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Theory and Practice of Counseling - PSY632

Lesson 44

DIAGNOSIS & ASSESSMENT

The DSM-IV Multiaxial Assessment

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV), published by the

American Psychiatric Association in 1994, is basic instrument in making and reporting formal mental

diagnosis all over the world. It has gone through 5 revisions since it was published first time. A text revision

of DSM-IV (DSM-IV-TR) was published in 2000. The DSM-IV attracts controversy and criticism as well as

praise. The major advantage of DSM-IV is its multiaxial system divided into five Axes:

Axis I Major clinical disorders

Axis II Stable, enduring problems

Axis III Medical conditions related to abnormal behavior

Axis IV Psychosocial problems

Axis V Global clinician rating of adaptive functioning

Following are the main characteristics of DSM-IV:

· Five axes describe full clinical presentation.

· Clear inclusion and exclusion criteria have been described for disorders.

· Disorders are categorized under broad headings.

· Empirically grounded prototypic approach to classification is adopted.

· The major advantage in using this multiaxial classification system is that it ensures that attention is

given to certain types of disorders, aspects of the environment and areas of functioning that might

he overlooked if the focus were on assessing a single presenting problem.

· In addition to diagnosing the client as to mental health, personality disorders, and physical

condition, scales have been developed to help the clinician make consistent determinations of the

severity of the psychosocial stressors (Axis IV) and the global assessment of functioning (GAF)

(Axis V). When using the GAP on Axis V, the clinician should record a current determination and

an estimate of the highest GAF for the past year.

· Thus, rather than give a one- or two-word label to a diagnosed person, such as "depressive

neurosis," as was the practice prior to the adoption of the DSM , the practitioner now can come up

with a diagnosis such as the following:

DSM-IV: An Example

Axis I: 296.24 Major depression, single episode; severe without psychotic features

Axis II: 301.60 Dependent personality disorders

Axis III: Diabetes

Axis IV: Psychosocial stressors: separated from spouse; conflicts with children

Axis V: Current GAF = 44 Highest GAF past year = 55

Use of Tests: A Controversial Issue

Among the ranks of counseling professionals, there also has been a great deal of controversy related to the

nature and appropriateness of assessment and diagnosis. Leo Goldman, an expert in the use of tests in

counseling, indicates that "there is increased feeling that the use of tests in counseling on the whole is a sad

disappointment and that in recent years matters have actually become worse" (Leo Goldman, 1972, p. 213).

However, a full understanding of assessment concepts and practices is necessary whether or not counselors

choose to use tests and other diagnostic instruments. It is necessary to communicate with those who do use

these tools in case conferences, referrals, and correspondence, as well as to understand the professional

literature.

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Sugarman (1978) points out that the objections to the use of assessment and appraisal techniques are based

on five different grounds:

· It is reductionistic, reducing the complexity of the person into diagnostic categories.

· It is artificial.

· It ignores the quality of the relationship between the examiner and the test taker.

· It judges people, casting a label on them.

· It is overly intellectual, relying on complex concepts, often at the expense of a true understanding

of the individual.

Businesses and industries have used tests and inventories for many years as primarily aids in the selection of

job candidates. Testing has been and continues to be a general accepted function in mental health centers,

employment offices, and other private public clinics and agencies. Tests and their use have not changed

significantly since objections were raised in 1970s and earlier. Basically, what seems to have changed is the

overall attitude of people toward tests. Recent Gallup polls of the U.S. population indicate a general

acceptance in the use of standardized tests. In Pakistan also, people feel more satisfied as clients if tests are

used for assessing their psychological problems or for career counseling. Assessment procedures of all types

are now an accepted form of contemporary society.

Assessment Techniques

Counselors use a variety of techniques and procedures in the process of gathering data. Some can be highly

structured and designed so that each time a procedure is used the process is exactly the same. This is called

using a standardized format. A less rigorous but also important way of obtaining information is through

the use of nonstandardized instruments. Such tools may be idiosyncratic, specific only to a given client or

set of circumstances, with a minimal chance for replication. A brief description of some nonstandardized

formats follows:

Nonstandardized Techniques

Observation

· Observation is the most fundamental assessment procedure. Highly developed skills in the use of

other assessment tools are negated if the powers of observation are not well developed.

· Signs vs. samples of behavior: Behavioral observation is common to all psychological approaches.

It is the use that is made of the data that distinguishes between approaches. In the psychodynamic

orientation behaviors serve as indirect signs of hypothesized underlying dispositions and motives.

Behavioral approaches treat observed behavior as a sample, and the focus is on how the specific

sample is affected by variations in the stimulus conditions.

· Importance in counseling: Half of the message that a client communicates is nonverbal. Counselors

should be attuned to all of the nonverbal cues available and note the discrepancies and

inconsistencies between these and verbal messages.

Gibson and Mitchell (1981) describe casual observation and two higher levels:

· First Level: Casual Information Observation:

o The daily unstructured and usually unplanned observations that provide casual

impressions. Nearly everyone engages in this type of activity. No training or

instrumentation is expected or required.

