HANDBOOK Psychological Assessment, Case Conceptualization ...€¦ · JWRO039-Hersen JWRO039-FM September 10, 2007 20:9. HANDBOOK. OF. Psychological Assessment, Case Conceptualization,

JWRO039-Hersen JWRO039-FM September 10, 2007 20:9

Michel Hersen, Editor-in-Chief

H A N D B O O K O F

PsychologicalAssessment,

CaseConceptualization,

and TreatmentVolume 1 Adults

Volume Editors

Michel Hersen and Johan Rosqvist

John Wiley & Sons, Inc.

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H A N D B O O K O F



and Treatment

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Michel Hersen, Editor-in-Chief

H A N D B O O K O F



and TreatmentVolume 1 Adults

Volume Editors

Michel Hersen and Johan Rosqvist

John Wiley & Sons, Inc.

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Handbook of psychological assessment, case conceptualization, andtreatment / editor-in-chief, Michel Hersen.

p. ; cm.Includes bibliographical references and index.ISBN-13: 978-0-471-77999-5 (cloth) Volume 1: AdultsISBN-13: 978-0-471-78000-7 (cloth) Volume 2: Children and AdolescentsISBN-13: 978-0-471-77998-8 (cloth) Set 1. Psychology,

Pathological—Handbooks, manuals, etc. I. Hersen, Michel. II. Rosqvist, Johan.III. Reitman, David[DNLM: 1. Mental Disorders—diagnosis. 2. Mental Disorders—therapy.WM 141 H2374 2008]RC454.H352 2008616.89—dc22 2007026314

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Contents

Preface to Volume 1 vii

Acknowledgments ix

Contributors xi

Part I GENERAL ISSUES

1 Overview of Behavioral Assessment with Adults 3Maureen C. Kenny, Krissan Alvarez, Brad C. Donohue,and Charles B. Winick

2 Diagnostic Issues 26Naomi R. Marmorstein and William G. Iacono

3 Behavioral Conceptualization 48Sara Wright and Paula Truax

4 Overview of Behavioral Treatment with Adults 76William H. O’Brien and Heather Schwetschenau

5 Medical and Pharmacological Issues in Assessment,Conceptualization, and Treatment 95

Jean Cottraux6 Ethical Issues 123

Catherine Miller

Part II ASSESSMENT, CONCEPTUALIZATION, AND TREATMENTOF SPECIFIC DISORDERS

7 Specific Phobias 139Derek R. Hopko, Sarah M. C. Robertson, Laura Widman,and C. W. Lejuez

8 Panic and Agoraphobia 171Maria Nazarian and Michelle G. Craske

9 Social Anxiety Disorder 204Luke T. Schultz, Richard G. Heimberg, and Thomas L. Rodebaugh

10 Obsessive-Compulsive Disorder 237Thröstur Björgvinsson and John Hart

11 Posttraumatic Stress Disorder 263William J. Koch and Michelle Haring

12 Generalized Anxiety Disorder 291Kathryn A. Sexton, Kylie Francis, and Michel J. Dugas

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vi Contents

13 Major Depressive Disorder 319Marlene Taube-Schiff and Mark A. Lau

14 Schizophrenia 352Dennis R. Combs, Michael R. Basso, Jill L. Wanner, and Sumer N. Ledet

15 Borderline Personality Disorder 403Alissa Sherry and Margaret R. Whilde

16 Other Personality Disorders 438Brian P. O’Connor

17 Bulimia Nervosa 463Tiffany M. Stewart and Don A. Williamson

18 Organic Disorder 498Gerald Goldstein

19 Alcohol Abuse 522F. Michler Bishop

Part III SPECIAL ISSUES

20 Marital Distress 563Brian D. Doss, Alexandra E. Mitchell, and Felicia De la Garza-Mercer

21 Sexual Deviation 590W. L. Marshall, G. A. Serran, L. E. Marshall, and M. D. O”Brien

22 Adults with Intellectual Disabilities 616Peter Sturmey

23 Older Adults 646Barry A. Edelstein, Sarah A. Stoner, and Erin Woodhead

24 Insomnia 674Daniel J. Taylor, Christina M. McCrae, Philip Gehrman,Natalie Dautovich, and Kenneth L. Lichstein

25 Health Anxiety and Its Disorders 701Gordon J. G. Asmundson and Steven Taylor

26 Compulsive Hoarding 728Suzanne A. Meunier, Nicholas A. Maltby, and David F. Tolin

Author Index 753

Subject Index 785


Preface to Volume 1

Many books have been written on assessment, conceptualization, and treat-ment over the past few decades. However, for the most part, these three is-sues critical to developing the most effective treatment regimens for clientshave not been linked in systematic fashion across the age spectrum. In this two-volumeset, we believe that we have filled a gap in the literature. Volume I does so for adults,while Volume II considers the issues in children and adolescents.

In Volume 1 on adults the chapters are divided into three parts. Part I (GeneralIssues) has six chapters dealing with an Overview of Behavioral Assessment withAdults, Diagnostic Issues, Behavioral Conceptualization, Overview of BehavioralTreatment with Adults, Medical and Pharmacological Issues, and Ethical Issues.

Part II deals with Assessment, Conceptualization, and Treatment of Specific Disor-ders, while Part III considers Special Issues, such as Marital Distress, Sexual Deviation,Adults with Developmental Disabilities, Older Adults, Insomnia, Health Anxiety, andCompulsive Hoarding.

In Parts II and III, authors were encouraged to include the following topics in theirchapters: Description of the Disorder, Diagnosis and Assessment, Conceptualization,Behavioral Treatment, Medical Treatment (if relevant), and a detailed Case Descrip-tion. Authors were also encouraged to consider the following issues in the sectionon Conceptualization: learning and modeling, life events, genetic influences, physicalaffecting behavior, drugs affecting behavior, and cultural and diversity issues.

