Transcript Lecture 2: Assessment of Psychopathology

Lecture 2: Major Forms
of Assessment
Dr. Antoinette Lee
The University of Hong Kong
Outline
1. Major Forms of Assessment
 Physical assessment
 Interview
 Observation
•
•
Behavioral observation
Self-monitoring
 Self-report measures
2. Behavioral and Cognitive-Behavioral
Assessment
Multidimensional
Nature of
Assessment
• Multiple forms
 Physical measures
 Interview
 Observation
 Behavioral Observation
 Self-monitoring
 Self-report measures
Multidimensional
Nature of
Assessment
• Multiple Aspects
– Biopsychosocial approach
• Multiple settings
• Multiple informants
Assessment and
Intervention
• Good assessment as a prerequisite of
good intervention
• Assessment and intervention often goes
hand in hand, representing a reciprocal
and iterative process
Physical
Assessment
• Blood pressure
• Pulse rate
• Laboratory tests
– Lipid profile
– Stress hormones
– Immune functioning
• Body Mass Index
• Waist-Hip Ratio
• Psychophysiological measures
Body Mass Index
•Body Mass Index (BMI) as an indication of
whether weight is appropriate for height
(weight status)
•Ratio of weight to height
• BMI = Weight in kg / Height in m2
WHO (2000)
Categories
BMI
BMI (kg/m2)
18.5
Normal
18.5 – 22.9
Overweight
23 – 24.9
Obese (moderate) 25 – 29.9
Obese (severe)
30
Underweight
The above categorization is suitable for individuals between 18 and 65 (excluding
pregnant women, lactating women, and athletes with high muscle mass)
Ideal: BMI = 22
Aged 10-18:
Age
Overweight
(Male)
Overweight
(Female)
Obese (Male)
Obese
(Female)
10
11
12
19.8
20.6
21.2
19.9
20.7
21.7
24.0
25.1
26.0
24.1
25.4
26.7
13
14
15
21.9
22.6
23.3
22.6
23.3
23.9
26.8
27.6
28.3
27.8
28.6
29.1
16
17
18
23.9
24.5
25
24.4
24.7
25
28.9
29.4
30
29.4
29.7
30
Waist-Hip Ratio
• Measurement of central obesity, which is the quantity of fat
accumulated around the waist
• Related to risk for cardiovascular diseases
• Calculation:
Waist Circumference (cm) / Hip Circumference (cm)
• A high ratio suggests that most of the body fat is
accumulated around the waist → an increased risk for
cardiovascular diseases
• Desirable waist-hip ratio should be:
less than 1.0 for men
less than 0.85 for women
Psychophysiological
Measures
•
•
•
•
•
EMG
Body temperature
Blood pressure
Breathing rate
Galvanic skin response
Interviews
• Assessment interview as a core
assessment tool
• Dialogue
Interviews
• Lipowski (1967): the physician’s view of a
psychiatrist (and psychologist):
“a scientifically unsophisticated, medically
ignorant, and impractical man, given to sweeping
statements about other people’s motive’s based
on obtuse theories of questionable validity”
Interviews
• The scientific status of interviews
• What is science?
– Odegaard (1988): “Advances in science depends on
developing means and techniques of inquiry
appropriate for the phenomena under investigation
and the conditions and circumstances under which
such can be studied”
• The science of studying the human mind
– Words…are still magic
The
– Relationship
Interview
Types of
Interviews
• Structured
• Unstructured / Semi-structured
→ depends on the goal of the interview and
the nature of the information one needs
SCID: An Example of a Structured Clinical Interview
Characteristics
of Interviews
• Mutual interaction between interviewer
and interviewee
• Attitudes and behaviors of each affect the
other, and affects the content and quality
of information collected
– social facilitation
Function of
Interviews
Means
Interview
End
Accurate, relevant, useful,
and comprehensive
Information
•Adequately understand the individual
and his/her problem
•Treatment planning
•Attitude
•Skills
Exercise
• Conduct an assessment interview with
your partner:
– What are the information you need?
– How can you best obtain these information?
