CLINICAL QUESTION: Using assessments in clinical work.

[Psyche007]

Has anyone been directed to use specific assessments during their clinical work, in practica, internship, or otherwise?

I'm not concerned with concentrations like neuropsychology or forensics, but general clinical work. I was discussing the clinical competency exam with my supervisor asked her if assessments were required. She said that many students use them because they're simple and easy, but you don't have to, as long as you can justify their exclusion.

I'm just curious. Anyone have any thoughts?

[justacigar]

My master's program emphasized using assessments as a way to track progress over time for clients, and I personally think they are useful not just for the therapist for the client as well. I'm a study therapist in a research study right now, so not pure clinical, but we use assessments throughout their time in treatment and beyond to see if the treatment was effective for certain symptoms. 

I think if you are addressing a very specific problem that is associated with very specific symptoms, using assessments is an evidence-based way to track progress. I personally can't imagine engaging in therapy without tracking something, though that was my specific training/experience as a graduate student. 

I think another important note is that while standardized assessments are preferred, if there isn't a specific assessment that tracks what you need it's simple to create a brief assessment of your own. 

Not sure if that is helpful or addressing your question! 

[PsycUndergrad]

The sites I’ve trained at generally used measures like the BDI and BAI for tracking progress throughout therapy for most clients. It’s useful for us as therapists, and a lot of my clients have found it very helpful because they can see the reduction in symptoms in a way that is much more concrete. I remember one of my clients being very excited when she realized she was responding “0” to symptoms for the first time and it was a big moment for her. 

[PsyDuck90]

Yes, I agree with the other 2 posters. Assessments are a good way to measure progress, as long as you are using validated measures. When I did a practicum at a college counseling center, we used the CCAPS (Counseling Center Assessment of Psychological Symptoms) bi-weekly to track changes/progress, and at my current site we use the PHQ-9 and a mini mental status exam because of the population I work with. Insurance companies, from what I've been told, also like seeing assessments, even self-report ones like the PHQ-9 or BDI, because they are tangible scores so that measurable change can be seen. If you are doing evidence-based treatment, you should be using some sort of validated measure to assess symptom changes over time. Also, there is plenty of research that shows that using semi-structured interviews like the SCID or the DIAMOND is more reliable/valid than pure clinical judgement in providing diagnoses. 

[bubble_psych]

Cognitive assessments like the WAIS and general mood and personality measures can be used in general clinical work. The thing that is not so kosher is using neuropsych assessments (and I'm guessing also forensic assessments too?) when you do not have the training (or your supervisor does not have the training) to understand and interpret the measures. As I understand it, this would be a violation of the ethical standard regarding competence.

Edited September 17, 2020 by dr. bubbles

[Psyche007]

22 hours ago, justacigar said:

My master's program emphasized using assessments as a way to track progress over time for clients, and I personally think they are useful not just for the therapist for the client as well. I'm a study therapist in a research study right now, so not pure clinical, but we use assessments throughout their time in treatment and beyond to see if the treatment was effective for certain symptoms. 

I think if you are addressing a very specific problem that is associated with very specific symptoms, using assessments is an evidence-based way to track progress. I personally can't imagine engaging in therapy without tracking something, though that was my specific training/experience as a graduate student. 

I think another important note is that while standardized assessments are preferred, if there isn't a specific assessment that tracks what you need it's simple to create a brief assessment of your own. 

Not sure if that is helpful or addressing your question! 

My question is just directed at your thoughts, and you provided your thoughts, so you were helpful. ?

[Psyche007]

23 hours ago, PsycUndergrad said:

The sites I’ve trained at generally used measures like the BDI and BAI for tracking progress throughout therapy for most clients. It’s useful for us as therapists, and a lot of my clients have found it very helpful because they can see the reduction in symptoms in a way that is much more concrete. I remember one of my clients being very excited when she realized she was responding “0” to symptoms for the first time and it was a big moment for her. 

I can appreciate the use of assessments to help patients track their progress.

Did the assessment results influence your choice of intervention or conceptualization?

[Psyche007]

23 hours ago, PsyDuck90 said:

Yes, I agree with the other 2 posters. Assessments are a good way to measure progress, as long as you are using validated measures. When I did a practicum at a college counseling center, we used the CCAPS (Counseling Center Assessment of Psychological Symptoms) bi-weekly to track changes/progress, and at my current site we use the PHQ-9 and a mini mental status exam because of the population I work with. Insurance companies, from what I've been told, also like seeing assessments, even self-report ones like the PHQ-9 or BDI, because they are tangible scores so that measurable change can be seen. If you are doing evidence-based treatment, you should be using some sort of validated measure to assess symptom changes over time. Also, there is plenty of research that shows that using semi-structured interviews like the SCID or the DIAMOND is more reliable/valid than pure clinical judgement in providing diagnoses. 

What do you think of science-based treatment as opposed to evidence-based treatment?

How does a reliable and valid diagnosis influence your intervention?