We believe that the way this volume is structured provides a valuable teachingtool so that students have a more holistic view of psychopathology, its etiology, andits ultimate remediation. The Case Description was included to help concretize thethinking of our experts and to help students understand the more subtle transitionsand connections of assessment, conceptualization, and treatment.

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iii


Acknowledgments

Many individuals have contributed to the fruition of this work. First, we thankour contributors who agreed to share their thinking and expertise with us.Second, we thank Carole Londerée for her technical help throughout the pro-cess of putting together this volume. Third, we thank Cynthia Polance and ChristopherBrown for their work on the indexes. And finally, but hardly least of all, we thankour editorial friends at John Wiley who understood the importance of this project andwho helped us keep on track to completion.

Michel HersenJohan Rosqvist

Portland, Oregon

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Contributors

Gordon J.G. Asmundson, Ph.DAnxiety and Illness Behaviours

LaboratoryUniversity of ReginaRegina, Saskatchewan, Canada

Krissan Alvarez, MADepartment of PsychologyUniversity of Nevada—Las VegasLas Vegas, Nevada

Michael R. Basso, PhDDepartment of PsychologyUniversity of TulsaTulsa, Oklahoma

F. Michler Bishop, PhD, CASAlcohol and Substance Abuse

ServicesDr. Albert Ellis InstituteNew York, New York

Thröstur Björgvinsson, PhDThe Menninger ClinicHouston, Texas

Dennis R. Combs, PhDDepartment of PsychologyUniversity of Texas at TylerTyler, Texas

Jean Cottraux, MD, PhDHopital NeurologiqueUnite de Traitement de L’Anxiete,Bron Cedex, France

Michelle G. Craske, PhDDepartment of PsychologyUniversity of California—

Los AngelesLos Angeles, California

Natalie DautovichCounseling DepartmentUniversity of FloridaGainesville, Florida

Felicia De la Garza-MercerGraduate Psychology ProgramUniversity of California—Los AngelesLos Angeles, California

Brad C. Donohue, PhDDepartment of PsychologyUniversity of Nevada—Las VegasLas Vegas, Nevada

Brian D. Doss, PhDDepartment of PsychologyTexas A&M UniversityCollege Station, Texas

Michel J. Dugas, PhDDepartment of PsychologyConcordia UniversityMontréal, Québec, Canada

Barry A. Edelstein, PhDDepartment of PsychologyWest Virginia UniversityMorgantown, West Virginia

Kylie FrancisDepartment of PsychologyConcordia UniversityMontréal, Québec, Canada

Philip Gehrman, PhDDepartment of Social SciencesUniversity of the Sciences—PhiladelphiaPhiladelphia, Pennsylvania

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xii Contributors

Gerald Goldstein, PhDPsychology ServiceVeterans Affairs Medical CenterPittsburgh, Pennsylvania

Michelle Haring, PhDBritish Columbia Women’s

Hospital and Health Centre, NorthShore Stress and Anxiety Clinic

Vancouver, British Columbia,Canada

John HartThe Menninger ClinicHouston, Texas

Richard G. Heimberg, PhDAdult Anxiety ClinicTemple UniversityPhiladelphia, Pennsylvania

Derek R. Hopko, PhDDepartment of PsychologyUniversity of Tennessee—

KnoxvilleKnoxville, Tennessee

William G. Iacono, PhDPsychology DepartmentUniversity of MinnesotaMinneapolis, Minnesota

Maureen C. Kenny, PhDDepartment of Educational

and Psychological StudiesFlorida International

UniversityMiami, Florida

William J. Koch, PhDDepartment of PsychiatryUniversity of British ColumbiaVancouver, British Columbia

Mark A. Lau, PhDBC Mental Health and Addiction

Services 201-601 West BroadwayVancouver, British Columbia,

Canada

Sumer N. Ledet, MADepartment of PsychologyUniversity of TulsaTulsa, Oklahoma

C. W. Lejuez, PhDDepartment of PsychologyUniversity of MarylandCollege Park, Maryland

Kenneth L. Lichstein, PhDDepartment of PsychologyThe University of AlabamaTuscaloosa, Alabama

Nicholas A. Maltby, PhDInstitute of LivingUniversity of Connecticut School

of MedicineHartford, Connecticut

Naomi R. Marmorstein, PhDDepartment of PsychologyRutgers University—CamdenCamden, New Jersey

L. E. MarshallRockwood Psychological ServicesKingston, Ontario, Canada

W. L. Marshall, PhDRockwood Psychological ServicesKingston, Ontario, Canada

Christina M. McCrae, PhDCenter for Gerontological

Studies and Departmentof Psychology

University of FloridaGainesville, Florida

Suzanne A. Meunier, PhDInstitute of LivingUniversity of Connecticut School

of MedicineHartford, Connecticut

Catherine Miller, PhDSchool of Professional PsychologyPacific UniversityHillsboro, Oregon


Contributors xiii

Alexandra MitchellDepartment of PsychologyTexas A&M UniversityCollege Station, Texas

Maria Nazarian, PhDDepartment of PsychologyUniversity of California—Los

AngelesLos Angeles, California

M. D. O’Brien, PhDRockwood Psychological ServicesKingston, Ontario, Canada

William H. O’Brien, MADepartment of PsychologyBowling Green State UniversityBowling Green, Ohio

Brian P. O’Connor, PhDDepartment of PsychiatryLakehead UniversityThunder Bay, Ontario

Sarah M. C. RobertsonDepartment of PsychologyUniversity of Tennessee—KnoxvilleKnoxville, Tennessee

Thomas L. Rodebaugh, PhDWashington University—St. LouisSt. Louis, Missouri

Luke T. SchultzAdult Anxiety ClinicTemple UniversityPhiladelphia, Pennsylvania

Heather SchwetschenauDepartment of PsychologyBowling Green State

UniversityBowling Green, Ohio

G. A. SerranRockwood Psychological

ServicesKingston, Ontario, Canada

Kathryn A. Sexton, PhDDepartment of PsychologyConcordia UniversityMontréal, Québec, Canada