· Second Level: Guided Observation:

o It is planned and directed observations for a purpose. Observation at this level is usually

facilitated by simple instruments such as checklists or rating scales. This is the highest level

used in most counseling programs. Some training is desired.

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Third Level: Clinical Level:

o These are the observations, often prolonged, and frequently under controlled conditions.

Sophisticated techniques and instruments are utilized, with training usually at a doctoral

level.

Observational Instruments

Checklists

The purpose of a checklist is to focus the observer's attention to the presence or absence of

predetermined characteristics. A simple check mark or "yes" or "no" indicates whether the

characteristic is observed.

Rating Scales

A rating scale is a special kind of checklist on which the observer can note not only the presence of

a given characteristic or attribute but also the degree to which it manifests itself. Rating scales can

be particularly helpful in making observations of individuals. A sample rating scale format is given

below:

1___

2____

3____

4_____ 5____

Never

Rarely Sometimes

Usually

Always

The benefits of rating scales and checklists include having an easy to use approach for making

objective observations of selected characteristics. They also offer the possibility of comparing the

observations of more than one observer using identical criteria.

There are also some limitations in the use of such instruments, including 1) often poor and unclear

directions for the scales' use; 2) a failure to define terms adequately; 3) limited scales for rating; 4)

items that tend to prejudice how one responds; 5) overlapping items; 6) excessive length; 7)

tendency to endorse middle rating, which means playing it safe by giving a middle or average rating

to everyone on every item; and 8) biased ratings.

Anecdotal Reports:

Anecdotal reports are subjective descriptions of a client's behavior at a specific time or for a

specific situation. These reports generally start out by noting the time, date, and place. These are

followed by a general description of the event and the manner in which the client participated in it.

The report ends with observer comments that may be evaluative in nature.

Self-Report Instruments

They can be short enough to be filled out by a client a few minutes before the first visit to a counselor and

can be designed to provide a variety of data. A few sellf-reported instruments are described below:

Questionnaires

Questionnaires can be used to collect vital information to determine the counseling or consulting needs

of groups or organizations.

Interviews

An interview is a form of questionnaire that is read to a client by a counselor. The client is encouraged

to respond as directly as possible to all questions, and the counselor has the opportunity to ask for

clarification or elaboration of any question. Such an interview may be required of all first time clients by

a mental health agency as part of a case management process. One purpose is to assign the client to the

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staff member or program that best meets the needs of the client. Another type of interview focuses on

a specific issue or syndrome, such as depression or alcoholism, and the questions are designed to

highlight related aspects of behavior. Careful records, including tape recordings, are generally made in

the case of interviews to be sure that all comments are noted and that nonverbal behaviors are also

included.

Personal Essays and Autobiographies

More extensive written material, such as having a client write a personal essay on a given topic (for

example, "the kind of job that I believe I would enjoy the most"), is another way to gather useful data in

a short time and can be given as a homework assignment. A more elaborate version of the personal

essay is to have the client write an autobiography.

Journals

Having a client keep a journal on a regular basis and noting new issues and changes provides another

method of obtaining self-report data on an ongoing basis. A journal is more than a diary or log of daily

events. It is an opportunity to record thoughts and feelings.

Standardized Assessment Techniques

There is also a need for assessment devices that can be administered in a consistent manner to a wide

variety of people. Many different tests, usually published instruments, are standardized. A standardized

test is one that has detailed, specific directions for the administration of the instrument, including the exact

words with which to introduce the instrument to the client and any time limits. The procedures for scoring

are also specifically detailed so that all people scoring a given test will record results in the same manner.

There are two basic categories of standardized tests: norm-referenced and criterion-referenced tests:

Norm-Referenced Tests

Another characteristic of most published instruments is that they have norms to which test scores can be

compared. Norms, or normative tables, are generally included in the manual accompanying published tests.

These tables provide data on the performance of various groups of people taking the same instrument

during the period of time when the test was being developed. Norm groups are often nationwide samples,

but they can also be regional or local. Test items are carefully tested and analyzed before being included in

the final instrument. The reliability, or consistency, of scores and the instrument's validity, the ability of a

test to measure what it purports to measure, are determined for constructing a standardized measure.

Three concepts, reliability, validity and standardization, determine the Value of assessment. Figure given

below illustrates this:

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Criterion-referenced tests

A criterion-referenced test is a test that is used to ascertain an individual's status with respect to a well-

defined behavioral domain. A well-constructed criterion-referenced test yields a clear description of what a

client can or cannot actually do.

Types of Standardized Instruments

Assessment instruments have been developed to measure virtually all aspects of humans. Published

standardized instruments are generally catalogued and reviewed in a series of volumes entitled the Mental

Measurement Yearbook.

Achievement Tests

Achievement tests are designed to assess what a person has learned in a given subject, such as music,

mathematics,

German,

result

specific

curricular

experience. The instrument can be designed for one subject or can include a variety of subjects.

Examples of the latter type of instrument are the Iowa Tests of Basic Skills and the Metropolitan

Achievement Tests.

