Chapter 1: The diagnostic process
1.1 Introduction
• Clinical psychodiagnostics is an exclusive specialism of the clinical psychology
o Was not popular for a long time, because it was seen as tedious, time-consuming and
labelling people on the basis of unreliable projective techniques and lengthy
questionnaires
▪ Now its agreed that a full diagnosis is a prerequisite for adequate care
• Clinical psychodiagnostics is a professional activity that is based on three elements:
1. Theory development of the problems/complaints and problematic behavior
2. Operationalization and its subsequent measurement
3. Application of relevant diagnostic methods
• Hypotheses about behavior, cognition and emotion/motivation are formulated on basis of a
theory, and are operationalized, measured and tested with a step-by-step diagnostic process
o It offers a framework and systematic approach for the step-by-step analysis of
complex diagnostic problems
1.2 Steps in the diagnostic process
1. (Usually) client’s referral to the diagnostician;
(occasionally) Client’s direct question to the
diagnostician
o Diagnostician analyses the client’s request
or help and the referrer’s request – it does
not need to be the same
2. Formulating questions out of referrer’s and clients’
needs and of aspects arising in the first session
3. Construction of a diagnostic scenario containing a
provisional theory about the client; describes what
the problems are and how they can be explained
o Diagnostic measures for testing the theory:
1. Converting the provisional theory
into concrete hypotheses
2. Selecting a specific set of research
tools, which can either support or
reject the formulated hypotheses
3. Making predictions about the
results/outcomes from this set of tools
4. Applying and processing instrument
5. On basis of obtained results, giving reasons for why the hypotheses have
been accepted or rejected → diagnostic conclusion
1.3 Five basic questions in clinical psychodiagnostics
1. Recognition: What are the problems; what works and what doesn’t?
2. Explanation: Why do certain problems exist and what perpetuates them?
, 3. Prediction: How will the client’s problems subsequently develop in the future?
4. Indication: How can the problems be resolved?
5. Evaluation: Have the problems been adequately resolved as a result of the intervention?
1.3.1 Recognition
• Diagnostician identifies complaints and adequate behavior of the client and/or their
environment
• Recognition includes: inventory & description; organization & categorization in
dysfunctional behavior clusters/disorders; examination of seriousness of the behavior
• Recognition may result from:
o Criterion-oriented measurement= Comparison to a predefined standard
o Normative measurement= comparison to a representative comparison group
o Ipsative measurement= comparison to the individual himself
• Distinction between classification and diagnostic formulation: (both have advantages and
disadvantages)
o Classification – clinical picture is assigned to a class of problems
▪ It’s done according to an all-or-nothing principle (e.g., DSM categories) or a
more-or-less principle (e.g. scores for dimensions)
▪ Leads to ‘labeling’ – is limited and can be the basis for comorbidity
▪ Facilitates communication between experts
o Diagnostic formulation – focuses on the individual and his own unique clinical
picture
▪ Allows uniqueness of the individual – helps the therapy planning but has an
occasional lack of empirical support
▪ Usually involves simultaneous recognition and explanation
1.3.2 Explanation
• Answering the question of why there is a problem or a behavioral problem includes:
1. Main problem or problem component
2. Conditions that explain the problem’s occurrence
3. Causal relationship between points 1 and 2
• Explanations may be classified according to:
1. The locus – i.e. the person or the situation
▪ Person-oriented explanations= explanatory factor lies in the person
• Occurs when the behavior is viewed separately from the context
▪ Situation-oriented explanation= explanatory factor lies in the event of a