Alissa Sherry, PhDDepartment of Educational

PsychologyUniversity of Texas—AustinAustin, Texas

Tiffany M. Stewart, PhDPennington Biomedical Research

CenterBaton Rouge, Louisiana

Sarah A. StonerDepartment of PsychologyWest Virginia UniversityMorgantown, West Virginia

Peter Sturmey, PhDDepartment of PsychologyQueens College, CUNYNew York, New York

Marlene Taube-Schiff, PhDPsychosocial Oncology

and Palliative Care DepartmentPrincess Margaret HospitalToronto, Ontario, Canada

Daniel J. Taylor, PhDDepartment of PsychologyUniversity of TexasDenton, Texas

Steven Taylor, PhDDepartment of PsychiatryUniversity of British ColumbiaVancouver, British Columbia, Canada

David F. Tolin, PhDAnxiety Disorders Center/Institute

of LivingUniversity of ConnecticutHartford, Connecticut

Paula Truax, PhDClinical PsychologistKaiser PermanentePortland, Oregon


xiv Contributors

Jill L. Wanner, MADepartment of Psychology,University of TulsaTulsa, Oklahoma

Margaret R. WhildeDepartment of Educational

PsychologyThe University of Texas—

AustinAustin, Texas

Laura WidmanDepartment of PsychologyUniversity of Tennessee—

KnoxvilleKnoxville, Tennessee

Donald A. Williamson, PhDPennington Biomedical

Research CenterBaton Rouge, Louisiana

Charles B. Winick, PsyDPsych TeamCooper City, Florida

Erin WoodheadDepartment of PsychologyWest Virginia UniversityMorgantown, West Virginia

Sara Wright, MSSchool of Professional PsychologyPacific UniversityHillsboro, Oregon

JWRO039-Hersen JWPR039-01 September 5, 2007 17:19

PA RT I

GENERAL ISSUES

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C H A P T E R 1

Overview of BehavioralAssessment with Adults

MAUREEN C. KENNY, KRISANN ALVAREZ,BRAD C. DONOHUE, AND CHARLES B. WINICK

H I S T O R I C A L D E V E L O P M E N T

Behavioral assessment stems from early research in classical and operant condi-tioning that demonstrated how behavioral and emotional responses could beconditioned, or in effect learned (Watson & Rayner, 1920). Treatments basedon behavioral principles were then initiated to ameliorate various problem behaviors(Jones, 1924). Despite the increase in the use of behavioral therapy in the late 1950s,behavioral assessment measures were not commonly utilized in a clinical contextuntil the mid-1960s. Early behavioral assessment focused on the observation of be-havior patterns. Specifically, assessment focused on quantifying the frequency, rate,and duration of behaviors that were very specifically described to enhance reliability(Ullmann & Krasner, 1965). The publication of Complex Human Behavior (Staats, 1963)and Behavior Analysis (Kanfer & Saslow, 1965) increased interest in the field.

In the 1970s, behavioral assessment expanded in application and focus. The conceptthat situational variables influenced behavior led researchers to investigate individ-uals’ behaviors within larger social contexts such as family, school, and business. Inaddition, assessment expanded to include feelings, sensations, internal imagery, cog-nitions, interpersonal relations, and psychophysiological functioning (Lazarus, 1973).To adequately assess these content areas, indirect measures, such as self-reports andratings by significant others were included in behavioral assessments (Cone, 1977,1978).

Diversification of behavioral assessment continued throughout the 1980s and 1990swith incorporation of other disciplines and traditions. Indeed, in a review of articlespublished in behavioral assessment journals in the early to mid-1980s, only 15% indi-cated observation as a mode of assessment (Fernandez-Ballesteros, 1988). Such diver-sity garnered interest in the topic and resulted in an increase in journal articles relatedto behavioral assessment. As a result, in the span of 3 years, articles containing theterm “behavioral assessment” increased from 50 articles in 1980 to 200 articles in 1983

3


4 General Issues

(Fernandez-Ballesteros, 1993). Inclusion of other disciplines was evident in a reviewof Behavior Therapy and Behavior Research and Therapy from 1988 through 1991 in which53% of articles detailed the utilization of standardized trait questionnaires (Haynes &Uchigakiuchi, 1993). Moreover, 82% of the articles that included trait measures did soin conjunction with traditional behavioral assessment methodologies. Along a slightlydifferent vein, objective measures of behavior (e.g., urine drug screens to detect druguse) have become customarily administered with subjective measures of behavior(e.g., ratings of satisfaction with drug use) in controlled treatment outcome studies(e.g., Azrin et al., 2001). Thus, behavioral assessment has developed over multipledecades and continues to expand through the incorporation of traditional forms ofassessment and application to various fields.

C O N C E P T U A L F O U N D AT I O N S

Contrasts with Traditional Assessment

Despite recent incorporation of traditional assessment strategies in behavioral as-sessment, differences between behavioral and traditional assessment models liewithin contrasting conceptual foundations. Traditional assessment including psycho-dynamic and personality approaches assume that behavior is the result of stable,internal, psychological processes. The assumption of this methodology is that behav-ior is the expression of enduring, underlying personality traits. Therefore, emphasisof traditional assessment is on the measurement of internal experiences and under-lying traits (O’Brien & Haynes, 2005). The stable nature of these traits does not lenditself to modification through therapy. In addition, traditional assessment requires theacceptance of abstract constructs used to conceptualize underlying traits that are notamenable to empirical investigation. These limitations, among others, led to develop-ment of behavioral assessment strategies.

Perhaps the most distinctive trait of behavioral assessment is the emphasis onsituational determinants of behavior and exclusion of trait assumptions. Behavioralassessment highlights the importance of environmental contributions and assumesthat behavior is situation specific. Assessment in this tradition emphasizes the mea-surement of environmental factors, situation specific behavior, and recently has incor-porated the examination of cognitive processes (O’Brien & Haynes, 2005). Behavioris considered to be initiated and maintained through a dynamic process and thus isassessed across time and environments. This dynamic process is assessed throughthe investigation of the antecedents and consequences of behavior. These variablesinclude stimuli that precede, co-occur, and follow behaviors of interest.

