Assessment
“It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories instead of theories to suit facts.” - Arthur Conan Doyle
But because theories are required before we can differentiate data from noise, data are not data unless we have theories.
Determine Purpose
Determine Focus
Gather Data
Generate Hypotheses
Test Hypotheses (Gather Data)
Assess Reliability of Data
Determine Data Clusters
Generate Diagnoses
Test Diagnoses Against Criteria
Resolve Diagnostic Uncertainty
Generate Formulation
Begin Service Planning
Assessment Domains
(This is just an example. Relevant domains are determined by purpose and focus.)
I. Identifying Information
II. Presenting Problem
III. Psychiatric Symptoms/Behavior
IV. Psychiatric History
V. Medical History
VI. Developmental/Family History
VII. Educational History
VIII. Social/Relationship History
IX. Work/Military History
X. Legal History
XI. Client Strengths/Activities/Interests
XII. Other Relevant Data
XIII. Mental Status Exam
XIV. Diagnostic Impressions
Turner’s Diagnostic Checklist
A.
1.
Overall mental status
2.
Intelligence
3.
Safety a.
In relations to the therapist b.
In relation to others c.
In relation to self
4.
Basic Value Set
5.
Basic personality characteristics
6.
Communication skills
7.
Credibility
B.
8.
Overall physical condition and status
9.
Medication
10.
Significant role set a.
Roles b.
Adequacy of role performance c.
Comfort in role set
11.
Cultural, gender, racial, ethnic, and religious factors a.
Identity b.
Significance
12.
Significant others a.
Strength b.
Quality c.
Availability
13.
Significant social systems
14.
Significant impinging history
15.
Substance use or abuse
16.
Interpersonal network a.
Strength b.
Quality c.
Availability
17.
Major strengths in a.
Persons b.
Significant Environments c.
Resources
18.
Major problem areas, if any in a.
Persons b.
Significant Environments c.
Resources
C.
19.
Perceived needs
20.
Clients wishes and expectations
21.
Perceived nature of service to be offered
22.
Required availability of help
23.
Present level of motivation
24.
Prognosis
25.
Overall level of certainty
Assessment Errors
Problems conceptualizing the assessment
Unclear purpose
Unclear focus
Problems gathering data
Incomplete data
Inaccurate data
Irrelevant data
Fact – inference confusion
Problems using data
Excess data gathering
Ignoring patterns
Finding nonexistent patterns
Human problems
Poor rapport
Inconsistent expectations
Over identification
Assessment – intervention confusion
Environmental problems
Lack of physical safety
Lack of psychological safety
Distractions