, ease their anxieties, and motivate them to be open, honest, and forthcoming with information. Moreover, beginning with a general open-ended interview and then progressing to more specific questions in a structured or semistructured format gives the client the opportunity to expand and focus on whatever he or she is most concerned about at the moment. We use the information attained from the unstructured interview to determine which psychological symptoms require further inquiry and to test for discrepancies between the client’s self-report and other information sources. In essence, the unstructured clinical interview assists us in generating and testing (i.e., confirming, invalidating, or moderating) hypotheses about the client. In addition, the clinical interview enables us to conduct firsthand observations and evaluations of the client’s coping and interpersonal styles. These psychological features provide essential data that are used to assess the client’s overall functioning.
Additionally, a specific component of this process involves noting the client’s behaviors. Often, the assessment situation represents a microcosm of the client’s behavioral and psychological functioning.Thus, observation of the client is an essential source of information, since it represents a sample of the patient’s pattern of functioning and can reveal some of the problems that brought the client to the assessment in the first place (Kellerman & Burry, 1981).
The second phase of psychological assessment involves the use of structured interviews and objective self-report measures to clarify Axis I and Axis II diagnoses. These types of assessment tools are used to assure that the assessment process adheres to an evidence-based model that is grounded in empirical data. As noted previously, such a process ensures that the assessment outcome is valid and clinically useful, thereby enhancing the likelihood that clients’ symptoms, problems, and distresses are correctly interpreted, that they are given accurate diagnoses, and that they are provided with treatment recommendations that are most likely to help them.
Axis I Diagnostic Clarification
Clients are often referred for psychological assessments because they are presenting with acute symptoms that are causing distress or are impeding their functioning to an extent that warrants being admitted to a mental health setting as an inpatient. Whereas some clients present with symptoms that are stereotypical of aspecific disorder, often they present with symptoms that appear to overlap across multiple disorders. The goal of the assessment is thus to make a differential diagnosis that captures and explains the nature of the client’s symptoms so that the proper treatment can be established. Other clients have been involved with the mental health care system for many years but have never received a formal assessment or diagnosis. In this case, our goal is to clarify the nature of the client’s symptoms, again to be used as a guide for treatment.
Consistent with our objectives, our assessments aimed at clarifying Axis I disorders are grounded on evidence-based principles. All assessment tools we use have been subjected to extensive empirical testing, meet acceptable standards for reliability and validity, and provide actuarial-based data. Currently, the DSM-IV manual is the basis upon which diagnoses are met, and clients must meet a certain number of criteria of specific severity and duration in order to receive a diagnosis. Consequently, we use the SCID-I/P (Patient Version 2.0; First et al., 1995) to guide our diagnoses because it is derived directly from the DSM-IV. This interview systematically and comprehensively assesses for the symptoms and syndromes of major mental illnesses, the results of which afford clinical diagnoses based on objective and evidence-based information. In particular, the SCID-I/P allows us to make differential diagnoses among overlapping and conflicting symptoms and to examine whether a client’s presenting symptomatology is better accounted for by another disorder or a medical condition. For example, symptoms typically associated with panic disorder with agoraphobia may be better explained as the sequelae of posttraumatic stress disorder (PTSD; e.g., hyperarousal and avoidance) if the other diagnostic criteria for PTSD are met. However, we are aware of the time constraints placed on the assessment process. Thus, we first use the SCID-I/P screener to screen briefly for the presence or absence of anxiety, substance abuse, and eating disorders. We find this screener to be a valuable and time-efficient test, because it determines which disorders should be further questioned and which warrant no further investigation.
Establishing a chronology of symptoms is essential for disentangling and clarifying diagnoses. As much as possible, we obtain dates of symptom onset and get a clinical picture of the course of client symptoms, including periods of remission, maintenance, and intensification. This information is helpful in differentiating between similar disorders.
Although the SCID-I/P enables us to assess directly DSM-IV diagnostic criteria, we supplement our assessment with various objective tests so that our clinical judgments are evidence-based. In so doing, we believe that we enhance the validity of our diagnostic impressions. Given that the clinical picture of the client is often quite complex, we seek validation of our clinical impressions from empirically supported test results. Moreover, as we realize the potential impact of diagnosing any client with a disorder, we recognize the importance of providing accurate and valid diagnoses. With regard to the assessment tools themselves, we use both general and specialized measures, all of which have been empirically validated for diagnostic use in a clinical population.