The emphasis on situational determinants in behavioral assessment lends itself tosensitivity to individual differences. Behavioral assessment accepts that individualsdiffer in past experiences and present environmental variables and allows for individ-ualized application of assessment strategies (O’Brien & Haynes, 2005). Individualizedapplication can be utilized to better understand the factors initiating and maintain-ing behavior as similar behavior may be a function of differing contextual variablesacross individuals. Unlike traditional assessment, such specificity provides for directtherapeutic application. Identification of contributing variables allows for behaviormodification through the manipulation of the environment (Nelson & Hayes, 1979).

Behavioral assessment is also distinct from traditional assessment in its empha-sis on empirical evaluation. The focus of behavioral assessment on specific actions


Overview of Behavioral Assessment with Adults 5

and contextual variables is better suited for empirical testing than conceptual traitcharacteristics utilized in traditional assessment (Goldfried & Kent, 1972). Applica-tion of empirical evaluation in behavioral assessment involves specific definitions ofbehavior, monitoring of contextual variables, systematic observation, and the use ofvalidated instruments. Several studies evaluating the reliability and validity of diag-noses, behavioral observation, and self-report inventories highlight the importanceof empirical validation in behavioral assessment (Follette & Hayes, 1992).

B A S I C I S S U E S I N B E H AV I O R A L A S S E S S M E N T

Assessment is a necessary first step in behavioral therapy. In many ways, it is thecomplementary partner of behavioral treatment. Behavioral assessment ideally oc-curs prior to commencing treatment to assess requisite goals for treatment, duringtreatment to assist in measuring therapeutic progress and adequacy of selected treat-ments, and after treatment to determine final outcomes and appropriateness of treat-ment termination.

Behavioral assessment is typically organized in three distinct, and increasinglymolecular stages. The first stage, or level, of behavioral assessment is focused onthe identification of global behaviors (e.g., noncompliance, sleep disturbance) thatare most contributory to the presenting problem. These behaviors are particularlydistressing, disruptive to daily functioning, socially unacceptable, or dangerous ordetrimental to health and well being. The focus of assessment then shifts to deter-mining the syndrome or cluster of symptoms that influence the onset of problembehaviors. Assessment concludes with an assessment of the system. This view holdsthat the individual is a system, whereby one symptom disturbance affects functioningin another area.

Although behavioral assessment and the Diagnostic and Statistical Manual of MentalDisorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association,2000) began on much different tracks (the former growing out of behavior therapyand the latter linked to the medical model), they have developed a working rela-tionship and can be used in conjunction with one another. For instance, behavioralassessment is often relied on to assist in diagnosing DSM-IV diagnoses, as these syn-dromes are often based on quantifiable actions that are quite amenable to behavioralassessment practices. The nosologic scheme of the DSM sets forth a descriptive set ofbehaviors that are necessary for diagnosis in a particular area. This is analogous to thesyndrome level of assessment discussed previously; where by a cluster of symptoms(which delineate a diagnosis) are identified as targets of treatment. Additionally, theDSM list of psychosocial stressors is consistent with behaviorism’s emphasis on envi-ronmental factors (Tyron, 1998). The atheoretical nature of the DSM does not precludeexplanations of disorders based on behavioral theory. However, the DSM is based ona nomotheic system (classifying groups of similar individuals), while behavioral as-sessment is idiographic (unique to the individual) (Nelson-Gray & Paulson, 2004). Asynthesis of behavioral assessment and DSM, where behavioral assessment is used tocreate a treatment that may be best for a specific individual, is possible.

Behavioral assessment may include many different instruments and types of as-sessment strategies. The domains that often need to be attended to when working witha client may best be assessed in different ways including self-report, self-monitoringand recording, surveys, direct behavioral recordings, and physiological assessment(Barlow, 2005). Generally, the start of an assessment identifies what behaviors are


6 General Issues

of interest. This usually involves some behavioral excess (e.g., crying all the time) ordeficit (e.g., unable to speak in social situations) (Tyron, 1998). Sometimes direct obser-vation of the client is essential, as this method is generally the most validated methodof specified behaviors, particularly when motivation is lacking. However, this methodis relatively costly as compared with subjective self-report measures (i.e., question-naires and other retrospective rating by others). Moreover, as compared with directobservation, subjective measures are easier to implement (i.e., direct observation of-ten requires the assessor to travel to naturalistic environments). Assessment in thenatural environment is preferred, but not always feasible and so artificial laboratorytesting circumstances may be used (Tyron, 1998). Physiological responses (which canimpact target behavior) can also be measured directly, requiring relevant equipmentand expertise. The various methods of behavioral assessment will be reviewed laterin the chapter.

F U N C T I O N A L A S S E S S M E N T

Functional assessment is often confused with functional analysis (O’Neill, 2005). How-ever, these terms are distinct from one another (Gresham, Quinn, & Restori, 1999;Herner, 1994). Functional assessment refers to the utilization of methods and tech-niques to identify target behaviors, including stimuli that precede (i.e., antecedents)and follow (i.e., consequences, target behaviors); conducting a functional analysis;and developing treatment interventions. Functional analysis is limited to the processby which environmental events are manipulated to estimate their impact on targetbehaviors, and is, therefore, a component of functional assessment.

Identification of Target Behaviors

The first step in the functional assessment process is the identification of target be-haviors. Generally, the clinician and client work together to identify target problembehaviors. This process begins by broadly identifying behavioral patterns, and laterspecifying these behavioral patterns into well-defined behaviors (Donohue, Ammer-man, & Zelis, 1998), including the manner by which these behaviors are performed,as well as their frequency, duration, and severity (O’Neill, 2005).