Aptitude (Intelligence) Tests

A test used as a predictor of some future performance is called an aptitude test. Aptitude tests are

designed to measure the propensity to perform certain tasks that may not already be a part of a person's

repertoire. Aptitude tests can be considered a form of ability testing, measuring the potential ability that

a person has in a specific area. Intelligence tests can be considered measures of general ability. There is

no generally agreed-on definition of intelligence; however, most intelligence tests are designed to be

indicators of the ability to be successful in school. Intelligence tests are used primarily as screening

devices in counseling and are followed by more specialized aptitude tests that assess aptitude in

particular area.

Examples of Aptitude Tests:

Differential Aptitude Test (DAT)

Aptitude Classification Test (ACT)

Scholastic Aptitude Test (SAT) which was renamed the Scholastic Achievement Test in 1993.

Examples of Intelligence Tests:

· Stanford-Binet Intelligence Scale: Stanford Binet is the father of American Intelligence tests. It is a

revision of Binet-simon scales, and was published in 1916 by Terman and colleagues. It has

traditionally been used with children than adults. In 1986, it underwent a fourth revision to include

More material for adults.

Wechsler Adult Intelligence Scale-Third Edition (WAIS-III): It is the most popular test of

intelligence which is used worldwide for assessment and research.

Problems with intelligence tests

According to Anastasi (1982) intelligence tests are usually overloaded with certain functions, such as

verbal ability and they are validated against scholastic ability.

Personality Assessment Instruments

Thorndike and Hagen (1977) describe several characteristics of personality other than abilities that can

be identified and assessed, including temperament, character, adjustment, interests, and attitudes:

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Attitude Questionnaires

Attitude questionnaires are designed to assess the intensity of a person's sentiments with regard to a

specific subject such as women's liberation, abortion, or gun control. A major limitation of

questionnaires is their low reliability. The responses people make to the statements on a questionnaire

may not correspond to their actions.

Interest/ Career Inventories

Instruments designed to determine patterns or tendencies that an individual has with regard to

personal interests are called interest inventories. Interest inventories can be designed for almost any

purpose--to determine interest in music, art, or athletics. Many inventories have been designed for

use in counseling and, in particular, for use in helping clients make career choices. Interest

instruments are usually constructed in the form of checklists or forced choice questions, on which

the client has to select a preference from a choice of activities.

There is generally a very low correlation between interest and ability, so having an interest in an

area does not guarantee success in it. The reverse is also true. Having a high degree of ability in an

area does not guarantee that a person will be satisfied with a career in that area. However, some

people maintain that a person's achievement in a learning situation or a career is greatly influenced

by his interests (Anastasi, 1982).

Examples:

Strong Vocational Interest Blank (SVIB)

Instruments that measure career/ interests began in a systematic and standardized way with the 1928

publication of SVIB. The revised form, SVII (Strong Vocational Interest Inventory) includes

description about 207 occupations. The manual suggests ways to deal with different cultures and special

populations and has more specific and general ways of examining people's interests.

Self-directed Search (Holland, 1985)

It is self administered, self scored and sometimes self interpreted. A total of 228 items are divided into

three sets: activities, competencies, and occupations. After scoring the client examines a three-letter

occupational code.

Kuder Occupational Interest Survey (1939)

Kuder Occupational Interest Survey (1939) provides 10 broad career areas: social services, persuasive,

clerical, computational, musical, artistic, literary, mechanical, outdoor, and scientific.

California Occupational Preference System

Personality Tests

A number of self-report instruments have been developed that are related to personal adjustment and

temperament, such as the Guilford-Zimmerman, MMPI, etc. There are two types of personality tests:

objective and projective

Objective Tests

The scoring in objective tests is independent of any judgment of the scorer. A few examples are:

Woodworth's Personal Data Sheet

The prototype of personality test was a self-report inventory developed during World War I.

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MMPI-II

The most widely used test in the world. Norms have been developed according to geographically end

ethically diverse population. It has 10 clinical and 3 validity scales. The client responds to 567 items, and

answers in three ways: true, false, cannot say.

Edwards Personal Preference Schedule (EPPS, 1938)

The EPPS is based on the need-press theory of personality developed by Henry Murray (1938). There

are 225 forced choice items that examine the strength of 15 individual needs in relation to a person's

other needs.

Myers Briggs Type Indicator

This test reflects Carl Jung's theory of personality. There are 166 two-choice items concerning

preferences in feeling and behavior. It yields 4 bipolar scales, e.g., extroversion or introversion, thinking

or feeling, etc.

California Psychological Inventory (CPI)

Guilford-Zimmerman Temperament Survey

Sixteen Personality Factor Questionnaire (16 PF)

Projective Tests

Projective tests have following characteristics:

· Project aspects of personality onto ambiguous stimuli, like inkblots, pictures, and incomplete

sentences.

· Roots in psychoanalytic tradition

· High degree of inference in scoring and interpretation

· Examples include the Rorschach Inkblot Test, Thematic Apperception Test

· Reliability and validity data tend to be mixed

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