How do you interpret subclinical symptoms?

[PsyDuck90]

4 hours ago, Psyche007 said:

What do you think of science-based treatment as opposed to evidence-based treatment?

How does a reliable and valid diagnosis influence your intervention?

How do you interpret subclinical symptoms?

I'm not quite sure how you differentiate science-based from evidence-based. The evidence is science-based. 

From what I have been taught, your intervention should be derived from the effective and efficacious treatments for that diagnosis. Typically, since most clients will have more than 1 concern, I will conceptualize all the concerns that the person is presenting with and figure out what the underlying problems are and, in part with a collaborative discussion with the client, will come up with a treatment plan that specifically targets what is believed to be the most pressing/underlying concerns. As far as subclinical symptoms, those would factor into the case conceptualization as well, but most often (in my experience) those will extinguish once you have addressed the primary problems. If not, then they are addressed after the larger concerns have been addressed if the client is interested/insurance/time allows. 

[Psyche007]

Not all evidence is created equally.

 

 

We have some serious issues with how psychopathology is constructed. It's why the NIMH moved away from the DSM for guiding research:

"It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”² The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."

https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

 

It sounds like your programme is prescriptive in nature. Do you forgo theoretical orientation in favour of an integrative approach based purely on the most effective intervention for a specific diagnosis?

Edited September 19, 2020 by Psyche007

[PsyDuck90]

There are definitely many flaws with the current DSM system and clustering people into symptom categories. And yes, being able to assess MH on a more biological level, as we do for medical diseases will be wonderful. But we aren't there yet, so we need to make the best of what we have at our disposal. So yes, not all evidence is created equal (which is why having a strong understanding of research methodology and statistics is important to be able to assess published studies), but there is still some pretty solid evidence for using certain protocols to treat certain issues, such as the evidence base for PE or CPT for PTSD, for instance. Right now I primarily work with individuals coping with post-stroke anxiety/depression, and so it is often very clear what the biological basis is for their current affective difficulties. However, aside from adaptations made to accommodate any other cognitive impacts of the acquired brain injury, the treatments that are effective for anxiety and depression in this population (with a clear organic cause) are by and large the same treatments that are effective in treating affective disorders in non-medically complicated patients. 

My program markets itself as an evidence-based program. Courses focus on teaching a wide range of theoretical orientations (CBT, DBT, Psychodynamic, etc), which is complimented by an assortment of practicum sites that offer varied, and often integrative, approaches. I personally am a big fan of the bio-psycho-social model, and looking at client concerns from that conceptual lens. 

I think it's also important to separate out the research ideals and what is currently available. Your article even says this, when the author writes, "RDoC, for now, is a research framework, not a clinical tool." While I anxiously await a time period where our diagnostic system is more in line with the rest of medicine, the IDC/DSM is what we got, and in the world of managed care, insurance companies want to see an F-code in order to pay out (which is another discussion for another day lol). 

Even when you look at the science behind psychotropic medication, most psychiatrists can't tell you why it works. They just know it does. We know serotonin is involved with depression, and SSRIs help. Researchers figured out (usually by accident) that certain drugs work for certain disorders and then hope they can work backward to figure out why. Research hasn't been able to definitively prove the serotonin deficiency theory, but we run with it because we know it works (for a lot of people). From a pure science perspective, mental health care has a looooooong way to go before it is anywhere near close to the scientific basis for standard medical care, so we use what we have at our disposal now. And then even further away from it being functional in a clinical setting. 

[Psyche007]

56 minutes ago, PsyDuck90 said:

There are definitely many flaws with the current DSM ... the author writes, "RDoC, for now, is a research framework, not a clinical tool." ... even further away from it being functional in a clinical setting. 

Yes - the RDoC was welcome news because it has the potential to usher in some long-overdue basic research. But at least in my programme, it's not being taught to clinical psychologists, so their research continues to be built around DSM diagnostic categories with questionable validity, instead of improving the fundamental understanding necessary for biologically-based psychopathological constructs and interventions. This is why the RDoC is a research framework - they can't displace the DSM as a diagnostic tool without risking serious pushback. Removing its credibility as a research tool is the first step. 

I think any APA-accredited programme is supposed to be evidenced-based, no? My programme is accredited and they talk about evidenced-based this and that all the time. For example, EMDR is evidenced-based. All that means it that someone studied it and interpreted the results to indicate efficacy. Beyond that, adherents becomes cult-like in their devotion to the protocol. There is no proposed mechanism of action and it is not grounded in science. Read the research. The methodology is laughable.

In your patient population, is the stroke itself the pathological etiology (i.e., the actual change in structure and function directly causing depression and anxiety) or is anxiety and depression a response to loss of function and subsequent adaption (making the stroke a catalyst but not the true cause)?