Functional Analysis

Functional analysis involves formulating hypotheses regarding the function, or pur-pose, of target behaviors (Gresham et al., 1999). Relationships between the variablesthat proceed, co-occur, and follow target behaviors are examined through the ABCmodel of functional analysis (i.e., antecedents, behaviors, consequences). An exten-sion of this model, the SORC model includes antecedent stimuli (S), factors inherentto organism (O), target response (R), and consequences (C) (Goldfried & Sprafkin,1976). This model includes current environmental stimuli and consequences, as wellas individual physiology and learning history. The way in which this information isobtained and utilized is dependent on the method of functional analysis.

Indirect functional analysis involves utilization of interviewing procedures that arespecifically designed to identify the function of relationships existing between targetbehaviors and relevant antecedents and consequences (Iwata & Worsdell, 2005). In thisprocess, clinicians formulate hypotheses about the maintenance of target behaviors



through inquiry about antecedents and consequences. Behavior analysts may assessinterviewee beliefs about how the behavior is maintained, how the problem may besolved, and successful and unsuccessful strategies that may have been used to copewith target behaviors. This method is easily implemented. However, verbal reportshave been reported to be unreliable (Sturmey, 1994).

Descriptive functional analysis involves systematic observation of target behaviorto aid in hypothesis formulation (Sulzer-Azaroff & Mayer, 1977). Data obtained in thismethod is utilized in the formulation of hypotheses regarding the function of targetbehaviors. These hypotheses are confirmed or disconfirmed by examining the cor-relations between occurrence of target behaviors and antecedents and consequences.Descriptive functional analysis is a more reliable method than indirect functional anal-ysis, as it does not rely upon self-report. However, this method relies on correlationsand fails to provide a means of experimentally testing hypotheses (Iwata & Worsdell,2005).

Experimental functional analysis is the method of experimentally manipulatingthe environment to develop and test hypotheses that are pertinent to the mainte-nance of target behaviors. Environmental events may be presented or withdrawn forshort time periods to assess the affect on target behaviors (O’Neill, 2005). Behavioroccurrence during these trials is compared to identify the function of the target behav-iors and the maintaining variables (Iwata & Worsdell, 2005). Although this methodis relatively time consuming, experimental manipulation offers great promise whenaccurate assessment is wanting.

Treatment Interventions

Once target behaviors and their functional relationships have been identified, treat-ment intervention may be developed and implemented. When multiple target behav-iors are identified, the clinician may choose to initially focus on a single behavior oraddress multiple behaviors concurrently. It is customary to initially target the behaviorcausing greatest distress to the client, thus assisting the client in being able to attendto other behaviors. Another approach is to first target the behavior most amenable tochange so that the client is encouraged by the effect of treatment (O’Leary & Wilson,1975). When the client lacks motivation, the clinician may choose to first address thebehavior that is most disruptive to the client’s significant others (Tharp &Wetzel, 1969).In addressing multiple behaviors concurrently, clinicians must examine whether be-haviors are influenced by one another. Related behaviors are referred to as responseclasses. Response classes include behaviors that have seemingly different character-istics, but have similar effects on the environment or contextual variables (O’Neill,2005).

S E L F - R E P O RT A S S E S S M E N T

Information from self-report assessment strategies (e.g., questionnaires, self-monitoring) is obtained directly from the client. Self-report methods are cost-effective,easily administered, and amenable to the assessment of motoric, physiological, andcognitive processes (Cone, 1978). Self-report assessment generally requires less timeand resources than other forms of assessment, such as behavioral observation. The pri-mary criticism of self-reports is that client’s may provide inaccurate information due tovarious factors, including intentional false reporting and memory deficits. However,


8 General Issues

Barlow, Hayes, and Nelson (1984) argued the client’s perception of their problem is animportant component of the therapeutic process, and Evans (1986) noted that the the-oretical assumptions of behavioral assessment do not include unconscious processesthat would lead to distortion of self-reports of behavior.

Self-Report Measures/Instruments

Self-report measures present clients with statements regarding the presence, fre-quency, or severity of their thoughts and behaviors. Measures differ in the their num-ber of items, but frequently utilize a Likert-type response scale (e.g., 7 = Extremelyhappy, 1 = Extremely unhappy). Standardized rating scales and problem behaviorchecklists are generally paper-and-pencil measures. However, some measures maybe administered via computer. Computer-administered assessments often have theadvantage of automated scoring, which can reduce the time of assessment interpre-tation. Although most measures are completed by the client, some measures may becompleted by significant others or family members to gain a greater understandingof the problem.

Self-report measures vary in their degree of specificity. Some instruments assessmultiple domains (e.g., depression, anxiety, conduct problems) broadly, while oth-ers assess specific behavioral categories more comprehensively. Determination of thetype of measure to employ is dependent upon the objective of assessment. Generalmeasures are beneficial in the initial stages of assessment to identify the areas in whichthe client is experiencing greatest relative difficulty. Specific measures are useful whenthe clinician is interested in assessing detailed information about a client’s identifiedproblem and usually are administered once the initial target behaviors have beenidentified during broad-based assessment. Determination of which measure to useshould include an examination of the reliability and validity of potential instrumentsbecause self-report inventories vary in degree of psychometric validation.

The Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994) is a broad-basedself-report checklist that assesses nine dimensions (i.e., Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxi-ety, Paranoid Ideation, and Psychoticism) and three global indices of distress (i.e.,Global Severity Index, Positive Symptom Distress Index, and Positive Symptom To-tal). Clients respond to 90 items measuring symptom presence and severity on a5-point rating scale ranging from “not at all” to “extremely.” The SCL-90-R may beutilized to initially identify problems and measure treatment progress and outcomes.The SCL-90-R includes computer-based administration requiring approximately 12to 15 minutes. The SCL-90-R has been reported to have above satisfactory ratingsof internal consistency (Derogatis, Rickels, & Rock, 1976; Horowitz, Rosenberg, Baer,Ureno, & Villasenor, 1988), and high levels of convergent-discriminant validity (seeDerogatis, 1983). Most SCL-90-R item stems are behaviorally specified, (e.g., shoutingor throwing things) although some are not amenable to functional analysis (e.g., neverfeeling close to another person).