The one global test that we administer to almost all clients is the MMPI-2, because it offers evidence-based interpretive value to client’s symptoms. As discussed previously, the MMPI-2 is an excellent example of a carefully developed psychological test with attention to details of reliability, validity, and normative information. Moreover, it provides a great deal of information in a variety of areas of client functioning. However, if the MMPI-2 is deemed invalid, the client is often asked to complete an alternative inventory such as the PAI.The PAI also has validity scales, can provide information about both psychopathology and personality, and offers actuarial-based information about clients’ symptoms. Other selfreport measures we use include the BDI and the BAI, since both provide indexes of the nature and intensity of clients’ current depressive and anxiety symptoms, respectively.
These general measures supplement the SCID-I/P, add evidence-based information to the client’s clinical picture, provide empirical support for a diagnosis, offer insight into the client’s coping styles, and provide treatment recommendations based on the client’s profile. However, the client may present with specific problems that should be further investigated by more specialized measures. For example, we often encounter clients that meet diagnostic criteria for acute or chronic PTSD. In such cases we typically administer the TSI to these clients in order to gain greater insight into the nature and severity of their posttraumatic symptomatology. The TSI also divides clients’ symptoms into factors that, in turn, help clarify diagnosis and determine which types of symptoms result in the most distress.
Axis II Diagnostic Clarification
Diagnostic clarification of Axis II disorders adheres to the same rationale as that used to clarify Axis I disorders. That is, we use an evidence-based multimodal approach when selecting tests and interpreting the results. Consequently, we base our diagnoses directly on DSM-IV criteria and on empirically validated and actuarial-based assessment tests. To ensure an efficient testing process, we screen for Axis II disorders by first administering the SCID-II Personality Questionnaire. If clients meet the minimum required number of criteria for a particular personality disorder, we follow up with either the SCID-II interview or the DIPD. Assessing personality disorders using an interview format is particularly advantageous because it allows us to clarify whether the presenting symptomatology has been present throughout a client’s life or whether it is a recent manifestation reflecting the client’s current psychological state or recent events.
As with the Axis I testing procedure, we supplement our Axis II diagnoses with general objective tests. Although various personality inventories are available, we rely on the NEO PI-R (Costa & McCrae, 1992). The NEO PI-R is advantageous because there are both self-report (first person: Form S), other report (third person: Form R), and structured interview formats available (Structured Interview for the Five-Factor Model, SIFFM; Trull & Widiger, 1997). These empirically based tests assess clients’ characterological psychopathology and provide directions for treatment.
Personality Profile, Coping, Self-Concept, and Interpersonal Styles
Clients’ personality profiles, coping styles, self-concept, and interpersonal patterns provide insightful and extended information that is directly pertinent to diagnosis and treatment recommendations. Information gleaned from these areas of a client’s psychological functioning serves several roles. First, it clarifies diagnosis. Examination of actuarial-based interpersonal and coping patterns associated with particular disorders can often assist with differential diagnosis. Second, the information, especially that which relates to a client’s personality style, offers added insight and clarification of Axis II personality disorders, including clarification of symptom criteria, intensity and duration of symptoms, and the pervasiveness of clients’ symptoms in their everyday functioning. Third, this information can provide insight into the extent of a client’s distress, the manner in which a client attempts to handle and adjust to difficulties, the effect that the symptoms have on significant people in the client’s life, and the degree to which the symptoms are affecting the client’s life. Fourth, integration of the information helps summarize the client’s functioning, problems, and strengths; clarifies the nature of the problem; and encapsulates the client’s functioning as well as the role that the client’s symptoms play in his or her daily functioning. This insight, in turn, is a powerful tool in guiding treatment recommendations.
The tests we use to assess clients’ personality profiles, coping styles, self-concept, and interpersonal patterns include the NEO PI-R, MMPI-2, PAI, and SIFFM. These tests are actuarial-based measures of clients’ enduring attributes, stylistic characteristics, and general personality structure. Of course, one critical issue is whether the client has the capacity to read at an appropriate grade level for these self-report inventories. Typically, we do not assess formally for reading level but do have the patient read out loud three to five questions from each of the tests. If we determine sufficient capacity, we proceed. If the reading level is not adequate, we administer the tape recorded versions of the MMPI-2 and PAI and administer only the SIFFM to assess personality.
