Behavioral Assessment and Case Formulation

Stephen N. Haynes, William O'Brien, Joseph Kaholokula

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9781118018644
• eBook ISBN: 9781118099773
• Edition: 1
• Topic: Psychology
• Subtopic: Research & Methodology in Psychology
• Index: Psychology

Comprehensive, scientifically based coverage on conducting behavioral assessments, analyzing results, and forming clinical recommendations

Behavioral Assessment and Case Formulation thoroughly outlines the underlying principles of the behavioral assessment process. This book clearly explains how the principles and methods of behavioral assessment central to the formulation of functional analysis are also helpful in guiding strategies for determining interventions and measuring the processes and outcomes.

This comprehensive resource offers up-to-date answers to relevant questions of the clinical assessment process, including:

• What is the best assessment strategy to use with a particular client?
  
  

• Which assessment methods will best capture a client's unique strengths, limitations, behavior problems, and intervention goals?
  
  

• How can data from multiple sources be integrated in order to yield a valid and clinically useful case formulation?
  
  

• Which procedures should be enacted in order to insure a positive clinician-client relationship?
  
  

• How should intervention processes and outcomes be measured and monitored?
  
  

Filled with case studies, Behavioral Assessment and Case Formulation provides guidelines for the application of behavioral assessment strategies and methods that can strengthen the validity and utility of clinical judgments, as well as improve the delivery of care.

Chapter 1

Introduction to Behavioral Assessment and Case Formulation

Clinicians and clinical researchers face many measurement and clinical judgment challenges that emphasize explanation and prediction. Will a client harm himself or others? Can a parent provide a loving and safe living environment for a child? To what degree is a client’s daily functioning affected by a traumatic brain injury? What learning environment would be most helpful for an elementary school child with developmental delays? Clinicians must also make judgments focused on determining what intervention strategies can, and should, be used for a particular client. Here, the central question is: What intervention will be most effective for a client’s behavior problem and have the greatest impact on his or her quality of life? This latter intervention-focused judgment requires an integration of many lower-level judgments. What are the client’s specific behavior problems and intervention goals? What variables affect his or her problems and goals? What variables might affect intervention outcome? How can intervention process and outcome be best measured? The aforementioned judgments are all elements of the clinical case formulation. The clinical case formulation, and the concepts and methods of behavioral assessment upon which it is based, is a major focus of this book.

In the following sections of this chapter, we first consider broader issues of psychological assessment and measurement. We then discuss the behavioral assessment paradigm, particularly as applied in case formulation and in other applications of psychological assessment. Throughout, we emphasize the importance of a thoughtful, scholarly, science-based approach to clinical assessment.

CLINICAL ASSESSMENT AND PSYCHOLOGICAL ASSESSMENT PARADIGMS

A psychological assessment paradigm is a set of assessment-related principles, beliefs, values, hypotheses, and methods advocated in a discipline or by its adherents. A psychological assessment paradigm includes beliefs and hypotheses about: (a) the relative importance of specific behavior problems (e.g., the relative importance of insight versus behavior change as a focus of assessment for a person who reports experiencing significant levels of depression), (b) the relative importance of a particular response mode subsumed within a behavior problem (e.g., emphases on the relative importance of behavioral, cognitive, or emotional aspects of depression), (c) the most important causal variables associated with a behavior problem (e.g., emphases on the relative importance of early learning experiences, genetic factors, relationship factors, or contemporaneous cognitive variables as causes of domestic violence), (d) the mechanisms of causal action that are presumed to underlie behavior problems (e.g., learning processes, neurotransmitter systems and functions, intrapsychic processes and conflicts), (e) the importance of assessment in the intervention process (e.g., a diagnostic approach versus a functional approach to intervention design), (f) the best strategies for interacting with clients during the assessment-intervention process (e.g., degree of structured versus unstructured interviewing), and (g) the best assessment strategies and methods for obtaining information (e.g., the extent to which interviewing, self-report inventories, observation, rating scales, projective tests, etc., relevant to particular paradigms are used).

Because psychological assessment paradigms vary in the beliefs and hypotheses outlined above, their assessment goals can also differ. For example, the goals of assessment could include diagnosis, the identification of neuropsychological deficits, or the identification of personality traits. The goals of behavioral assessment are unique in that they emphasize the specification and measurement of a client’s target behaviors1 in relation to ongoing intraindividual (e.g., internal processes such as cognitive experiences or physiological responses), interindividual (e.g., social relationships), and nonsocial environmental (e.g., temperature, noise levels, etc.) events that can have causal and noncausal relations with them.