Beck Depression Inventory II The Beck Depression Inventory Second Edition(BDI-II; Beck, Brown, & Steer, 1996a) is a specific self-report inventory used to assessthe presence and severity of various symptoms of depression. The measure consistsof 21 items; each item has four alternative responses from which the individual canchoose, which are then scored, 0 to 3. The BDI-II is available in a paper-and-pencil



version. Total administration requires approximately 5 minutes and may be conductedby the clinician or self-administered by the client. The BDI-II has been reported tohave good reliability, and high content and convergent validity (Beck, Brown, & Steer,1996b). Although frequently utilized to measure depression, many of the items aredesigned to measure cognitive processes (e.g., I feel that I am a total failure as a person)limiting its application to traditional functional assessment.

Self-Monitoring

Self-monitoring is the process of “systematically observing and recording aspects ofone’s own behavior” (Bornstein, Hamilton, & Bornstein, 1986, p. 176). Functionallyrelated internal and external environmental events may be recorded to gain better un-derstanding of the client’s behavior (Cone, 1999). This form of self-report assessmentis frequently used in clinical psychology. Indeed, in a survey of behavioral practi-tioners, 83% reported using self-monitoring with their clients (Elliott, Miltenberger,Kaster-Bundgaard, & Lumley, 1996).

Clients may use self-monitoring to track thoughts, feelings, and behaviors. Clientrecordings may include the frequency and duration of target behavior, as well asrelevant antecedents and consequences to assist in understanding the function ofbehavior. Because clients are responsible for monitoring their behavior, the client andclinician should agree on operational definitions of the target behavior and relevantcontextual variables to be monitored (Korotitsch & Nelson-Gray, 1999). Some authorsreported finding increased accuracy when clients were trained in how to monitorbehavior (Hamilton & Bornstein, 1977; Nelson, Lapinski, & Boykin, 1978). Thus, clientsshould have a thorough understanding of the recording process.

The way in which self-monitoring is structured may vary. Clients may record be-havior at every occurrence, during a specific time period, or during specific situa-tions. Barton, Blanchard, and Veazy (1999) recommend that the time period mon-itored by clients be specific to the monitored behavior and purpose of the data.Cone (1999) suggested that clinicians consider: (a) when and how frequent be-havior should be monitored, (b) the time period for monitoring, (c) what is to berecorded, (d) the format of the record, (e) whether and how to use cues, (f) thenumber of different variables to be recorded, and (g) any techniques for assuringcompliance.

Clients most often record their behavior on paper-and-pencil forms, although coun-ters, tape recorders, and journals are also useful in the monitoring process. Paper-and-pencil forms and counters can quickly capture the frequency of behavior. Unlikecounters, paper-and-pencil forms allow detailed information including severity rat-ings and contextual variables to be recorded. Tape recorders and journals offer theadditional advantage of comprehensive verbatim responses, although much of theinformation recorded may be irrelevant to the treatment plan.

Self-monitoring may assist in the initial assessment process through identificationof target behaviors and relevant contextual variables. Monitoring can also be used toestablish baseline rates of behavior (Ciminero, Nelson, & Lipinski, 1977; Korotisch &Nelson-Gray, 1999). This gathering of information further contributes to the develop-ment of a functional analysis through the formulation of hypotheses regarding targetbehavior and maintaining variables. When diagnostic classification is unclear, self-monitoring can aid in appropriate diagnosis. Treatment plans can then be developedaccordingly (Korotisch & Nelson-Gray, 1999).


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Utilization of self-monitoring during treatment assists clients in gaining increasedawareness of behavior occurrence and behavior management (Korotitsch & Nelson-Gray, 1999; Wilson & Vitousek, 1999). Indeed, merely attending to the occurrence ofbehavior may alter behavior in the direction of the therapeutic goal (Baird & Nelson-Gray, 1999). Monitoring can also be used in treatment to monitor treatment gainsand outcomes. Recordings throughout treatment can be compared to base rate infor-mation to assess behavior changes. If behavior change is not reflected in recordings,intervention strategies may be altered.

Self-monitoring is an inexpensive, convenient technique that requires less of theclinician’s time and resources than other methods (e.g., behavioral observation). Inaddition to convenience, self-monitoring is less intrusive. Since clients record be-haviors themselves, there is no need for the presence of observers, and recordingsare less likely to be biased by observer perception. Clients are also benefited by be-ing provided with a method of attending to their behavior and responses. Bornsteinand colleagues (1986) noted the immediate self-derived feedback outside of therapythrough self-reporting methods empowers clients. Self-monitoring also has a widerange of application.

Despite benefits of self-monitoring, the technique is not without criticism. Reactiv-ity to monitoring may occur. Response reactivity occurs when clients purposely altertheir report of behavior as a result of attention (Ciminero et al., 1977). Frequency orseverity of problem behavior may be inflated to signal need for treatment (Craske &Tsao, 1999), or underreported if the client fears negative consequences for failing to re-flect treatment gains. Contrarily, clients may underreport problem behavior to impressthe therapist or “get out” of therapy commitments. Accuracy may also be affected bythe limitations of memory. If the client records retrospectively, aspects of the moni-tored variables may not be remembered. Further, easily remembered events might berecorded as occurring more frequently (Craske & Tsao, 1999). To increase accuracy ofdata, observer load is an important consideration (Hayes & Cavior, 1977, 1980). Bairdand Nelson-Gray (1999) suggest it is best to initiate the monitoring process with afew behaviors, and gradually increase the number of monitored behaviors with thepassage of time.

Behavioral Interviews

Behavioral interviewing uses the framework of learning principles (i.e., operant andclassical conditioning) to elicit information from the client, and initiate functionalanalysis of the problem (Sarwer & Sayers, 1998). The interview is often the first stepin identifying the problem behavior(s), generating hypotheses, and gathering infor-mation (Glass & Arnkoff, 1989). Most clients are cooperative and provide detailedinformation regarding their problems and the antecedents and consequences. How-ever, there are times when clients are not able to fully describe what is wrong. Ininstances such as these, it may be helpful for the clinician to ascertain motivations forthe referral.