well-known context
• The explanatory events may precede the behavior that is to be
explained or follow it
2. The nature of control
▪ Cause, i.e. determined by previous conditions
• Explain behavior
▪ Reason, i.e. determined by a voluntary or intentional choice
• Make behavior understandable
▪ Cause and reason do not constitute a dichotomy, but a continuum
3. Synchronous and diachronous explanatory conditions
, ▪ Synchronous explanatory conditions= match with the behavior that is to be
explained at the time
▪ Diachronous explanatory conditions= precede this behavior
• E.g., in psychoanalytic diagnostics the structural explanation is
synchronous and the psychogenic explanation is diachronous
4. Induced and persistent conditions
▪ Induced conditions – give rise to a behavioral problem
▪ Persistent conditions – perpetuate the behavioral problem
• Some diagnosticians have the tendency to work from one specific theory in their
explanation, even if there are additional explanatory theories → this influences and limits
the diagnostic process and predominantly influences and limits the indication
• Some professionals strive for a generally accepted, central theory, which should, together
with the biological influences, simultaneously identify the situational influences, personal
characteristics, development and systemic patterns
1.3.3 Prediction
• Prediction – making a statement about the problem behavior in the future
o It is a chance statement, e.g. the chance of fully resuming one’s work duties after a
head trauma
o This chance plays a part in determining the treatment proposal, e.g. short-term or
long-term treatment
• Prediction pertains to a relation between a predictor and a criterion
o Predictor= present behavior
o Criterion= future behavior
o The relationship may be known on the basis of examination, but it may occasionally
need to be determined for specific relationships between the client’s present and
future behavior
• In actual research, relations (correlations) are never perfect and we can only determine the
chance that behaviors will collectively occur in a particular population
• Even though the empirical evidence is ineffective, the diagnostician may occasionally need
to give an answer to a practical question – the diagnostician can make use of a model or
clinical prediction, in which he decides which information he will include in the prediction
and how he will intuitively integrate it
• In prediction, the margins of error (standard errors of an estimation) are often so large that
the high expectations of legal and other societal contexts cannot be met
1.3.4 Indication
• Indication – focuses on the question of whether the client requires treatment and, if so,
which caregiver and assistance are the most suitable for this client and problem
• Indication is characteristic of an orientation, a search process that involves finding which
treatment and which caregiver are most compatible with the client’s complaints, problems,
traits and preferences
• Before we can proceed to the indication, the steps for explanation and prediction must be
completed, however there are three additional elements:
1. Knowledge of treatments and therapists – requirements for treatments and therapists
are not clear, because many treatments are not clearly defined
, ▪ Exceptions are ambulant treatment vs. residential treatment,
psychotherapeutic treatment vs. pharmacological treatment and individual
treatment vs. group therapeutic treatment
2. Knowledge of the relative usefulness of treatments – studies are often not specific
enough to support certain therapeutic interventions and types of clients
▪ Meta-analyses of the effective components of different therapies can be
helpful when selecting a treatment
3. Knowledge of the client’s acceptance of the indication – there is a chance that a
client will not follow a recommendation if the proposed treatment deviates from his
preference
▪ There is an indication strategy that has been developed which takes the
client’s preferences into account; it contains four principles:
