Clinical Assessment

CLINICAL ASSESSMENT
AND DIAGNOSIS
CLINICAL ASSESSMENT
an evaluation of an individual’s
or family’s strengths and weaknesses,
a conceptualization of the problem at hand
(as well as possible etiological factors),
and some prescription for alleviating

the problem.
Assessment
• The process of gathering information
about people’s symptoms and the possible
causes of these symptoms
Sources: biological, psychological, socio-cultural

- GI is used to determine the appropriate diagnosis for a person’s problems
CLINICAL ASSESSMENT
Is the collection of relevant information in an effort to
reach a conclusion
- used to determine how and why a person is behaving
abnormally
- How that person may be helped
- It is idiographic
ASSESSMENT is …
an on-going process
even an everyday process
is the means to an end
Purpose of assessment
1. for a more accurate diagnosis

2. as a basis for clinical intervention
3. and prognosis
Purpose of assessment
Our capacity to solve

clinical problem is directly
related to our skill in
defining them.
Trull et al. 2011
Assessment involves a series of steps
Identify first
the clinical problem!...
…and arrive to a solution

PROCESS OF ASSESSMENT
1. THE REFERRAL QUESTION
Understand precisely
what the question is
or
what the referral source is seeking!
How best can we find the answer to it?
Why is Mary disobedient?

Why can’t Joy learn to read
like other children her age?
Is this patient capable of murder?
Unanswerable unless….
Before accepting the referral…
discuss first with the family

the important considerations
and implications of the
assessment and diagnosis.
2. Plan Assessment Procedures
-collect assessment data
Sources:
interviews
behavioral observations
psychological tests
case history data
2. Plan Assessment Procedures
considerations:
the referral question
assessment instruments
characteristics of the client
3. Assessment Proper
data collection
* It is best to use multiple data sources

4. Interpretations of
Assessment Data
- interpretations of data collected

- comparing data to form conclusion
5. DIAGNOSIS/CLINICAL
JUDGMENT
What do these results mean?
What decisions are to be made?

JUDGMENT
- go back to the referral question

- what is the diagnosis
JUDGMENT
CLINICAL JUDGMENT
Is this patient psychotic?
What’s wrong with him?

DIAGNOSIS (Psychodiagnosis)
- involves classifying mental disorders
- but it involves more than that
- The specific pattern of behavior is emphasized
- Concerned with adaptive and maladaptive behaviors not
only the maladaptive to avoid overpathologizing
* Clinical psychologists are psychodiagnocians

DIAGNOSIS
• Diagnosis requires assessment
• No assessment, no diagnosis; no diagnosis, no treatment
GOALS of DIAGNOSIS
• Treatment
• Prognosis
• Development of insight
TYPES OF DIAGNOSIS
• Symptomatic diagnosis
• Characteriological diagnosis
JUDGMENT
CLINICAL JUDGMENT
How these questions answered depends on the:

cognitive structure
and theoretical orientation
of the clinician
Clinician’s theoretical commitment:
“headache”
Psychodynamic – presence of underlying hostility

Behavioral – mere stress related to job, etc.
CLINICAL JUDGMENT
Involves sensitive integration of many sources of data into a
coherent picture of the patient using
1. quantitative/statistcical approach
- relies on data to make clinical judgments
2. Subjective, clinical approach
Experiential, intuitive, sensitive capacity to integrate material:
events, history, test responses
Like a detective; Seeing a bit of him in the patient
( assumed similarity: use own experience in interpreting the
behavior and feelings of another)
6. COMMUNICATING THE CLINICAL REPORT
Address the referral question!