Interviews used in behavioral assessment vary in structure. The content and or-ganization of unstructured interviews is dependent upon the clinician and the goalof the interview. Semi-structured and structured interviews are less flexible. Semi-structured interviews include standardized questions and formats, but do permit theclinician leeway to ask follow-up questions, select questions to ask from an avail-able list, and permit idiosyncratic queries. Structured interviews are fully structured



interviews that clearly delineate the format of the interview and the questions to beread verbatim by the clinician. They do not allow rephrasing or additional questionsto be posed to the client.

Unstructured Interviews Clinicians frequently use unstructured interviews at theoutset of the assessment and therapeutic process to identify client’s problem. The clin-ician works with the client to identify, and operationally define the problem. Lazarus(1973) proposed the BASIC ID approach to assessing content areas in interviews [i.e.,behavior (B), affect (A), sensation (S), imagery (I), cognitions (C), interpersonal re-lationships (I), and possible drug utilization (D)]. Assessment of medical history iscustomary, as medical conditions may contribute to problem behavior. In keepingwith behavioral assumptions, interviews are chiefly focused on current problem be-havior, contextual variables, and treatment utility. The history of the problem may beassessed, but the emphasis is on recent events.

Kratochwill (1985) provides a four-stage format relevant to discussing topics duringan unstructured interview:

1. Problem identification is the specification of problem to establish base rates andtreatment goals.

2. Problem analysis is the assessment of contextual variables and client resources.3. Plan implementation is the proposed data collection for evaluation of treatment

progress.4. Treatment evaluation concerns how pre- and postlevels of behavior will be

compared.

Witt and Elliott (1983) suggested a more detailed organization for unstructuredinterviews:

1. The clinician begins by providing an overview of the interview agenda and arationale for problem specification.

2. Clinician and client work together to identify and clearly define problem be-haviors.

3. The problem behavior is further defined by assessing frequency, duration, andintensity.

4. Relevant antecedents and consequences are identified.5. Realistic treatment goals and deadlines are discussed and agreed upon by the

clinician and client.6. The client’s strengths are identified.7. Any behavior to be recorded and the method of the recording are identified.8. The way in which treatment efficacy will be assessed is discussed.9. The clinician summarizes the information discussed and obtains agreement

from the client.

These suggestions provide the clinician with a format for organizing unstructuredinterviews. However, clinicians have the freedom to vary the content of the interview,the specific questions posed, and the amount of time spent on each area. Unstructuredinterviews should be tailored to the client’s needs and responses during the interviewprocess. Through individualization of the interview, the clinician may obtain infor-mation from the client that would not have otherwise been disclosed.


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A major advantage of unstructured interviews is the flexibility to assess multipleareas and spontaneously alter the interview format based on information obtained.In addition to identifying problem behavior and contextual variables, unstructuredinterviews provide an opportunity for clinicians to formulate and inquire about hy-potheses regarding the function of behavior. Depending on the information obtained,the clinician may determine whether further assessment measures are necessitated.Flexibility of the unstructured interview allows the clinician to explore client initiatedcontent, and provide empathy, which may assist in establishing rapport. The interac-tion also provides an opportunity for the clinician to gain an impression of the client,and may serve as an observation measure if the client displays problem behaviorduring the interview.

Semi-Structured and Structured Interviews Semi-structured and structured in-terviews provide an organized approach to interviewing. Both forms of interviewprovide clinicians with a standardized set of questions, sequence for asking questions,and behavior ratings. The difference lies in the degree of structure. Semi-structuredinterviews allow clinicians to rephrase questions and ask additional questions for clar-ification. Structured interviews require clinicians to ask questions verbatim withoutdeviation. This may be beneficial for interviewers with less experience and clinicalskill, provided they receive training on the specific interview.

As compared with unstructured interviews, clinicians may achieve more accuratediagnoses through the use of semi-structured and structured interviews as they as-sure coverage of diagnostic criteria. Diagnostic accuracy is particularly important inresearch, and clinical settings for which accurate classification is crucial (i.e., forensicsettings). Structured interviews are also used to verify diagnostic impressions gainedduring unstructured interviews. If clinicians are unsure of a client’s diagnosis, theymay use a semi-structured or structured interview to assist in differential diagnosis.The emphasis on diagnostic criteria, however, does not provide a thorough examina-tion of contextual variables.

Although structured interviews have been criticized for failing to provide an op-portunity to build rapport (Segal & Coolidge, 2003), they have demonstrated greaterreliability and validity than unstructured interviews (Rogers, 2001; Segal & Coolidge,2003). Reliability across interviewers is an important aspect of assessment when work-ing with managed care systems that require diagnostic certainty and base reimburse-ment on diagnosis. Reliable measures also provide a more accurate measure of treat-ment outcome. However, it is important to note that psychometric properties varyacross specific interviews, as indicated below.

Structured Clinical Interview for DSM-IV Axis I Disorders TheStructured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) is a semi-structured interview for assessing Diagnostic and Statistical Manual disorders (DSM-IV) (American Psychiatric Association, 1994) Axis I disorders. Multiple versions ofthe interview are available depending on the type of client to be interviewed andthe setting in which the interview is to be conducted (e.g., patient/nonpatient client,research/clinical setting). The clinical version (SCID-CV; First, Spitzer, Gibbon, &Williams, 1997) provides open-ended prompts with close-ended follow-up questionsto assess both current (i.e., within the past month) and lifetime symptomology. Theinterview is comprised of 6 major modules: Mood Episodes, Psychotic Symptoms, Psy-chotic Disorders, Mood Disorders, Substance Use Disorders, and Anxiety and otherDisorders, and requires 30 to 90 minutes for administration. However, the clinician



has the discretion to utilize all modules, or chose the modules that are most relevant tothe client’s presenting problem. The SCID-I has been used as the “gold standard” forvalidity (e.g., Shear, Greeno, & Kang, 2000; Steiner, Tebes, & Sledge, 1995). Reliabilityis generally good, and varies across modules (Zanarini, et al., 2000).