Interviews
• Specific questions (and focus) depend on
nature of problem and the purpose of the
interview but in general, areas to probe
into may include:
Areas to be included in
an interview:
 Basic personal data
 Presenting problem / complaint
 Nature, frequency, severity
 History of present problem
 Strategies of coping with the
problem
 Explanatory model
 Personal history







Developmental
Educational
Employment
Social / relationship
Legal
Significant life events
Childhood memories
 Medical (including
psychological) history
 Substance use
 Family history
 Composition
 Relationship
 Family history of significant
medical or psychological
problems
 Marital and sexual history
 Personality
 Expectations regarding
treatment
Effective
Interviewing
• Attitudes
– Proper attitude to bring about a facilitative
environment
– Essential to rapport building
• Skills
Attitude
• If you really want to help somebody, first of all you must
find him where he is and start there. This is the secret
of caring. If you cannot do that, it is only an illusion, if
you think you can help another human being. Helping
somebody implies your understanding more than he
does, but first of all you must understand as he
understands. If you cannot do that, your understanding,
will be of no avail. All true caring starts with humiliation.
The helper must be humble in the attitude towards the
person he wants to help. He must understand that
helping is not dominating, but serving. Caring implies
patience as well as acceptance of not being right and of
not understand what the other person understands.
Kierkegaard 1959
Attitudes
• Interest and involvement
– Interest in the individual and his/her problem
– Commitment to understanding the individual
and enhancing his/her well-being
– Not simply playing a professional role
Attitudes
• Positive regard and respect (Rogers, 1957)
– The belief in client’s innate worth and
potential and the ability to communicate this
belief to the client
– Nonpossessive warmth and respect for the
client
– Nonevaluative and nonjudgemental
– Empowering
Attitudes
• Genuineness and congruence (Rogers, 1957)
– Ability to be authentic and real, and to behave
as one feels, to be oneself without the need to
present a professional front
– Self-awareness of feelings and awareness
– Congruence among internal reactions, verbal
responses, and nonverbal behaviors
– Helps client to be genuine and congruent too,
develop trust
Attitudes
• Warmth (Eagan, 1994)
– Ability to demonstrate and communicate
genuine caring and concern for clients
– Convey acceptance of clients, desire for their
well-being, and sincere interest in helping
them
– Verbal and nonverbal behaviors
Interviewing
Skills
• Video demonstration
Interviewing
Skills
• Responses to Avoid
• Facilitative Interviewing Skills
– Empathy
– Basic attending behaviors
– Encouragers
– Questioning skills
– Active listening
– Paraphrasing
– Summarizing
– Structuring
– Clarification
- Assessing underlying
problems and meanings:
interpretation
- Reflection of feelings
- Cultural and subcultural
awareness
-Maintaining control
- Changing topics
- Dealing with sensitive issues
Responses to
Avoid
• Judgmental or evaluative statements
• Inappropriate probing statements
– “Why” questions
• Hostile responses
• False reassurance
Empathy
• Enter the individual’s world and understand his/her
feelings, thoughts, and experiences from his/her frame
of reference
• “ trying, as sensitively and as accurately as he can,
to understand the client, from the latter’s own point
of view” (Raskin, 1974)
• “an experiencing of the consciousness “behind”
another’s outward communication, but with
continuous awareness that this consciousness is
originating and proceeding in the other ( BarrettLennard, 1962).
• Ability to feel with clients as opposed to feeling for
clients ( sympathy)
Empathy
• The need to communicate this understanding to the
client
• Measuring understanding (Carkhuff & Berenson, 1967)
– 5 levels of empathy:
• Level 1 – little or no relationship to the interviewee’s
response
– A: I finally finished my paper!
– B: How did the Hang Seng Index go today?
• Level 2 – communicates a superficial awareness of the
meaning of a statement
– A: I feel so good. I finally finished my paper.
– B: You’re lucky. It’s not my day today. The price of the stock I
bought dropped by 50 cents.
Empathy
• Level 3 – response is interchangeable with
interviewee’s response; minimum level of
responding that can help the interviewee
– E.g. paraphrasing, repetition, clarification
• Levels 4 & 5 – goes beyond what is said to
demonstrate true empathy
– A: I finally finished my paper!
– B: You feel relieved and have a sense of
accomplishment.
– A: Yes, I’ve been working so hard on it for a whole
week. It really took a toll on me……..
Basic Attending
Behaviors (Egan,
1986)
•
•
•
•
•
Eye contact
Open posture
Facing the patient squarely
Leans slightly forward
Natural and relaxed position
Encouragers
•
•
•
•
Repetition encourager
Nonverbal encourager
Semiverbal encourager
Phrase encourager (transitional phrase)
– e.g. “yes”, “tell me more about it”
Questioning
Skills
• The most direct way of exploring an individual’s
experiences, feelings, thoughts, problems….