Avoid jargons
Use style and language that can be
understood by the intelligent layperson.
6. COMMUNICATING THE CLINICAL REPORT
Avoid the Barnum Effect!
Interpretations that seem valid

but in actuality characterize everybody
Examples of Barnum
• You have a great need for other people to like and admire you.
• You have a great deal of unused capacity, which you have not turned to your
advantage.
• Disciplined and self-controlled outside, you tend to be worrisome and insecure
inside.
• You prefer a certain amount of change and variety and become dissatisfied when
hemmed in by restrictions and limitations.
• You pride yourself as an independent thinker and do not accept others statements
without satisfactory proof.
• You have a tendency to be critical of yourself.
• At times you have serious doubts as to whether you have made the right decision
or done the right thing.
• At times you are extroverted, sociable, while at other times you are introverted,
wary, reserved.
• While you have some personality weaknesses, you are generally able to
compensate for them.
Referral question
Plan Assessment
Procedures
Assessment Proper
Interpretation of
Assessment Data
The Assessment Process
Diagnosis/Clinical
Judgment
Communicating the
Clinical Report
THREE BROAD METHODS OF CA
• Clinical Observations
• Clinical interviews
• Clinical Tests
CRITERIA FOR TEST SELECTION
•Relevance to the problem
•Appropriate to the subject
•Familiar to the clinician
•Adaptable to the time table
•Valid and reliable
SOME PRINCIPLES IN THE USE OF TEST
SELECTION
• Tests are samples of behavior
• Tests do not measure traits or capacities directly
• Psychological maladjustments selectively and
differentially affect test scores
• Psychometric and projective tests complement
each other
1. Clinical Interview
Types:
Unstructured Interviews –clinicians ask
open-ended questions
ASSESSMENT Structured Interview – clinicians ask
TOOLS questions from an interview schedule
Example:
• mental status exam
- assesses the person’s general
functioning
2. Symptom Questionnaire
ASSESSMENT
TOOLS Clients are asked to complete
Beck Anxiety Inventory
3. Physical Examination
4. Clinical Tests
a. Projective Tests
• current concerns and feelings,
• their relationships with others,
ASSESSMENT
• and conflicts or desires.
TOOLS ambiguous stimulus
People are thought to project these issues onto their description of the
“content” of the stimulus
4. Clinical Tests
b. Personality Inventories
• assess people’s typical ways of thinking,
ASSESSMENT feeling, and behaving
TOOLS
Example: MMPI
4. b Personality Inventories
MMPI
• I would rather win than lose in a game.

ASSESSMENT • I am never happier than when alone.
TOOLS • My hardest battles are with myself.
• I wish I were not bothered by thoughts
• about sex.
4. Clinical Tests
c. Response Inventories
ASSESSMENT Self response measures that focus on one

specific area of functioning
TOOLS -affective inventories measure anxiety and
depression
Ex. Beck Anxiety Inventory
Beck Depression Inventory
4. Clinical Tests
d. Neurological and Neuropsychological
Tests
ASSESSMENT Neurological Tests – directly assess brain
TOOLS function by assessing brain structure
and activity
Example:
EEG, PET Scan, MRI
4. Clinical tests
d. Neurological and Neuropsychological Tests
Neuropsychological Tests
Indirectly assesses brain function by measuring
abilities in areas
ASSESSMENT such as receptive and expressive language,
attention and concentration,
TOOLS memory, motor skills, perceptual abilities, and
learning and abstraction
in such a way that the clinician can make educated
guesses about
the person’s performance and the possible
existence of brain impairment.
4. Clinical tests
d. Neurological and Neuropsychological
Tests
ASSESSMENT Neuropsychological Tests
TOOLS
detects specific cognitive deficits such as a
memory problem
(dementia)
ASSESSMENT TOOLS
Neuropsychogical
Test
Indirectly measure
intellectual ability
(verbal and non-
verbal)
Ex.
Bender-Gestalt II
4. Clinical tests
e. Intelligence Tests
used to get a sense of an individual’s

ASSESSMENT intellectual strengths and weaknesses,
TOOLS particularly when mental retardation or
brain damage is suspected
Ex. WAIS, WISC