I've looked at plenty of research regarding psychiatric medication. There isn't a single psychiatrist alive who can tell you the role that serotonin plays in depressed mood, and by that, I mean the underlying mechanism of mood. The 'chemical imbalance' hypothesis has become an urban legend, widely accepted, poorly supported. SSRIs do help some people, some times. We don't have a clear understanding into the neurology of affective response. The best understood emotional experience at the neural level is fear and that hasn't yet translated from affective neuroscience into falsifiable theory that has real clinical utility.  

I originally considered neuroscience because I wanted to help answer some of the fundamental questions of the discipline. What is consciousness? Do we have free will? How do we perceive pain? What is intelligence? However, I have a real interest in and talent for clinical work. I felt that clinical psych could do with some people trying to push for reform from within. The gap between clinical psychology and other disciplines, such as cognitive, is bad enough as it is.

I doubt I'll be successful, but I'll have a frustratingly fun time trying.

Edited September 19, 2020 by Psyche007

[PsyDuck90]

11 minutes ago, Psyche007 said:

I think any APA-accredited programme is supposed to be evidenced-based, no? My programme is accredited and they talk about evidenced-based this and that all the time. For example, EMDR is evidenced-based. All that means it that someone studied it and interpreted the results to indicate efficacy. Beyond that, adherents becomes cult-like in their devotion to the protocol. There is no proposed mechanism of action and it is not grounded in science. Read the research. The methodology is laughable.

Yeah, that is why I said earlier that it is important to have a strong understanding of research methodology and stats and such so you can make sense of the research and critically evaluate it. With EMDR, the reason it's effective, when you look at dismantling studies, is the exposure component (so seem reason why PE is so effective). The eye movement stuff is really just smoke and mirrors. It works, but the mechanism of change is not what the creators purport it to be. 

14 minutes ago, Psyche007 said:

In your patient population, is the stroke itself the pathological etiology (i.e., the actual change in structure and function directly causing depression and anxiety) or is anxiety and depression a response to loss of function and subsequent adaption (making the stroke a catalyst but not the true cause)?

From what I've read thus far, it can be one or the other or both. Often times, the level of awareness they have of their condition is a clear indication of whether it is due to the physiological changes resulting from stroke or the response to loss of functioning. If they are unaware of their cognitive deficits or that they have had a stroke (or really any brain injury) but are presenting with new symptoms of anxiety or depression, the likely culprit is the stroke itself. You can also sometimes discern based on imaging of where the stroke was located in the brain (for instance, cerebellar stroke probably not bio-based, but if there is a lesion in the amygdala or hippocampus...more likely). Post-stroke anxiety/depression is also very common, even in people who have no history of mental illness, again suggesting a potential biological change. Epidemiological studies suggest that around a third of stroke survivors experience post-stroke depression. From what I've learned thus far in my several years of training, the answer to pretty much every question in psych is "it depends." When it comes to the brain, we still know so little. 

 

31 minutes ago, Psyche007 said:

I originally considered neuroscience because I wanted to help answer some of the fundamental questions of the discipline. What is consciousness? Do we have free will? How do we perceive pain? What is intelligence? However, I have a real interest in and talent for clinical work. I felt that clinical psych could do with some people trying to push for reform from within. The gap between clinical psychology and other disciplines, such as cognitive, is bad enough as it is.

Yeah, I love neurobiology and neuroscience as well, but have a passion for clinical mental health work. The brain is so incredibly complex and simultaneously delicate and resilient (by means of neuroplasticity). We're still not at a point in science of understanding exactly how the brain influences our perceived environment and how the environment impacts our brain function. We know a bit, but only like....a micron worth of information lol. That's why I like the bio-psycho-social model because I think all those aspects impact behavior and affect in some way, and certain combinations of things can create a perfect storm that leads to maladaptive functioning. 

[MarineBluePsy]

I'm currently in my doc program and yes I have been instructed to use specific assessments with therapy clients to track progress (these are usually depression, anxiety, or how would you rate the session type measures).  As I learned more I was able to add my own to the standard battery the department requires as long as I could justify its use.  I personally prefer to have my clinical impression, the client's self-report, and the assessment to get a sense of what is going on because I have learned that some clients are more forthcoming in one of those rather than equally forthcoming in all of them.  Also since I need to accrue hours for internship combining assessments with treatment generates hours in both categories.  Assessment data can also be easily used in research and students in my department have frequently done that.

[PsyZei]

On 9/17/2020 at 10:40 AM, Psyche007 said:

Has anyone been directed to use specific assessments during their clinical work, in practica, internship, or otherwise?

I'm not concerned with concentrations like neuropsychology or forensics, but general clinical work. I was discussing the clinical competency exam with my supervisor asked her if assessments were required. She said that many students use them because they're simple and easy, but you don't have to, as long as you can justify their exclusion.

I'm just curious. Anyone have any thoughts?

This (your supervisor's answer) has been my experience as well as I have not been directed to use anything (although one program I considered did use them as a normal required tool by all clinicians). I have some that I habitually use with psychotherapy clients- but they are pretty specific to my specific focus around trauma and systems.