Treatment Implications and Recommendations
Finally, the information we obtain from clinical structured and unstructured interviews, objective test results, behavioral observations, and additional information from client chart reviews is integrated and interpreted. In effect, the initial problems of the client “have been given a context that serves as a . . . map in which the relevant details of the problem can be made visible and related to each other” (Kellerman & Burry, 1981, p. 4). In addition, the relations among the client’s responses, the client’s meanings, and the situational context are all assessed and integrated. This integration provides the most valid indicator of whether the client is suffering from a disorder and, if so, the type of disorder (Wakefield, 1998). Each detail of the client’s symptoms, behaviors, and history is encapsulated into larger concepts that are then organized in relation to one another. Thus, the presenting problem is demonstrated to be part of a larger system that includes the client’s history, personality, coping style, and interpersonal pattern of relating to others. This integration reveals the meaning of the presenting symptoms and provides both information and guidelines in the treatment of the initial problem. Again, we stress that the integration and interpretation of a client’s psychological status must be validated by empirical data.
As previously stated, the conceptualization of each client, including his or her diagnoses, symptoms, behaviors, and characterological patterns, is used to provide treatment recommendations. The nature of the recommendations depends on the client and on the referral question. Based on our experience, treatment recommendations tend to focus on several areas, including recommending a medication review, commencing a certain therapeutic intervention or changing current treatment, or discussing suitability for therapy. Additional information tends to pertain to the client’s prognosis and preexisting factors, as well as precautions and restrictions.
Skill Sets and Other Issues to Consider in Psychological Assessment
Clinicians must be familiar with the following set of issues so as to provide the most effective psychological assessments. It is important to note that clinicians must have numerous skills in order to be proficient in psychological assessment. The following section, although not inclusive, highlights several of these skills that we feel are critical for accurate, insightful, and beneficial assessment of adult patients in a psychiatric setting. Clinicians must first be able to define and clarify the referral question. Clinicians also must possess psychological knowledge about a variety of psychopathology and personality content areas so they can be attentive to important and relevant areas of client functioning, know the relevant data to collect and the methods to obtain this data, and recognize the meaning of test results. With specific reference to the client, clinicians must possess the ability to obtain accurate descriptions of abnormal behavior from the patient or other sources, have an extensive and comprehensive understanding of the patient’s history, and determine when patients are presenting insufficient or inaccurate information. Clinicians must additionally possess proficient interpersonal skills, such as establishing a professional relationship and trust with the patient, acting as a participant observer, knowing how to ask questions about inner experiences that the patient will be able to understand and answer, being aware of the patient’s interaction with self and others, and engaging in skillful interviewing. Another area of expertise involves the ability to effectively interpret interviews, behavioral observations, and test results; draw valid inferences; determine how behavioral and experiential difficulties may be related; and, finally, consider, evaluate, check, and integrate the data from the various sources in developing the results, diagnosis, and treatment recommendations (Halleck, 1991; Maloney & Ward, 1976).
Second, an integrated approach to psychological assessment must involve specifying the effects of situational variables on clients’symptomatology and behavioral patterns. Clinicians must examine and evaluate potential situational elements and how they interact with the client’s cognitive, emotional, and behavioral functioning. Thus a psychological assessment should include the nature, intensity, and duration of the demands placed on the client (Maloney & Ward, 1976).
Mental disorders are often influenced by a client’s physical, social, and interpersonal environment. Consequently, the nature of a client’s environment, particularly psychological stressors, is an important source of information to obtain in a psychological assessment. Common environmental stressors include marital, familial, financial, occupational, legal, and physical difficulties. Other stressors to examine include specific events, such as a natural disaster or a life cycle transition. The Axis-IV of DSM-IV addresses such environmental factors. Unfortunately, despite their importance and contribution to the onset, maintenance, and exacerbation of a client’s current psychological symptoms, these factors are often not considered in the assessment process.