1. Client’s perspective is examined and explicated
2. Diagnostician provides the client with information about the courses
of treatment, processes, and therapists
3. Client’s expectations and preferences are compared to those that the
diagnostician deems to be suitable and useful and, during a mutual
consultation, a number of possible treatments, which are acceptable to
both parties, are formulated
4. Client selects a therapist and a treatment.
1.3.5 Evaluation
• Evaluation of the assertions about diagnosis and/or intervention takes place on the basis of
both the progress of the therapeutic process and the results of the treatment
o This establishes whether the therapy took account of the diagnosis and treatment
proposal – if this was not the case, the diagnostic process was unnecessary – and
whether the process and the treatment have brought about a change in the client’s
behavior and experience
• Can be carried out in two ways
o We can establish whether the complaints or problems decreased to the desired degree
without discussing if the changes were brought about by the therapy
o We can prove that the changes were caused by the therapy, e.g. with the help of n=1
designs, which have largely been developed within behavioral therapy
1.4 The diagnostic cycle
• One way to regulate and discipline the diagnostic process is to structure it according to the
empirical cycle of scientific research
• Diagnostic cycle= model for answering questions in a scientifically justified manner
• Consists of observation, induction, deduction, testing and evaluation
1. Observation – collecting and classifying empirical materials (provide the basis for
forming thoughts about the creation and persistence of problem behavior)
2. Induction – formulation of theory and hypotheses about the behavior
3. Deduction – testable predictions are derived from these hypotheses
4. Testing – new materials are used to determine whether the predictions are correct or
incorrect
5. Evaluation of final results
1.1 Introduction
• Clinical psychodiagnostics is an exclusive specialism of the clinical psychology
o Was not popular for a long time, because it was seen as tedious, time-consuming and
labelling people on the basis of unreliable projective techniques and lengthy
questionnaires
▪ Now its agreed that a full diagnosis is a prerequisite for adequate care
• Clinical psychodiagnostics is a professional activity that is based on three elements:
1. Theory development of the problems/complaints and problematic behavior
2. Operationalization and its subsequent measurement
3. Application of relevant diagnostic methods
• Hypotheses about behavior, cognition and emotion/motivation are formulated on basis of a
theory, and are operationalized, measured and tested with a step-by-step diagnostic process
o It offers a framework and systematic approach for the step-by-step analysis of
complex diagnostic problems
1.2 Steps in the diagnostic process
1. (Usually) client’s referral to the diagnostician;
(occasionally) Client’s direct question to the
diagnostician
o Diagnostician analyses the client’s request
or help and the referrer’s request – it does
not need to be the same
2. Formulating questions out of referrer’s and clients’
needs and of aspects arising in the first session
3. Construction of a diagnostic scenario containing a
provisional theory about the client; describes what
the problems are and how they can be explained
o Diagnostic measures for testing the theory:
1. Converting the provisional theory
into concrete hypotheses
2. Selecting a specific set of research
tools, which can either support or
reject the formulated hypotheses
3. Making predictions about the
results/outcomes from this set of tools
4. Applying and processing instrument
5. On basis of obtained results, giving reasons for why the hypotheses have
been accepted or rejected → diagnostic conclusion
1.3 Five basic questions in clinical psychodiagnostics
1. Recognition: What are the problems; what works and what doesn’t?
2. Explanation: Why do certain problems exist and what perpetuates them?
, 3. Prediction: How will the client’s problems subsequently develop in the future?
4. Indication: How can the problems be resolved?
5. Evaluation: Have the problems been adequately resolved as a result of the intervention?
1.3.1 Recognition
• Diagnostician identifies complaints and adequate behavior of the client and/or their
environment
• Recognition includes: inventory & description; organization & categorization in
dysfunctional behavior clusters/disorders; examination of seriousness of the behavior
• Recognition may result from:
o Criterion-oriented measurement= Comparison to a predefined standard
o Normative measurement= comparison to a representative comparison group
o Ipsative measurement= comparison to the individual himself
• Distinction between classification and diagnostic formulation: (both have advantages and
disadvantages)
o Classification – clinical picture is assigned to a class of problems
▪ It’s done according to an all-or-nothing principle (e.g., DSM categories) or a
more-or-less principle (e.g. scores for dimensions)
▪ Leads to ‘labeling’ – is limited and can be the basis for comorbidity
▪ Facilitates communication between experts
o Diagnostic formulation – focuses on the individual and his own unique clinical
picture
▪ Allows uniqueness of the individual – helps the therapy planning but has an
occasional lack of empirical support
▪ Usually involves simultaneous recognition and explanation
1.3.2 Explanation
• Answering the question of why there is a problem or a behavioral problem includes:
1. Main problem or problem component
2. Conditions that explain the problem’s occurrence
3. Causal relationship between points 1 and 2
• Explanations may be classified according to:
1. The locus – i.e. the person or the situation
▪ Person-oriented explanations= explanatory factor lies in the person
• Occurs when the behavior is viewed separately from the context
▪ Situation-oriented explanation= explanatory factor lies in the event of a