– Content and feeling
• open versus closed ended questions
• Legitimizing patient’s feelings
• Eliciting patient’s explanatory model
Types of Useful
Questions
Question Type
Purpose
Application
Open-ended Qs
•Assist pt in self-disclosure
•Facilitate continued
communication
•Elaboration of a topic
•Expansion of focus
beyond a topic
Systematic Inquiry
•Solicit general information
and specific details
•Assessment and historytaking
•diagnosis
Clarifying Qs
•Create insight and
cognitive awareness in pt
•Lead pt to a conclusion
that the therapist has
already drawn
•Used in therapeutic phase
•Helps pt to recognize
patterns, discover
meanings, solve problems,
and draw interpretation
Open-ended
Questions
•
•
•
•
T: How have you been feeling this week?
P: That’s a hard question.
T: What makes it hard?
P: Oh, I’m not sure. Probably because I don’t really pay
attention to my feeling. But I suppose that’s why you
ask, right?
• T: (simply smiles and nods)
• P: Well, I guess I’ve been OK. There weren’t any crisis.
• T: How are you feeling right now? (use of immediacy)
Closed Questions
CLOSED Questions
Do you like your mother?
Do you have a best friend?
OPEN-ENDED Alternative
How do you feel about your mother?
Closed Questions
CLOSED Questions
OPEN-ENDED Alternative
Do you like your mother?
How do you feel about your mother?
Do you have a best friend?
Can you tell me about your best friend?
Were you hospitalized?
Closed Questions
CLOSED Questions
OPEN-ENDED Alternative
Do you like your mother?
How do you feel about your mother?
Do you have a best friend?
Can you tell me about your best friend?
Were you hospitalized?
How bad were the injuries?
Did you find a job after your
graduation?
Closed Questions
CLOSED Questions
OPEN-ENDED Alternative
Do you like your mother?
How do you feel about your mother?
Do you have a best friend?
Can you tell me about your best friend?
Were you hospitalized?
How bad were the injuries?
Did you go back to work after you
were discharged from the hospital?
What happened after you were
discharged from the hospital?
Did you try using nicotine gums?
What kinds of things did you try?
Sometimes, Closed
Questions May be Useful…
Situation
Rationale
Example
During a crisis situation
(e.g. suicide threat)
•Help pt get focused on
detail
•To solicit very specific
information
“You say you want to kill
yourself. Do you have any
specific plans in mind?”
When pt is self-disclosing
too much too early on
•Keep pt safe from
opening too many wounds
•Keep pt from being
feeling vulnerable later
“Let’s slow down and get
back to your husband. Do
you fight with him a lot?”
When pt is self-disclosing
during the end of session
•Prevent opening new
issues
•Get a good closure
“Let me stop you there.
Did you finally confront
him?”
When pt is excessively
anxious or emotional
•To diffuse anxiety
•Help pt feel safe
“Did that help?”
Problematic
Questioning
 Suggestive Questions
– “Have you tried diverting your attention to something else?”; “Do
you think you should start finding a job?”
 Assumptive Questions
– “You don’t really believe that, do you?”; “You didn’t really take all
those pills, did you?”
 Pseudoquestions
– “Do you want to get started?”, “Would you like to start where we
left off last week?”
 Judgemental Questions
– “Couldn’t you have dealt with that in a better way?”; “You did
that?”; “Why did you do that?”
 Attacking Questions
– “So what is your point here?”; “So?”; “So what?”; “Yes?”
 Shotgunning
Some Useful
Hints…..
• Avoid the problematic questioning style-use alternative ways to phrase your
question
– “What makes you feel that way?”
– “Now that you’re looking back at it, how
would you have handled it differently?”
– “That must be awful. What do you make of
it?”
Some Useful
Hints….
• Ask questions with a purpose
– Don’t use it to kill time
• Give patients time to respond
• You do not HAVE to ask questions
– Sometimes a statement or a nod will do
• Note timing of question
• Paraphrase/reflect feelings, then followup with a question
Active Listening
• Listening with your ears, eyes, “heart”, and brain
• To listen more: senses, posture, communication skills
• An active process of attending, decoding, information
processing, and responding
• Responding with emphatic statements and understanding
responses
• Attending to verbal messages and nonverbal behaviors (often
less distorted)
• Discrepancy between verbal and
nonverbal messages
• Be sure to monitor your own nonverbal
behavior!