The interaction between an individual and his or her environment as it relates to mental illness is complex in nature. When individuals behave in a certain way, they have an impact on their surrounding environment. Unfortunately, responses to an individual with a mental disorder often create new stresses for that individual, thereby perpetuating a cycle of increasing stress. Conversely, some symptoms can elicit reinforcing responses from the surrounding environment, thus making the symptoms difficult to treat (Halleck, 1991). Assessing a client’s environment, and obtaining knowledge of the relationship between the individual and his or her environment can help explain the nature of the client’s symptoms and even guide therapeutic interventions. Halleck (1991) suggests obtaining this information through three general types of inquiries, namely how characteristics of the client’s environment adversely influenced the client, how characteristics of the client interfered with his or her capacity to meet environmental expectations, and how the environment responded to the client’s deficiencies. In addition, clinicians must attempt to distinguish between paranoia and appropriate and justified reactions to situations that may have occurred (although the client may be unable to corroborate these situations) and to distinguish between deleterious personality styles and appropriate reactions to difficult situations.
Third, one common goal of adult assessment is to make differential diagnoses and attribute a client’s symptoms to specific disorders. It is important to be familiar with the key diagnostic signs that differentiate disorders that have similar criteria (Olin & Keatinge, 1998).
Fourth, a related challenge in adult assessment is the issue of multiple diagnoses. Often, both inpatients and outpatients meet diagnostic criteria for more than one diagnosis, particularly Axis II disorders (Barron, 1998). This raises several important questions. First, what is the clinical utility in making multiple diagnoses? Second, what are the treatment implications? If the client presents with comorbid disorders, how are they treated?
Fifth, another issue in psychological assessment is that a comprehensive intake must include ascertaining information about the clients’ past and present medications, as well as determining possible misuse (under- or overmedicating). Clients’ reactions to, and the side effects of, their medications can easily influence their presenting symptomatology. Thus, clients’ medication may confound diagnostic impressions.
Sixth, another important issue is that of discrepancies. Test scores can sometimes lead to conclusions opposite to those obtained from test behavior, background information, and previous tests (O’Neill, 1993). Moreover, actuarial and clinical judgments may conflict, as can patient self-report and either test results or clinical impression. This is particularly problematic if the discrepant information influences the conclusions drawn. Clinicians must examine the validity of the test results and other potential reasons (e.g., test behavior) for the inconsistencies before documenting them in the report.
Thus, the accuracy of client reports (self-reports or interviews) must also be considered. Even when clients are skillfully interviewed, their reports may be insufficient, inaccurate, or distorted (Halleck, 1991). They may bias or present misleading information, either unknowingly or purposefully, or may be experiencing problems with their memory either independent of, or associated with, their presenting symptomatology. Moreover, clients’ motivations for reporting their symptoms often influence the accuracy of their communications.
Regarding underreporting or withholding information, unintentional factors include poor cognitive or expressive capacities to communicate essential information and high levels of anxiety during the assessment that diminishes a client’s capacity to think and communicate clearly (Halleck, 1991). In contrast, some clients intentionally choose to withhold information to avoid humiliation, the discovery of previously hidden shortcomings, and the revelation of personal inadequacies in order to prevent the often accompanying feelings of shame and fear (Halleck, 1991). Furthermore, clients may withhold information if they are skeptical or distrustful of the psychologist (which may relate to paranoia) or feel that they will be blamed for willfully creating their symptoms.
A more common occurrence is the tendency for clients to overreport their symptoms and exaggerate their level of dysfunction. Again, the motivation for symptom exaggeration can be either unintentional or intentional. Unintentional overreporting is often attributed to distorted memories. Furthermore, people who are seriously depressed or diagnosed with personality disorders or somatoform disorders may unconsciously exaggerate their symptoms (Halleck, 1991). In contrast, potential gains for intentionally exaggerating one’s symptoms include the attention and nurturance of loved ones or medical personnel, a social or interpersonal advantage, power over their physicians, forensic reasons, and receiving disability compensation. Furthermore, individuals who experience memory loss or a factitious disorder may confabulate (Halleck, 1991).
During psychological assessments, certain cues can help alert the psychologist as to whether clients’ reports may be inaccurate. Such cues include brief answers to questions even when clients are encouraged to expand their answers; inability or unwillingness to provide details of symptomatology history; presentation of contradictory information; attempts to take control of the interview; descriptions of symptomatology that are unusual in terms of severity, type, or frequency; denial of universal experiences such as sometimes feeling angry or sad; and presentation of an excessively idyllic or abysmal situation (Halleck, 1991). Furthermore, clinicians can review validity scales on psychological tests to help determine whether clients are reporting accurately.