Diagnostic Interview Schedule for DSM-IV The Diagnostic InterviewSchedule (DIS-IV) for DSM-IV (Robins et al., 2000) is a fully structured interview forassessing DSM-IV (American Psychiatric Association, 1994) disorders. All questionsand probes are provided, and presented verbatim. Questions are close-ended as ameans of limiting variability. The DIS-IV requires 90 to 120 minutes to administer.Clinicians may choose which modules to administer, or utilize the optional termi-nation points within each disorder section if the client does not endorse sufficientsymptoms. Given the complexity of the interview, training is recommended.

D I R E C T B E H AV I O R A L O B S E RVAT I O N

Behavioral observation of specified behaviors is the hallmark of behavioral assessment(Algozzine, Konrad, & Test, 2005) and is the preferred method of obtaining informa-tion about problem behaviors (Groth-Marnat, 2003). Jordan and Franklin (2003) reportbehavioral observation is one of the most effective measures of frequency and dura-tion of behavior. Although other methods are more commonly utilized, these methodsare more likely to be influenced by reporting biases. The more removed from the timeand place of the occurrence of the behavior, the more indirect the assessment and thegreater chance of error. Behavioral observation should ideally occur in naturalisticenvironments (e.g., home, school, work), and should involve a range of appropri-ate and inappropriate social behavior (Algozzine et al., 2005). In conducting in vivoassessment the observer has little control over the behaviors that are observed. Invivo observations are most effective when assessing high frequency, global behaviorsand are valuable for measuring change following clinical intervention (Groth-Marnat,2003).

Defining the target behavior, in measurable, observable terms is a necessary firststep to behavioral observation (Groth-Marnat, 2003). Any definition of a behaviorshould include specific examples of behavioral performance to assist in achievingsufficient reliability between raters. For some behaviors, such as measuring how manyalcoholic beverages the client consumes (e.g., 12 ounces of beer, 5 ounces of wine),this is an easy process. Other behaviors, such as assertiveness, are more difficultand must be clearly defined (e.g., refusing an offer to ingest an alcoholic beverage).The target behaviors for observation will be derived from information obtained fromthe interview, anecdotal observations (e.g., observation of argument with spouse inwaiting room), self-report inventories, and other assessment strategies (Groth-Marnat,2003).

An observational assessment generally focuses on the here and now. Thus, theclinician’s attention is focused on the immediate behavior, its antecedents (what hap-pened just before the behavior) and its consequences (what happens right afterward).In conducting informal observations, an observer may observe behavior for a spe-cific period of time and provide a narrative summary of relevant actions, often calleda narrative recording. For example, a clinician working with an individual who self-reports social skill deficits may observe this person at a party. The clinician wouldthen return to the office and make notes of observed actions. This type of observationis very helpful in defining more specific areas for future assessment to be measured


14 General Issues

quantitatively (Groth-Marnat, 2003). Formal observations identify previously definedbehaviors. In a formal observation, the observer decides ahead of time who will beobserved, what they will be doing, when and where the observation will take place,and how the behavior will be counted. The behavior must be operationalized priorto the observation so that the observer is able to measure it and keep a record. Anexample of a well-defined behavior would be, “asking a coworker how she is feelingduring a work break,” whereas a poorly defined behavior would be, “being friendly.”Once the target behavior occurs, the clinician records its occurrence, along with rel-evant antecedents (e.g., presence of one person who smiles, solving a work-relatedproblem successfully) and consequences (e.g., person returns salutation).

It is necessary to fully understand the various dimensions of behavior prior toconducting formal observations (Algozzine et al., 2005). For instance, frequency is thenumber of times an individual engages in the target behavior within a given timeframe; the clinician must be clear about when the behavior begins and ends (e.g., Samswore at his supervisee three times during the 8-hour work day). Rates per minute,hour or day can be derived from frequency data, thereby allowing comparisons acrossobservations. Duration is how long the individual engages in the target behavior dur-ing the specified time period (e.g., Sam engaged in a conversation with his coworkerfor 2 minutes during the 1-hour lunch). Latency refers to the length of time that elapsesbetween the antecedent stimulus and the onset of the behavior (e.g., Thirty minutesafter Sam arrived home, he began crying). The magnitude of the behavior is the force,intensity, or severity of the behavior, but relies on a qualitative judgment (1 = Ex-tremely angry, 5 = Extremely happy). What the behavior looks like motorically is thetopography of behavior, while locus is where the behavior occurs.

Participant and Nonparticipant Observers

O’Brien, Kaplar, and Haynes (2005) describe both nonparticipant and participant ob-servers. Nonparticipant observers are generally individuals who are trained to recordthe occurrence of behaviors and contributing variables. These individuals are not,however, part of the client’s environment. They receive formal training and are hiredto conduct the observations and collect data on the problem behavior and causal vari-ables. One downfall of this type of assessment is the cost associated with the trainingand hiring of such individuals. Participant observers are involved in the client’s nat-ural environment. They may include family members, coworkers, teachers, hospitalstaff, or other caregivers. Due to their regular involvement in the client’s life, they areable to conduct observations in many different settings across substantial periods oftime. There are drawbacks to utilizing these individuals. Given their multiple rolesand responsibilities, they are generally able to record a limited number of events. Inaddition, their reports may be biased due to their relationship with the client, thusaffecting objectivity of their recordings (O’Brien et al., 2005).

Direct behavioral observation can also be conducted with more than one observer ata time, making it a very effective measurement strategy (Jordan & Franklin, 2003). Twoobservers might be used in a residential or hospital setting. For instance, both a nurseand a mental health technician might be trained to observe a client’s behavior, andwould record their observations. Then, interobserver agreement could be obtained asa measure of reliability. The use of two observers is time consuming, expensive, andnot always practical, usually demanding an assessment of interrater/interobserverreliability.

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