Active Listening
• Obstacles to listening:
– Sender variables:
• Loudness and softness of voice
• Speed
• Tone
• Difficulty in expression/inarticulate
• Clarity/organization
• Too emotional
• Jargons
Active Listening
– Receiver variables:
•
•
•
•
•
•
•
Inattention
Selective attention
Bias
Preoccupation
Impatience
Insensitivity
Neglect of nonverbal cues
– Match between sender and receiver
Paraphrasing and
Restatement
• Captures the essential meaning of what the individual
has said
• Use different words to restate what has been said
• “Re-packaging” using your own language
• Functions:
–
–
–
–
Shows you understand
Perception checking
Highlights a point
Let the individual hear his experiences or viewpoints from a
different perspective
Paraphrasing and
Restatement
• Opening stem
– e.g. “What you’re saying is”; “What I’m
hearing is”; “What I hear you saying is”; “It
sounds to me as though”; “The picture I am
getting from what you are saying is…..”
• Closing stem
– e.g. “Is that close?”; “Am I getting the right
picture?”; “Does that capture it?”
An Example:
I: Interviewer, C: Client/Interviewee
I: How did you feel after being diagnosed?
C: I was totally shattered. I never expected that to happen in my life.
I: Your life seems completely changed. (paraphrasing)
C: Yes….Nothing is the same. I don’t know what to do and
where to start. Do I focus on my treatment or my
responsibilities? Do I quit my job? Do I tell my son’s teacher
that I’m sick?
I: You need to figure out all the implications, sort of one by one and
then for each one, figure out what you need to do. Is that it?
(paraphrasing)
C: Yes, exactly. You don’t really notice how complex your life
is until something like this happens. You begin to
question……
Another
Example:
C: I’m not sure where to start. So much has happened that my
head of spinning. I can’t tell you how much I’ve been looking
forward to this session – I really need it! But now that I’m
here I don’t even know where to start
I: You’re on overload and that makes it hard to sort out what is
the most important thing to deal with first. Is that it?
(paraphrasing)
C: That’s it exactly. I’m on overload. Just too much for one
person to deal with.
Clarification
•
Clarifying what the client said
–
To clear up vague, unclear messages
•
•
–
–
•
e.g. “We get along well”, “I take things easy”, teacher’s
complaint of conduct problems in school
Ask for examples
To clarify client’s problem
To check out the accuracy of your understanding
Function: clarification and perception-checking,
encourage further elaboration from the client
Summarizing
•
•
•
•
Pulling together the meaning of several
interviewee responses
Ties together multiple elements of client
messages
To identify a common theme or pattern
Can also be useful in dealing with excessive
rambling
Structuring
•
•
•
•
Finding the focus of what was said
Links among the main points
Seeing the larger picture
Use of summarizing to achieve this
Assessing Underlying
Meanings and Problems
• Assessing what is felt/meant but not said
• To show understanding of “essential meaning” of
the individual’s experiences
• “To hear my meanings a little more deeply than I
have known them” (Rogers, 1969)
• Seeing the target problem
• Interpretation
Reflection of
Feelings
• Learning to
– (1) “feel” the feeling
– (2) verbalize and reflect it back to the patient
• Reflection
– Accurately perceiving and reflecting the patient’s
feelings
– Like a mirror
– Attend to words, nonverbal expressions, and
emotional subtones
• Acknowledgement, reflection, empathy
Responding to
Feelings
• Functions of reflection:
– Shows you “really” understand - for rapport building
– Promotes awareness of feelings
– Facilitates further exploration and expression of feelings
– Focuses on main feelings
– Feelings to events, rather than events themselves, that
matter
– Brings out new dimensions and directions
• Things to note:
– Timing
– Words to use
An Example:
C: Every evening, the same thing happens. I ask her to go to
bed; she starts to cry. I can’t stand this any longer. She’s
eight and has no respect for authority. My other kids aren’t
like that; and she’s the eldest.
I: I think what I’m hearing are really two worries. First, you are
overwhelmed with the struggle every night Second, you are
afraid that her behavior may affect the little ones
C: Yes. They look up to her so much. Right now, they still
listen to me but what if I lose control over them too! What
am I supposed to do? And my husband is no help. I just
don’t know what to do…(starts to sob)
I: It’s all too much for you, with so many overwhelming feelings
and problems, you feel paralyzed and powerless
C: And no one’s there to lean on
I: You feel so alone.
Exercise
What is the feeling conveyed and how
would you reflect the feeling?
a.
b.
c.