There are many psychological assessment paradigms and some assessment methods are congruent with multiple paradigms. The Handbook of Psychological Assessment by Goldstein and Hersen (1999) includes chapters on intellectual assessment, achievement testing, neuropsychological assessment, projective assessment, personality assessment, computer-assisted assessment, and behavioral assessment. Books by Butcher (2009), Corsini and Wedding (2010), Hunsley and Mash (2008), and a four-volume series on psychological assessment edited by Hersen (2004) present various psychological assessment paradigms applied to a variety of behavior problems and assessment goals. A comparative review of these paradigms is beyond the scope of this book, but interested readers are referred to these sources.

EVALUATING PSYCHOLOGICAL ASSESSMENT PARADIGMS

It can be difficult to evaluate the relative strengths and weaknesses of psychological assessment paradigms because they differ in the principles, strategies, and criteria used to guide the evaluation. For example, a demonstration that behavioral assessment methods are superior to projective methods in measuring the situational specificity of a client’s social anxiety may not be persuasive to adherents of a psychodynamic paradigm who presuppose that dispositional factors, rather than situational factors, are the central determinants of this disorder. Additionally, adherents of a psychodynamic paradigm may not value the more molecular level information (as opposed to more generalized traits) that results from behavioral assessment and may fault behavioral assessment for its failure to sufficiently emphasize critical early learning experiences in parent-child interactions. However, all assessment paradigms can be evaluated in terms of clinical utility and validity—the degree to which they facilitate specific goals of assessment. For example, assessment methods from different paradigms (more specifically, the measures derived from an assessment method and associated instruments) can be evaluated on the basis of predictive validity—the degree to which they are correlated with the future occurrence of relevant behaviors such as tantrums, suicide, panic attacks, manic episodes, or child abuse. Similarly, different assessment methods can be evaluated on the degree to which they help identify important causal variables for behavior problems and/or evaluate the immediate and ultimate effects of intervention. One difficulty with such psychometric evaluations of assessment data, which we discuss in later chapters, is that the utility and validity of a measure can vary according to the goals of assessment (e.g., diagnosis versus risk assessment versus case formulation) and client characteristics.

Selecting an assessment strategy based on the goals of assessment is a key element of the functional approach to psychological assessment. That is, the utility and validity of a particular assessment strategy is always conditional. Consequently, an assessment method or instrument can be valid and useful in some assessment contexts and not in others. Additionally, it is important to note that utility and validity evidence applies to the measure derived from an assessment process, rather than to the instrument itself. For example, some instruments provide multiple measures that can differ in their utility and validity.

ADOPTING A SCHOLARLY AND SCIENCE-BASED APPROACH TO CLINICAL ASSESSMENT

Because there are important relationships between assessment paradigms and assessment strategies, a clinician should carefully consider the conceptual implications of any assessment strategy that he or she uses. If, for example, a clinician chooses to use projective assessment instruments, he or she is embracing a paradigm that emphasizes the primacy of unconscious processes in the expression of behavior problems and the need to use highly inferential measures that are interpreted as markers (e.g., responses to ink blots) of these processes. A projective assessment strategy also deemphasizes the importance of the conditional nature of behavior problems and undervalues the identification of specific, minimally inferential, and modifiable behavioral and environmental variables in clinical assessment.

Under some circumstances it can be useful to blend assessment strategies from different assessment paradigms. In 1993, the journal Behavior Modification (vol. l7, no. 1) published a series of articles that examined the integration of behavioral and personality assessment strategies. It is clear, for example, that clients often differ in the likelihood that they will exhibit problem behaviors (e.g., social avoidance) that are associated with certain traits (e.g., neuroticism) across settings. Further, there are data indicating that self-report personality inventories can help the clinician identify such behaviors and their corresponding traits. In a further discussion of integration across paradigms, Nelson-Gray and Paulson (2004) discussed how behavioral assessment and psychiatric diagnosis can be used collaboratively. Although diagnosis is based on a syndromal taxonomy (i.e., matching behavioral symptoms and signs to criteria designated in a diagnostic category) and does not address many important aspects of client functioning, the authors argued that psychiatric diagnoses provide a means for systematically organizing and communicating the outcomes of assessment data.

The selection of assessment strategies from conceptually divergent paradigms is sometimes described as an eclectic approach to assessment. However, the use of conceptually incompatible assessment strategies often reflects the clinician’s lack of familiarity with the conceptual foundations and underlying assumptions of the assessment paradigm. For all assessment strategies, the assessor should consider “What assumptions about behavior problems and their causes am I making by using this assessment strategy?”

BEHAVIORAL ASSESSMENT, CLINICAL CASE FORMULATION, AND MEASUREMENT

One of the principle challenges faced by clinicians early in the assessment and case formulation process is that many clients have multiple interacting behavior problems. Complicating matters further is the very real probability that each behavior problem is influenced by multiple interacting causal factors. Clinical case formulations, and the assessment strategies upon which they are based, are designed to help clinicians integrate data on these multiple interacting variables. Additionally, clinical case formulations can be used to help the clinician design and evaluate interventions.