A specific form of symptom overreporting is malingering. DSM-IV defines malingering as the voluntary presentation of false, or grossly exaggerated, physical or psychological symptoms. Psychologists should be alerted to the possibility of malingering if any of the following are present: a medical or legal context to the referral, discrepancy between objective findings and reported symptoms, compliance problems, a high number of obvious and improbable symptoms, symptoms that have an unlikely course and severity, sudden onset with vague and inconsistent symptoms, inconsistent test results, an inexplicable decrease from premorbid functioning, and significant gains associated with being impaired (Olin & Keatinge, 1998).
Clinicians should be particularly attentive to signs of malingering when conducting assessments requested from domains such as insurance companies, because these patients may receive secondary gains from presenting with severe symptomatology. When considering malingering, one must distinguish between symptom exaggeration and symptom fabrication, as well as between conscious and unconscious distortion of symptoms. In addition, when assessing whether a client may be overreporting, either generally or in reference to symptoms associated with a specific disorder, the clinician should be cognizant that according to analogue research, it is easier to detect global fakers than specific fakers (Berry, Baer, & Harris, 1991; Berry, Wetter, & Baer, 1995). Malingering may also be more difficult to detect if clients are coached by other individuals (Rogers, Bagby, & Chakraborty, 1993; Storm & Graham, 2000) and as they gain more knowledge of mental disorders and the validity scales embedded within many questionnaires. A final issue in the assessment of malingering relates to the significant and serious consequences of such a diagnosis. Thus, the clinician must recognize the damage of a false positive error and consequently ensure that there is considerable evidence to support a malingering diagnosis. However, one must also consider that the failure to diagnose malingering results in the expenditure of a great deal of money—money that is therefore not available to those who are in genuine serious distress.
Seventh, another aspect of assessment that can be challenging is distinguishing between chronic personality traits and current symptomatology. Clients are often unable to distinguish between the two, especially if they are in an acute state of distress. In addition, they may be unable to recall much of their childhood, or they may be experiencing overall difficulties with memory. It is important to clarify with clients when you are questioning them about lifelong symptoms and when you are inquiring about current problems. We strongly advise clinicians to obtain several examples from their clients that can be dated in order to formulate more accurate client conceptualizations and chronology of symptoms.
Eighth, sometimes psychological testing of Axis I and Axis II disorders requires additional screening for neuropsychological disorders that might be mediating or moderating a client’s psychological profile and pattern of functioning. For example, early stages of dementia are often marked by the presence of depressive and anxiety symptoms. Whenever a clinician suspects the presence of a neuropsychological disorder, clients should receive a full neuropsychological battery. The results of neuropsychological assessments can guide diagnoses and affect treatment recommendations.
Conversely, neuropsychological assessments should assess clients’ current mood, because the presence of psychological symptomatology, particularly depressive symptoms, can influence test results and interpretations. Thus, clients should receive a comprehensive clinical interview assessing for the presence of psychological symptoms, and they should be screened for Axis I disorders. The results of such a psychological assessment should then guide interpretation of neurological findings.
Ninth, clinicians must also keep in mind the limitations of diagnosis. Psychological diagnoses cannot always provide specific guidelines for treatment, because most mental disorders are classified descriptively on the basis of behavior and experience, rather than etiologically, as has been the practice of medicine. Because mental disorders often have multiple etiological pathways, including both genetics and the environment, the best we can do is classify them on the basis of their clinical features that over time, and with substantial empirical research, have been associated with particular outcomes (Halleck, 1991). Consequently, there is no linear path between diagnosis and treatment.
Regardless of such limitations, clinicians often confer diagnoses or are even legally obligated to diagnose. Moreover, they may provide an overall description of the client, including their clinical impressions. When writing their reports, clinicians must take into account the fact that the client may have access to the report. That is, the clinician must recognize the consequences of using labels (including diagnoses) and negative statements to describe the client.
Tenth, another issue pertaining to psychological assessment is the multiple roles of the psychologist. Within an inpatient setting, the psychologist conducting an assessment has numerous roles and relationships that can affect the assessment process and outcome. First and foremost, the clinician has a unique relationship with the client. Second, the clinician is involved in a teaching relationship with the referring psychiatrists or other mental health professional. The clinician is responsible for communicating the results and recommendations in as succinct but comprehensive a form as possible. However, even in this role, the clinician is advocating for the client, by ensuring that the client’s difficulties and needs are clearly articulated and will be subsequently addressed by the treating mental health professional(s).