(describing relationship with boss): I try and try but it hardly
seem to succeed. Every time I try to do what he wants, he
doesn’t seem to be satisfied. When I try to do things the way I
think they should be done, he doesn’t like that either. I just don’t
know what to do.
(discussing a family member): It bothers me and I really worry
about him. I want to help but I just can’t get through to him.
There was a time when I felt really depressed but now, thanks to
you, I don’t feel that way anymore.
Cultural
Awareness
• Awareness of the cultural and subcultural
context in which the client lives in
• Place clients’ experiences, feelings, and
concerns into proper perspective
• Local idioms of distress
Some Other Useful
Interviewing Skills
• Changing topic
– Use of bridging statements
• Maintaining control
• Sensitive issues
• Legitimizing feelings
Other Factors Affecting
Client’s Experience and
Expression of Emotions
+
-
•Safe, private environment
•Clinician’s conveyed fear of emotions
•Clinician’s lowered voice, slowed body
language
•Clinician asking questions about content
while client is in an affective state
• Clinician’s ability to tolerate emotions
•Clinician’s conveyed willingness to
allow emotional expression
•Clinician’s encouragement of client to
stay with emotional experience
•Clinician guiding pt towards
intellectualization and rationalization
•Clinician giving advice
•Clinician pointing out outward sign of
emotions
•Clinician showing discomfort
•Clinician’s ability to stay with the client
and show empathy
•Clinician providing sympathy instead than
showing empathy
Dealing with
Silence
• Silence exercise
• Silence-what can it mean?
–
–
–
–
–
–
–
Waiting for you to respond
Something hard to say: welling up the courage
Hesitation
Need a rest after saying something emotional
Organizing what you’ve said
Lack of rapport
Hostility, power struggle
• Don’t be afraid of silence- allow, reflect, and use it!
Observe non-verbal behaviors during silence
Nonverbal
Behavior
• Perceiving patient’s nonverbal behavior
– Aspects of nonverbal behavior:
• (1) Facial
– Eye gaze, smile, facial muscles
• (2) Vocal signals
– Pace, tone, change, smooth or disrupted
• (3) Movement signals
• (4) Attire and posture
– Inconsistencies between verbal and
nonverbal behavior
Some Final Tips
for Clinical
Interviews
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Assure the interviewee of confidentiality of the interview.
Convey a feeling of interest and warmth (rapport).
Try to put the interviewee at ease.
Try to get in touch with how the interviewee feels (empathy).
Be courteous, patient, and accepting.
Encourage the interviewee to express his or her thoughts and feelings freely.
Adjust the questions to the cultural and educational background of the
interviewee.
Avoid psychiatry or psychological jargon.
Avoid leading questions.
Share personal information and experiences with the interviewee (self-disclosure)
if appropriate and accurately timed.
Use humor sparingly, and only if appropriate and not insulting.
Listen without overreacting emotionally.
Attend not only to what is said, but also to how it is said.
Take notes or make a recording as inconspicuously as possible.
Interviewing
elderly patients
• What are the things to note?
Quality of an
Interview
• Reliability
– Inter-interviewer agreement
– Intra-interviewer across time
• Validity
– Is the interview helping us to answer our questions?
– Are the conclusions made from the interview correct?
– Biases:
• Selective attention, halo effect, and general standoutishness
• Mismatch between interviewer and interviewee
Observation
• A wealth of information can be obtained through observation
• Observation is a core assessment component in behavioral and
cognitive-behavioral assessment (see later section) although
behavioral interviews and self-report measures are also used in
behavioral and cognitive-behavioral assessment
• Observation
– Behavioral observation
• Clinical
• Naturalistic
– Self-monitoring
– Ecological Momentary Assessment (EMA)
Clinical
Observation
1. Observing relevant behaviors during a clinical session
– E.g. nonverbal behaviors, physical appearance,
interactional patterns of family members
– Usually conducted hand I hand with clinical
interviews
2. Creating situations that occur infrequently in nature
and observing behaviors under such situations
Naturalistic
Observation
• Natural setting
• Events occur naturally and not manipulated
by the observer
• Nonparticipant or participant observation
• Allows for longer periods of observations
compared to clinical observation and
observation with intervention
• Effect of observer on behaviors
Self-Monitoring
• Individuals to observe and record their own
behaviors / mood
– Target behavior / mood: frequency, intensity etc
– Antecedent factors
– Consequences
• Variations: self-monitoring of coping behaviours
used
• Self-monitoring can itself lead to changes in
behaviors
Ecological
Momentary
Assessment
• Ecological Momentary Assessment (EMA)
involves the collection of data in real time
• E.g. asking client to complete diaries at
specified times during the day (signaled by a
beep on a wristwatch), carrying a monitor
that records required information at
specified time
Problems with
Behavioral
Observations
• Reactivity
– Among observers / raters
– Among subjects
• Drift
• Expectancies
– Observer bias
• Deception
• Social desirability effect
• Demand characteristics
Self-Report
Measures
• A widely used assessment tool
• Paper-and-pencil / computer-administered self-report
inventories
• Reliability and validity important
• Advantages:
– Quick and efficient
– A large amount of data can be collected within a
short period of time
– Good for collecting sensitive information
• Disadvantages
– Breadth versus depth
Designing SelfReport
Inventories
•
•
Reliability and validity issues
Item formats to consider:
1. Dichotomous format
2. Polytomous format:
a. Likert format
b. Category format
c. Checklists
Item Formats
1.