As the title of our book indicates, we describe one of several psychological assessment paradigms—the behavioral assessment paradigm—and emphasize its application in clinical case formulation. We also discuss behavioral assessment strategies applied to the monitoring of intervention processes and outcomes that are often based on the clinical case formulation. Because they emphasize the importance of precise multimethod assessment, behavioral assessment principles and strategies are also applicable to psychopathology, the study of the characteristics and causes of behavior problems. Before we discuss the behavioral assessment paradigm, we review the challenges faced by clinicians in making the intervention decisions for their clients.2 We review the context in which clinical cases are formulated and consider several models of clinical case formulation in cognitive-behavior therapy (CBT). We also introduce the functional analysis as a useful clinical case formulation model for describing and explaining clients’ behavior problems and intervention goals and for guiding intervention decisions. In Chapter 2, we introduce Functional Analytic Clinical Case Diagrams (FACCDs) as a strategy for visually organizing and communicating the functional analysis. Subsequent chapters discuss the conceptual foundations of behavioral assessment and case formulation and strategies of behavioral assessment.

THE CONTEXT OF CLINICAL CASE FORMULATION: THE CHALLENGE OF MAKING INTERVENTION DECISIONS

As indicated earlier, one of the most challenging tasks faced by clinicians is to design the best intervention plan for a client. Several factors make intervention planning for persons with behavior problems challenging. In the following section we review these factors.

The first challenge faced by a clinician is that most clients present to a clinician with multiple target behaviors and intervention goals. For example, in Krueger, Kristian, and Markon’s (2006) review of comorbidity research, they noted that it is not uncommon for clients to present with three or more behavior disorders. Consider the not-unusual example of a client who comes to a mental health center with a major depressive disorder, excessive alcohol use, and marital discord. Where should the clinician focus his or her interventions? This target behavior selection decision partially depends on the clinician’s judgment of the relative importance of each behavior problem. Relative importance, in turn, may be based on the degree of distress associated with each behavior problem or the extent to which each behavior problem affects quality of life. However, this target behavior selection decision can also be based on the interactions among these multiple behavior problems. For example, it may be that the client’s depressed mood leads to overuse of alcohol and marital discord. Alternatively, it may be the case that marital discord leads to alcohol use and depressed mood. Notice how the intervention foci and strategies are likely to be different, depending on judgments about relative importance and causal interrelations (i.e., their functional relations). These are difficult judgments to make but are essential elements of a clinical case formulation. Importantly, the validity of these judgments depends on the validity of data obtained in clinical assessment. Inadequate assessment strategies or invalid clinical assessment data will diminish the validity of the case formulation and the consequent benefits of an intervention.

A second challenge to the clinical judgment process is that a client’s multiple behavior problems can be influenced by many causal variables. Additionally, a single causal variable can influence a behavior problem through many causal pathways. For example, panic disorder has been associated with a diverse set of causal factors, including genetic influences, family modeling, traumatic life events, social reinforcement, classical conditioning, operant conditioning, threat processing, intrusive thoughts, physiological hyperreactivity, serotonin dysregulation, and medical conditions (Beidel & Stipelman, 2007). As we discuss in Chapter 6, identifying causal variables and the causal relations relevant to a client’s target behaviors and intervention goals is an important aspect of behavioral case formulations. This is because behavioral interventions often attempt to modify the variables and pathways hypothesized to influence a client’s behavior problems. Thus, behavioral case formulations, particularly the functional analysis model of case formulation, emphasize the identification of important and modifiable causal variables.

From our discussion thus far, it should be apparent that case formulation and the strategies for measuring treatment process and outcome are closely related. For example, if a clinician designs an intervention aimed at decreasing the frequency or...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Preface
• Chapter 1: Introduction to Behavioral Assessment and Case Formulation
• Chapter 2: Introduction to the Functional Analysis as a Paradigm for Behavioral Case Formulation
• Chapter 3: Illustrating the Functional Analysis With Functional Analytic Clinical Case Diagrams
• Chapter 4: Conceptual and Empirical Foundations of Behavioral Assessment and the Functional Analysis I
• Chapter 5: Conceptual and Empirical Foundations of Behavioral Assessment and the Functional Analysis II
• Chapter 6: Conceptual and Empirical Foundations of Behavioral Assessment and the Functional Analysis III
• Chapter 7: Principles of Behavioral Assessment
• Chapter 8: Self-Report Methods in Behavioral Assessment
• Chapter 9: Direct Methods in Behavioral Assessment
• Chapter 10: Identifying Causal Relations in Behavioral Assessment
• Chapter 11: Twenty-Two Steps in Preintervention Behavioral Assessment and the Development of a Functional Analysis
• References
• Author Index
• Subject Index