5. Behavioral Observation/Assessment
and Self-Monitoring
ASSESSMENT
TOOLS • to assess deficits in their skills or ways of
handling situations.
• Systematic observations of behavior
5. Behavioral Observation
and Self-Monitoring
ASSESSMENT
TOOLS Ex.
watch a child interact with other children to determine what situations
provoke the child to act aggressively.
Self-monitoring:
and Self-Monitoring
ASSESSMENT a. Naturalistic observation
TOOLS b. Analog
c. Self-monitoring
and Self-Monitoring
ASSESSMENT a. Naturalistic observation
TOOLS -observe the client’s interactions with his
everyday environment as they occur naturally
at home, schools, institutions, and community
settings
and Self-Monitoring
ASSESSMENT b. Analog Observation
TOOLS -occur in artificial settings e.g. clinics,
laboratories
- Simulations of the observed behavior
and Self-Monitoring
c. Self-monitoring
- Clients observe themselves and carefully
ASSESSMENT record the frequency of behaviors,
feelings, or thoughts
TOOLS
- The client is asked to keep track of how many times he engages
in specific behavior in a day
6. Brain Imaging Techniques
• Brain structures: CT, MRI
ASSESSMENT • Brain functions: PET, SPECT
TOOLS single photon emission computed
tomography
7. Psychophysiological Tests
- Measure physiological responses as an

indication
ASSESSMENT of psychological problems
TOOLS - Look into changes in the nervous system that
reflect emotional or psychological events
Ex. Blood pressure, Heart rate, GSR, polygraph

ASSESSMENT • also used to assess people’s emotional

response to specific types of stimuli,
TOOLS such as response to war scenes in a
veteran with post-traumatic stress
disorder.
Ex. EEG
ASSESSMENT electrodermal response
TOOLS • detects electrical conductivity between
two points on the skin and this can reflect
emotional arousal.
A. The CLINICAL INTERVIEW
1. Characteristics:
• An interaction between the clinician and the client

• Purposeful, with a goal/s
• The interviewer is the director
• Carefully planned, deliberately and skillfully executed, goal
oriented
1. Characteristics:
• The clinician uses it to elicit data, information, beliefs, or

attitudes in the most skilled fashion possible.
1. Characteristics:
• is an art
when to probe
when to be silent
when to be indirect or subtle
• Sensitive to cues
1. Characteristics:
• Is not a psychological test

x Different from structured interview
2. Components
a. Rapport
a positive, comfortable relationship between

interviewer and the client.
2. Components
a. Rapport
= connection with the client
= empathize with their issues
client’s disclosure & investment
2. Components
a. Rapport (How?)
1. make an effort to make the client at ease
2. Components
a. Rapport (How?)
2. acknowledge the unique unusual situation of the
clinical interview
*disclose to a stranger
* allow them to ask questions about the interview process
2. Components
a. Rapport (How?)
3. follow the client’s language
Client: “It’s like I’m juggling, and
I can’t keep all the balls in the air.”
Clinician: “What if one of the balls fell?”

2. Components
b. Techniques (What)
1) Directive vs. Nondirective style
Directive
- elicit information the client may not choose to discuss
Directive
for important historical information
“How often have you attempted suicide
in the past?”
Directive
the presence or absence of a particular symptom
“How many hours per day do you typically sleep?”
Directive
frequency of behavior
“How often have you had panic attacks?”
Directive
duration of a problem
“How has your son had problems
with hyperactivity?”
Techniques (What)
b.
Non-directive
- elicit information the interviewer may not otherwise
know to inquire about
b.Techniques (What)
Non-directive
“Can you tell me more about your feelings of
sadness?”
2) Specific Interviewer Response s
✓Open-and closed ended questions
✓Clarification
✓Confrontation
✓Paraphrasing
✓Reflection of feelings
✓Summarizing
• Can you please tell me more about…
• How many times per week do purge?
• Mr. Jones’ case
• Did you mention that you have been struggling with eating?
• “I only binge when I’m alone”,
“you only binge when no one is around”
* Do you feel embarrassed about it?
Qualities of Assessment Techniques
• Validity
• Reliability
• Clinical utility
c. Conclusions
Summarization
Initial conceptualization of the
client’s problem
Diagnosis
Recommendation
(e.g. outpatient/inpatient treatment)
further evaluation
3. Pragmatics
a. Interview room
b. Note taking
c. Audio/video recording
d. Confidentiality
3. Pragmatics
e. The clinician’s impact

(socially, professionally, robust presence, gender, age)
(intimidation, encouragement)
3. Pragmatics
f. The clinician’s values and background

(biases)
3. Pragmatics
g. The patient’s frame of reference

(client’s views, perceptions)
3. Pragmatics
h. The clinician’s frame of reference