2.
Dichotomous format: “True-False”, “Yes-No”, “AgreeDisagree”
Likert format: allows the respondents to choose a degree
of agreement for a question; 5-6 options are normally seen
–
5 options: (neutral point present)
e.g. Strongly disagree, somewhat disagree, neither agree nor
disagree, somewhat agree, strongly agree
–
6 options: (no neutral point)
e.g. Strongly disagree, moderately disagree, mildly disagree, mildly
agree, moderately agree, strongly agree
–
Facilitates analysis of results
Item Formats
3.
Category format: similar to the Likert format but with more options
–
E.g. “On a scale of 1-10 with 1 being not tolerable at all to 10 being
very tolerable, describe the pain you feel.”
–
Number of categories required depends on the required fineness of
discrimination
–
Visual analogue scale
No pain
at all
4.
Extreme
pain
Checklists: self-explanatory from its name, a list of items is given for the
respondent
–
E.g. “Check any of the following symptoms you have:
difficulty breathing, heart pounding, muscle tension…….”
Problems With
Self-Report
Measures
• Social Desirability: answering questions
according to what society deems appropriate
• Subjects may give careless responses if the
survey is long
• Validity of the self-report instrument needs to be
established before any conclusions are to be
made on the basis of test results
• Lack of contextual information
• Breadth versus depth
Using Self-Report
Measures in Survey
Research
1. Cross-Sectional Design
2. Longitudinal Design
3. Cross-Sequential Design
Cross-Sectional
Design
Time N
Sample
2
Sample
1
Sample
4
Sample
3
One or more samples taken from a population and surveyed at one point in time
Longitudinal
Design
Time N
Sample
1
Time N +1
Sample
1
Same sample surveyed more than once over time
Time N + 2
Sample
1
Cross-Sequential
Design
Time N
Time N +1
Sample
1
Sample
1
Sample
2
Sample
2
Combination of cross-sectional and longitudinal design:
Especially useful fro developmental research
Time N + 2
Sample
1
Sample
2
Behavioral and
Cognitive-Behavioral
Assessment
• Behaviors and thought processes that define
the disordered condition (problem) as the focus
of assessment
• Evaluation of the nature of the problem, and
factors that precede and follow (maintain) the
problem
• Purposes:
– To identify target behaviors and their maintaining
conditions
– Basis for intervention and clinical management
– Baseline for assessment of treatment progress &
efficacy
Behavioral and
Cognitive-Behavioral
Assessment
• Functional analysis: ABC model
– Antecedents, Behavior, Consequences
• A and C:
– Environmental and internal (thoughts/internal
dialogues, affect)
• B:
– Nature, frequency, intensity, pattern
– Behavioral deficits, excesses……
• Direct implication for treatment plan
Behavioral and
Cognitive-Behavioral
Assessment
Areas of assessment:
• Identifying target problem
– Operationalization
• Nature of the problem
– Behavioral excess
– Behavioral deficit
• ABC of the problem:
– Antecedents
– Problem behavior: Frequency, severity, duration, form…….
– Consequences
An Example
• E.g. A 7-year-old boy with eating problems. At the
age of 4, he had an illness in which he could not
eat solid food for 25 days because it made him
gag. Ever since he had recovered from the illness,
he was reluctant to eat all but a few select foods.
He refused to eat meat or vegetables, and ate
small amounts of food in general. This is affecting
his growth and his mother is very concerned. She
had taken him to a number of pediatrician but they
could not help.