well-known context
• The explanatory events may precede the behavior that is to be
explained or follow it
2. The nature of control
▪ Cause, i.e. determined by previous conditions
• Explain behavior
▪ Reason, i.e. determined by a voluntary or intentional choice
• Make behavior understandable
▪ Cause and reason do not constitute a dichotomy, but a continuum
3. Synchronous and diachronous explanatory conditions
, ▪ Synchronous explanatory conditions= match with the behavior that is to be
explained at the time
▪ Diachronous explanatory conditions= precede this behavior
• E.g., in psychoanalytic diagnostics the structural explanation is
synchronous and the psychogenic explanation is diachronous
4. Induced and persistent conditions
▪ Induced conditions – give rise to a behavioral problem
▪ Persistent conditions – perpetuate the behavioral problem
• Some diagnosticians have the tendency to work from one specific theory in their
explanation, even if there are additional explanatory theories → this influences and limits
the diagnostic process and predominantly influences and limits the indication
• Some professionals strive for a generally accepted, central theory, which should, together
with the biological influences, simultaneously identify the situational influences, personal
characteristics, development and systemic patterns
1.3.3 Prediction
• Prediction – making a statement about the problem behavior in the future
o It is a chance statement, e.g. the chance of fully resuming one’s work duties after a
head trauma
o This chance plays a part in determining the treatment proposal, e.g. short-term or
long-term treatment
• Prediction pertains to a relation between a predictor and a criterion
o Predictor= present behavior
o Criterion= future behavior
o The relationship may be known on the basis of examination, but it may occasionally
need to be determined for specific relationships between the client’s present and
future behavior
• In actual research, relations (correlations) are never perfect and we can only determine the
chance that behaviors will collectively occur in a particular population
• Even though the empirical evidence is ineffective, the diagnostician may occasionally need
to give an answer to a practical question – the diagnostician can make use of a model or
clinical prediction, in which he decides which information he will include in the prediction
and how he will intuitively integrate it
• In prediction, the margins of error (standard errors of an estimation) are often so large that
the high expectations of legal and other societal contexts cannot be met
1.3.4 Indication
• Indication – focuses on the question of whether the client requires treatment and, if so,
which caregiver and assistance are the most suitable for this client and problem
• Indication is characteristic of an orientation, a search process that involves finding which
treatment and which caregiver are most compatible with the client’s complaints, problems,
traits and preferences
• Before we can proceed to the indication, the steps for explanation and prediction must be
completed, however there are three additional elements:
1. Knowledge of treatments and therapists – requirements for treatments and therapists
are not clear, because many treatments are not clearly defined
, ▪ Exceptions are ambulant treatment vs. residential treatment,
psychotherapeutic treatment vs. pharmacological treatment and individual
treatment vs. group therapeutic treatment
2. Knowledge of the relative usefulness of treatments – studies are often not specific
enough to support certain therapeutic interventions and types of clients
▪ Meta-analyses of the effective components of different therapies can be
helpful when selecting a treatment
3. Knowledge of the client’s acceptance of the indication – there is a chance that a
client will not follow a recommendation if the proposed treatment deviates from his
preference
▪ There is an indication strategy that has been developed which takes the
client’s preferences into account; it contains four principles:
1. Client’s perspective is examined and explicated
2. Diagnostician provides the client with information about the courses
of treatment, processes, and therapists
3. Client’s expectations and preferences are compared to those that the
diagnostician deems to be suitable and useful and, during a mutual
consultation, a number of possible treatments, which are acceptable to
both parties, are formulated
4. Client selects a therapist and a treatment.
1.3.5 Evaluation
• Evaluation of the assertions about diagnosis and/or intervention takes place on the basis of
both the progress of the therapeutic process and the results of the treatment
o This establishes whether the therapy took account of the diagnosis and treatment
proposal – if this was not the case, the diagnostic process was unnecessary – and
whether the process and the treatment have brought about a change in the client’s
behavior and experience
• Can be carried out in two ways
o We can establish whether the complaints or problems decreased to the desired degree
without discussing if the changes were brought about by the therapy
o We can prove that the changes were caused by the therapy, e.g. with the help of n=1
designs, which have largely been developed within behavioral therapy
1.4 The diagnostic cycle
• One way to regulate and discipline the diagnostic process is to structure it according to the
empirical cycle of scientific research
• Diagnostic cycle= model for answering questions in a scientifically justified manner
• Consists of observation, induction, deduction, testing and evaluation
1. Observation – collecting and classifying empirical materials (provide the basis for
forming thoughts about the creation and persistence of problem behavior)
2. Induction – formulation of theory and hypotheses about the behavior
3. Deduction – testable predictions are derived from these hypotheses
4. Testing – new materials are used to determine whether the predictions are correct or
incorrect
5. Evaluation of final results