(first obligation is to understand, stay focused to the purpose of the interview)
4. TYPES OF INTERVIEWS
a. Intake-Admission interview
b. Diagnostic interview
c. Mental Status Exam
d. Crisis interviews
e. Case-History
a. Intake-Admission interview
To determine whether to
“intake” the client or not
Whether the client needs a treatment or not;
What form of treatment is appropriate

(inpatient, outpatient, specialized provider, referral)
a. Intake interview
Involves detailed questioning about

the presenting problem
b. Diagnostic Interviews
Involves detailed questioning about

the presenting problem
Include questions that relate

to the criteria of the disorders
1) Structured DI
is a predetermined, planned sequence
of questions that an interviewer
asks a client.
1) Structured DI
Standardized in administration
SCID
2) Unstructured DI
involves no predetermined
or planned questions
c. Mental Status Exam Interview
is typically conducted
to assess the presence
of cognitive, emotional,
or behavioral problems.
c. Mental Status Exam Interview
• Most often employed in medical setting.

• To quickly assess how the client is functioning (cognitive,
psychological, emotional) right now
d. Crisis Interviews
are designed not only to assess a problem demanding urgent

attention but also to provide immediate and effective
intervention for that problem.
d. Crisis Interviews
- can be conducted in person but also take place often on the telephone via suicide hotlines, crisis lines, etc.
e. Case History Interview
-a complete personal and social history is taken.
concrete facts, dates, and events, and in the patient’s feelings about them.
- family history, medical history,
e. Case History Interview
-to provide a broad background and context in which both the patient and the
problem can be placed.
5. Cultural Components
Appreciate cultural context
All human behaviors of the client take place in a cultural context

Understand the client within appropriate cultural context
5. Cultural Components
Appreciate cultural context
All human behaviors of the client take place in a cultural context

Understand the client within appropriate cultural context
Acknowledge cultural differences

Reliability of Interviews
• Interrater reliability
The level of agreement between at least 2 raters who evaluated

the same patient or clients.
Reliability of Interviews
• Test-retest reliability
Structured interview
with clear scoring instructions
Validity of Interviews
• How well the interview measures what it intends to measure.

• Content Validity
Scores from depression interview correlate highly with scores from

a well-respected
self- report depression test.
Predictive validity
High scores in depression interview highly correlates

with poor academic performance
(evidence supporting validity)
• Discriminant validity
The interview does not correlate with measures

that are not theoretically related
to the construct being measured.
CLINICAL
INTERVIEWING
FACTORS THAT INFLUENCE
THE CONDUCT OF CLINICAL INTERVIEW
1. Interview setting and purpose
- setting and purpose of interview are intertwined
e.g. DSWD, private clinics, psychiatric wards, forensic,