An Example
ABC of his problem:
• Target problem: amount of eating (behavioral
deficit)  target of intervention (increasing
amount of eating
Antecedents:
Internal dialogue: “I don’t
want to eat; it will make
me sick”
Behavior:
Refusal to
eat
Consequences:
•Mother says: “That’s
OK, you don’t have to
eat”
•Feels relieved
An Example
• Behavior: amount & type of food
eaten……..
– Baseline, during and upon termination of
intervention
– Self (or informant)-monitoring
– Treatment goal
Number of Calories
Baseline
1800
1600
1400
1200
1000
800
600
400
200
0
Mon Tues Wed Thurs Fri
Sat Sun
Number of Calories
One month of
intervention
1800
1600
1400
1200
1000
800
600
400
200
0
Mon Tues Wed Thurs Fri
Sat Sun
Behavioral
Assessment of
Obesity
•
•
•
•
•
•
•
•
Amount of calorie intake
Type of food eaten
Distribution of total intake over the day
Speed of eating
Situations in which eating occurred
Consequences
Amount of exercise
Type of exercise
Methods of
Assessment
• Observation
– Clinical observation
– Behavioral coding
– Behavioral rating scales
• Patient’s self-monitoring
• Clinical behavioral interviews
• Self-Report Measures
– E.g. Dysfunctional Attitude Scale
• Psychophysiological recording
CognitiveBehavioral
Assessment
• Specific focus on the role of thoughts
• E.g.
situational antecedents (criticized by boss) 
thoughts (I can’t do anything right; I expect to do
everything perfectly, so criticisms upset me) 
emotional, behavioral and physiological responses
(depressed mood, withdrawal, tension headache
Additional Areas of
Assessment in CognitiveBehavioral Assessment
• Inter-relatedness of thoughts, moods,
behaviours, physical reactions, and
environment
Environment
Thoughts
Physical
Reactions
Moods
Behaviours
Greenberger & Padesky, 1995
Case
Conceptualization
• Mr. Chan is a 67 year-old retired investment consultant.
He has 2 children and 3 grandchildren. His eldest son,
daughter-in-law, and 2 grandchildren used to live next to
him. He cooked for them every day since his retirement.
In the past six months, a number of stressors occurred in
his life, including the death of his best friend and his son
and 2 grandchildren moving to new flat. He used to lead
an active life but has become very withdrawn in the past
six months. He complains of difficulty sleeping and
tiredness. His wife finds that he is becoming more and
more irritable. He used to spend a lot of time playing
mahjong and going hiking with his friends especially after
retirement but has been avoiding his friends and shows
no interest in any activity in the past few months.
The Five Aspects
of Mr. A’s
Problem
• Environment / Life Situation: death of friends, son and
grandchildren moving away
• Thoughts: “My life is drawing to an end”, “My children and
grandchildren do not need me any more”, “My friends are all
getting old and will die soon”
• Mood: depressed mood, irritability
• Behaviour: avoidance of friends, lack of interest in activity
• Physical reaction: sleep problem, tiredness
Useful Questions In
Conducting a CBT
Assessment
• Can you take me through a recent example in great detail?
• What makes it better / worse?
• Are there particular situations / times of day / people present
/activities you are engaged in when this problem occurs?
• What happened right before you feel / think / do this?
• What happened after you feel / think / do this?
• What do you do then?
• How do other people react?
• What went through your mind before / when it occurred?
Example:
Assessment in
Panic Disorder
• Medical evaluation
– To rule out medical conditions for the observed problem
(e.g. thyroid conditions, caffeine intoxication, hypoglycemia,
temporal lobe epilepsy)
• Cognitive-Behavioral Assessment
– Interview: Focus on a specific example and ask the pt to take
you through that incident in a detailed manner
– Self-monitoring
• Panic Attack Record (Barlow, 2000)
• Self-monitoring form
Areas to focus on
• Antecedents / Activating events
– Internal: bodily sensations, affect (e.g. anger)
– Situational: in a crowd, alone at night….