Finally, psychologists must note that they can only provide recommendations for possible treatment.Although the end result of a psychological assessment can provide extensive and invaluable information about the client’s psychological profile, style of functioning, strengths, and weaknesses, as well as guiding treatment recommendations and predicting outcomes, the utility of the assessment depends on the referring physician’s judgment. Unfortunately, we can only provide diagnoses and recommend possible treatments. The outcome of the assessment and the potential benefit to the client are ultimately in the hands of the referring psychiatrists.
Issues Specific to the Psychological Assessment Oo Inpatients in the Mental Health Setting
There are also some issues regarding psychological assessment that are particularly relevant to assessing inpatients in adult mental health settings. First, unfortunately, time constraints may dictate the depth and breadth of psychological assessments. Clinicians find themselves having to triage because of the cost of keeping inpatients at the facility and the fact that clients often stay at the facility for short periods of time. Consequently, a comprehensive, in-depth assessment that measures all aspects of a client’s psychological functioning, including current symptomatology, history, chronic difficulties, coping patterns, interaction styles, personality, and environmental factors, is rarely done. However, we feel that despite the time constraints, a psychological assessment should be as inclusive and comprehensive as possible, in order to best answer the referral question, make a diagnosis, and provide accurate treatment recommendations. To demand any less than this can cause great risk, detriment, and harm to the client.
Second, it is important to note that the severity of clients’ psychopathology may affect their self-reports, both within the interview and on psychological tests. Many clients who are in an acute state of distress tend to generalize and overpathologize their symptoms, to the extent that results from various instruments, such as the MMPI-2 and the PAI, become invalid. It is important for the clinician to tease apart the most salient problems from the client’s tendency to use the psychological assessment as a cry for help.
Third, comorbidity of psychological disorders is high within the adult clinical population. Another problem is determining which disorder should be addressed first in treatment, particularly since the symptomatology, etiology, and environmental factors influencing one disorder may also present in another disorder. Of particular concern to the adult inpatient population is the high prevalence of substance abuse or dependence disorders in conjunction with another Axis I or Axis II disorder. Clinicians assessing inpatients should always test for possible substance abuse, because this affects the treatment plan and likely outcome for the client.
Fourth, another critical area to assess is the client’s risk of harm to self and others, particularly with respect to suicidal ideology. This matter should not be taken lightly. Any suicidal ideation, plan, or intent should be documented and the appropriate measures taken to decrease the risk of harm. Furthermore, it is important that the clinician examine specific stressors, events, or other variables that are likely to increase a patient’s risk of suicide.
Fifth, in psychiatry, an analysis of the influence of the environment on a patient’s symptomatology is indispensable. Research suggests that the environment (both positive and negative) exerts an impact on symptom occurrence, development, and maintenance (Clarkin & Mattis, 1991; Halleck, 1991). The environment also exerts a long-term influence on the patient’s experiences and behaviors that in turn can contribute to the patient’s current psychological state or can develop into certain personality dimensions that complicate symptomatology (Halleck, 1991). The relationship between environment and symptoms is acknowledged in the DSM-IV Axis IV. Even more important, understanding a patient’s social, developmental, and familial history can guide therapeutic interventions.
It is our opinion that adult inpatients are experiencing a greater number of, and often more intense, Axis IV problems, particularly in the areas of interpersonal difficulty, financial constraints, and employment difficulties. This observation highlights the multidimensional nature of psychopathology, specifically that people’s surrounding environmental situations and constraints often influence the onset, severity, maintenance, and outcome of their psychological symptoms.As previously mentioned, Axis IV difficulties must be given strong consideration and value in a psychological assessment.
Formulation has been defined as the process by which we systematically, comprehensibly, and objectively assemble and integrate available information to arrive at an understanding of what is happening with the patient (Hertzman, 1984). It is essentially a working hypothesis upon which we base our diagnoses and treatment recommendations. Hertzman recommends integrating the patient’s symptoms, functions with which the symptoms interfere, history, premorbid personality structure, external stressors, and defenses and coping styles into a working formulation, which in turn guides diagnostic impression and treatment suggestions.
An effective psychological assessment should have high clinical utility.All of the information obtained about a client’s symptomatology, personality, and coping and interpersonal styles within a psychological assessment should be used to guide treatment recommendations.
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