OPDs: adoption evaluation, diagnosis and intervention,
cognitive functioning, personality assessment,
psychological well-being of witnesses, victims etc.
2. Client factors
FACTORS a. Presenting problems or goals e.g. . in crisis clients: brief
THAT and structured clinical interviews; clients struggling with
divorce: less structured, more time for free talk
INFLUENCE b. preferences about therapy
AND DRIVE c. religious or spiritual identity
CLINICAL d.
d.
coping style
Expectations
INTERVIEW e. Culture
3. Clinician factors b. theoretical orientation
a. Professional discipline • Adlerian therapist is likely to
conduct a family
FACTORS • psychiatrists and
constellation interview
during a first session
psychologists use
THAT interviews for assessment,
• Family systems therapists
might engage clients in a
similar process but call it a
INFLUENCE diagnosis, and treatment
planning.
genogram assessment
• CBT Orientation conduct in-
AND DRIVE • Social workers focus more
session or in vivo functional
behavioral assessments -
CLINICAL on psychosocial history, their focus would be on
defining specific
family history, and systemic
INTERVIEW or cultural issues
• problem behaviors and
identifying behavioral
antecedents and consequences
• Counselors interview for • Theory-based interview
relationship development, approaches contribute to
case formulation and
collaborative engagement, treatment planning.
and client wellness or c. Clinician’s skills
strengths.
FACTORS THAT INFLUENCE AND DRIVE
CLINICAL INTERVIEW
4. Time and structure of interview
a. Structured interview- the most prescriptive clinical interview
- follow a predetermined question list
• Almost all structured interviews are psychodiagnostics - gather symptom-related information
with diagnostic formulation or behavioral prediction as their ultimate goal.
b. Unstructured interview
- allows clients to talk freely while clinicians respond with reflections, summaries, and
open questions.
c. Semi-structured interviews
- a middle ground of sorts
- provide clinicians with structure and focus while retaining flexibility to explore content areas that
emerge organically.
GENERIC CLINICAL INTERVIEWING MODEL
• atheoretical model
1. Introduction
2. Opening
3. Body
4. Closing
5. Termination
* Each stage includes specific relational and technical tasks.
A. INTRODUCTION
• The introduction stage begins at first contact
• Can be done via telephone, online, or when prospective clients read information
about their therapist (e.g., online descriptions, informed consents).
• Central topics and activities are client expectations, role induction, first
impressions, and initial rapport-building are central issues and activities.
• First impressions has a great influence in the interview process and clinical
outcomes.
• respectful and culturally sensitive interviews are likely to facilitate trust and
collaboration, consequently resulting in more reliable and valid assessment data
(Ganzini et al., 2013).
• Rapport-building
A. INTRODUCTION
Discussion of
1. Confidentiality
2. Therapist theoretical orientation
3. role induction
e.g. “Today I’ll be doing a diagnostic interview with you. That means I’ll be asking lots
of questions. My goal is to better understand what’s been troubling you.”
- ends when clinicians shift from paperwork and small talk to a focused inquiry into
the client’s problems or goals.
B. OPENING
• provides an initial focus

“What concerns bring you to clinic today?”
- This question guides clients toward describing their presenting problem
How are you today?” or “How was your week?”

- prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage
More helpful opening questions:
“What are your goals for our meeting today?”

• Opening questions should be culturally appropriate – make clients comfortable
• For structured or semi-structured interview protocol – formal opening statement may be scripted or geared toward
the exact information
e.g., “Does anyone in your family have a history of mental health problems?”
C. BODY
• Governed by the purpose of the interview
e.g.
• If the purpose is diagnosis: the body includes diagnostic focused questions
• Initiation of psychotherapy: the history of the problem and what specific
behaviors, people, and experiences (including previous therapy) clients have found
more or less helpful.
• Assessment: focuses on information gathering -frequency, duration, intensity, and
quality
D. CLOSING
• It is the clinician’s responsibility to organize and close the session in ways that assure there
is adequate time to accomplish the primary interview goals.
Tasks and activities:
1. providing support and reassurance for clients
2. returning to role induction and client expectations
3. summarizing crucial themes and issues
4. providing an early case formulation or mental disorder diagnosis
5. instilling hope
6. focusing on future homework, future sessions, and scheduling if applicable/as needed
E. TERMINATION
• involves ending the session and parting ways.
• Dealing with termination can be challenging
• requires excellent time management skills; intentional sensitivity and
responsiveness to how clients might react to endings in general or leaving the clinic
• May talk about gathering collateral information IF NEEDED
CLINICAL INTERVIEWING AS ASSESSMENT
• Clinical interview
- involves more assessment and less intervention
“be patient,” because accurate psychiatric diagnosis may