• Beliefs
– Cognitive appraisals
• Consequences
– Affect, safety behaviors, others’ behaviors, social and
occupational impairment
Panic Attack Record
Date: ______16/2/2004________
Time: ___5:20pm_______

Alone
 With others
(With whom?________________ )

Stressful situation
 Non-stressful situation

Expected
 Unexpected
Triggers:
Duration: _____5________(mins)
Home alone and shortness of breath _________________________________________________
______________________________________________________________________________
Maximum anxiety (circle)
0
1
None
2
3
Mild
4
Moderate
5
6
Strong
7
8
Extreme
Symptoms (Check all symptoms present to at least a mild degree)

Difficulty Breathing
 Racing/Pounding Heart
Choking
Nausea/Abdominal Distress
Unsteadiness/Dizziness/ Faintness
Chest Pain/Discomfort
Fear of Dying
Hot/Cold Flashes
 Numbness/Tingling
 Sweating
 Feelings of Unreality
 Breathless
Thoughts:
 Fear of Losing Control
Fear of Going Crazy
 Trembling/Shaking
I’ll have a heart attack; there’s no one to take me to the hospital; I’ll die._____________________
Self-Monitoring
Mood
(& intensity
rating :
0 to 100)
Situation
Symptoms /
Sensations
Automatic
Thoughts
(thoughts &
images)
Consequences
Fear (95%)
Oct 20
8 pm
•Heart pounding
•I don’t feel well
•My heart is
beating faster and
faster
•I can’t breath
•I’m having a heart
attack
•I can’t get to the
hospital on time
•I’ll die
•Leave the
restaurant
immediately
•Extremely anxious
•Chest pain
Having dinner with
husband in a
crowded restaurant
•Difficulty breathing
•Dizziness
Assessment Profile for Panic Disorder with
Agoraphobia
•
•
•
•
•
•
•
Panic topography
– Sensations: unreality, dizziness, palpitations
– Frequency: 3 per week on average
– Duration: 5 minutes on average
– Apprehension: on her mind 75% of the time
Antecedents
– Situational: driving on freeways, crowds of people, being alone…specially at night, restaurants, dusk
– Internal physical: hearth fluctuations, lightheaded feelings, hunger feelings, weakness due to lack of food
– Internal cognitive: thoughts of the “big one” happening, thoughts of not being able to cope with this for much longer
– Internal emotional: sometimes anger
– Activities: reading and concentrating for long periods of time, aerobic activity
– Stimulations: caffeine
– Stressful life events: arguments with mother about sister
Misappraisals
– Physical: impending heart attack
– Mental: never returning to normality, going crazy
– Social: others will see I’m anxious and think I’m weird
Behavioral reactions to panic attacks
– Escape: pull off to side of road, leave restaurants and other crowded places
– Help seeking: have called spouse on occasion but rarely now
– Protection: cool air, carries valium although rarely uses
Behavioral reactions to anticipation of panic attacks
– Situational avoidance: avoids driving long distances alone, unfamiliar roads and freeways, crowded areas
– Activity avoidance: avoids exercise and doing any one thing for a long period of time
– Cognitive avoidance: tries not to think about anxiety
– Safety signals: carries medication, always knows location of husband
Long-term Consequences
– Family: husband is concerned and supportive; mother thinks she should pull herself together because its all in her head
– Work: still woks but has cut back number of hours
– Leisure: travels much less
– Social: socializes much less
General anxiety
– Some difficulty concentrating, sleep restlessness, headaches, muscular pains and aches
Case Study
• In-depth assessment of an individual and
his/her problem
• Information collected through interviews,
observations, psychological tests and
documented records
• Converging evidence from multiple sources
• Pros and cons
• More of this in Lecture 4
Biases in
Assessment
• Errors arising from the assessment tool or the
assessment process such that conclusions do
not reflect the true state of affairs
• Nature and extent of bias depends on the form
of assessment used, quality pf the specific
assessment tool, quality of the assessor(s), and
characteristics of the respondents
Type of Bias
Description
Example
Content Bias
Test questions understood only Medical jargons
by some subjects (due to
difficult vocabulary)
Selection Bias
Test does not represent the
general population but rather
specific groups
Norms of a scholastic
aptitude test based on
middle class children
Cultural Bias
Tests impartial to one cultural
group and not to another
Certain questions on test of
mental status or IQ may be
biased against nonCaucasians
Type of Bias
Description
Example
Observer Bias
Expectancy effect:
Expectancies from the
assessor affecting the
result of observation
- single/double-blind
designs can minimize this
Researcher “observing”
an intervention effect
because he believes that
the intervention should
work, Rosenhan’s study
Subject Bias
Expectancy from the
subject alters the test
results
•Demand
characteristics
•Social desirability
effect
Subject distorts truth
about thoughts on
abortion so that she is
seen more favorably
Measurement Bias
Errors in test
measurements contribute
to inaccurate results
An incorrect blood test
diagnoses a patient with
HIV