take “five minutes,” “five hours,” “five months, or even
five years by Allen Frances (2013), chair of the DSM-IV
task force
COMMON assessment interviews:
1. Intake interview
• Focuses on three assessment areas:
a. Presenting problem – may include a structured diagnostic interview, generation
and analysis of a problem list, or clients free associating to their presenting
problem.
b. Psychosocial history - past relationships, medical history or a rich and extended
examination of his childhood.
a. current situation and functioning - can range from an informal query about the
client’s typical day to a formal MSE
2. Psychodiagnostic interview
• is a variant of the intake interview
• Medical model interview, the initial interview is often diagnostic interviews
• the purpose is to establish a psychiatric diagnosis
• the purpose of psychiatric diagnosis is to describe the client’s current condition,
prognosis, and guide treatment.
2. Psychodiagnostic interview
Examples:
• Structured Clinical Interview for DSM-5 Disorders – Clinician Version
• Autism Diagnostic Interview
3. MSE
• is a semi-structured interview protocol used to organize, assess, and communicate
information about clients’ current mental state
• Uses highly structured or semi-structured; or combination of S and US; or Piaget
semi clinical interview – converting a few structured MSE questions into a less
structured interview process; unstructured assessment interview then organize
your observations into a short mental status report.
• Knowledge of diagnostic terminology and symptoms is a prerequisite to conducting
and reporting on mental status.
1. MSE
Common domains for psychiatric-symptom oriented MSE.
1. Appearance
2. Behavior/psychomotor activity • MSE reports are typically
3. Attitude toward examiner (interviewer) limited to one paragraph
4. Affect and mood or one page.
5. Speech and thought
• The content focuses on
6. Perceptual disturbances
the 9 domains
7. Orientation and consciousness
8. Memory and intelligence
9. Reliability, judgment, and insight.
4. Crisis interview (Suicide assessment interview)
- to assess and provide intervention for suicide, clinical interview is the gold standard
• clinicians frame suicide ideation as a communication of client distress rather than psychopathology
- gather information pertaining to 8 superordinate suicide dimensions:
a. Unbearable emotional or psychological distress:
- can involve one or many trauma, loss, or emotionally disturbing experiences.
b. Problem-solving impairments: Suicide theory and empirical evidence both point to ways in which
depressive states can reduce client problem-solving abilities.
c. Interpersonal disconnection, isolation, or feelings of being a social burden
d. Arousal or agitation: Many different physiological states can increase arousal/agitation and push
clients toward using suicide as a solution to their unbearable distress.
4. Crisis interview (Suicide assessment interview) information pertaining to
8 superordinate suicide dimensions:
e. Hopelessness: is a cognitive variable linked to suicide risk. It can also contribute to

problem-solving impairments.
f. Suicide intent and plan
g. Desensitization to physical pain and thoughts of death: Fear of death and aversion
to physical pain are natural suicide deterrents; when clients lose their fear of
death or become desensitized to pain, suicide behaviors can increase.
h. Access to firearms: Availability of a lethal means, and access to firearms,
substantially increase suicide risk.

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CLINICAL ASSESSMENT

a conceptualization of the problem at hand

(as well as possible etiological factors),

and some prescription for alleviating

Sources: biological, psychological, socio-cultural

1. for a more accurate diagnosis

Our capacity to solve

…and arrive to a solution

Why is Mary disobedient?

Is this patient capable of murder?

discuss first with the family

-collect assessment data

* It is best to use multiple data sources

- interpretations of data collected

What do these results mean?

What decisions are to be made?

- go back to the referral question

Is this patient psychotic?

What’s wrong with him?

* Clinical psychologists are psychodiagnocians

How these questions answered depends on the:

Psychodynamic – presence of underlying hostility

Address the referral question!

Avoid the Barnum Effect!

Interpretations that seem valid

• I would rather win than lose in a game.

ASSESSMENT Self response measures that focus on one

used to get a sense of an individual’s

Ex. WAIS, WISC

- Measure physiological responses as an

Ex. Blood pressure, Heart rate, GSR, polygraph

ASSESSMENT • also used to assess people’s emotional

• An interaction between the clinician and the client

• The clinician uses it to elicit data, information, beliefs, or

• Is not a psychological test

a positive, comfortable relationship between

Clinician: “What if one of the balls fell?”

e. The clinician’s impact

f. The clinician’s values and background

g. The patient’s frame of reference

h. The clinician’s frame of reference

Whether the client needs a treatment or not;

What form of treatment is appropriate

Involves detailed questioning about

Involves detailed questioning about

Include questions that relate

• Most often employed in medical setting.

are designed not only to assess a problem demanding urgent

-a complete personal and social history is taken.

Appreciate cultural context

All human behaviors of the client take place in a cultural context

Appreciate cultural context

All human behaviors of the client take place in a cultural context

Acknowledge cultural differences

The level of agreement between at least 2 raters who evaluated

• How well the interview measures what it intends to measure.

Scores from depression interview correlate highly with scores from

High scores in depression interview highly correlates

The interview does not correlate with measures

e.g. DSWD, private clinics, psychiatric wards, forensic,