Groenier Et Al 2008

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Clinical Psychology and PsychotherapyClin. Psychol. Psychother.15, 256265 (2008)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.587

Copyright 2008 John Wiley & Sons, Ltd.

Psychologists Judgements ofDiagnostic Activities: Deviations

from a Theoretical ModelMarleen Groenier,1* Jules M. Pieters,1Casper D. Hulshof,1Pascal Wilhelm1andCilia L. M. Witteman2,31Faculty of Behavioural Sciences, University of Twente, Enschede, the Netherlands2Diagnostic Decision Making, Behavioural Science Institute, RadboudUniversity, Nmegen, the Netherlands3Faculty of Psychology, University of Bergen, Bergen, Norway

In this article, we describe an investigation into the diagnostic activ-ities of practicing clinical psychologists. Two questionnaires werefilled in by 313 psychologists. One group of psychologists (N =175)judged the necessity of diagnostic activities; the other group (N=138)selected the activities they would actually perform. Results showedthat more participants thought that diagnostic activities were neces-sary than there were participants who intended to actually performthose activities. Causal analysis, by generating and testing diagnostichypotheses to form an integrated client model with an explanationfor the problem, was judged least necessary and would not be per-formed. We conclude that a discrepancy exists between the numberand types of activities psychologists judged to be necessary and theyintend to actually perform. The lack of attention for causal analysisis remarkable as causal explanations are crucial to effective treatmentplanning. Copyright 2008 John Wiley & Sons, Ltd.

* Correspondence to: Marleen Groenier, Faculty of Behav-ioural Sciences, University of Twente, P.O. Box 217, 7500 AEEnschede, the Netherlands.E-mail: [email protected]

several methods to collect relevant information,such as diagnostic interviews, tests or question-naires. The final diagnosis is the result of an integra-tion of the information gathered and the decisionsmade along the way. Theoretical models have beendeveloped to aid psychologists in organizing andjudging the importance of client information. Thesemodels usually contain several sequential phasesfrom describing the problem to selecting a treat-ment method (De Bruyn et al., 2003; Vertommen,Ter Laak, & Bijttebier, 2005). This paper focuseson the question of which diagnostic activities are

considered theoretically necessary in diagnosing aclient and which would be actually used. As furthertreatment planning depends on an accurate diagno-sis and an effective diagnostic process, research intodiagnostic activities can be used to improve both thediagnostic process and the diagnosis.

Since Meehl (1954) challenged the value of intui-tive clinical judgement, prescriptive methods forcollecting and interpreting information in psycho-

INTRODUCTION

The goal of psychodiagnosis is to understand thecomplaints of a client and to provide an indicationfor their treatment. In the psychodiagnostic process,information about the clients complaints, problemsand environment is gathered in interviews andthrough tests, until a classifying and explanatorydiagnosis is reached and treatment decisions canbe made (De Bruyn, Ruijssenaars, Pamijer, & VanAarle, 2003; Ruiter & Hildebrand, 2006). The goalof the psychodiagnostic process is to form an inte-

grated picture of the client, with a problem descrip-tion and an explanation for the problem, and topropose a possible treatment for the problem basedon this integrated picture. Psychologists may use


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Judgements of Diagnostic Activities 257

Copyright 2008 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 15, 256265 (2008)DOI: 10.1002/cpp

diagnosis have been proposed to counteract thelow reliability and validity of diagnostic judgement(Garb, 1998). The central idea of prescriptive psy-chodiagnostic models such as the diagnostic cycle(DC) is that psychodiagnosis should adhere to thescientific method of obtaining knowledge in psy-

chology by generating and testing hypotheses (DeBruyn et al., 2003). The DC prescribes three phases:observations of the client, formulation and testing ofthe hypotheses about the problem and the possiblecauses of the problem based on these observations,and an evaluation of the outcomes of testing thesehypotheses (Van Aarle & Van den Bercken, 1999).For example, a psychologist may see a child who iseasily distracted and at times aggressive. A hypoth-esis is generated about the origin of the aggressivebehaviour and a test is performed showing that thechild has limited social abilities. Based on studiesthat show that limited social abilities may result

from deprived sensory stimulation in early develop-ment, the psychologist then hypothesizes that thechild may have lacked physical contact in her earlyyears. This hypothesis is confirmed by the childsparents, who explain that due to an illness the childhad to be physically restrained and was not to becuddled for a short period after birth. The goal offormulating and testing hypothesized explanationsof a clients problem is to make sure that a plau-sible explanation is found by explicitly consideringand ruling out other possible causes, and conse-quently a focus in treatment can be selected on afirm foundation (De Bruyn et al., 2003). Identifying

causal factors that affect the problem is necessary inplanning effective treatment (Haynes & Williams,2003). Although formulating an explanation for aproblem is not always necessary to start treatment,it provides much-needed insight to direct treatmentif the problem is complex or the first-choice treat-ment method is not working as expected and theintervention needs to be adjusted.

The problem with most prescriptive models,including the psychodiagnostic models, is that theyare rather time-consuming. They propose strict andlengthy procedures that require much mental effort(Van Aarle & Van den Bercken, 1999). Also, imme-

diate feedback on the hypothesis-testing processnecessary to improve diagnostic performance islacking (Dawes, 1996; Garb, 1989). Psychologistsreceive minimal feedback on the accuracy of theirdiagnoses or on the quality of the hypotheses theygenerate, and if they receive feedback it is oftentoo late to be effective. In clinical practice, cognitiveand time limitations force psychologists to use theirmental resources efficiently. Psychologists often

generate mental short cuts (heuristics) to quicklydiagnose a client (see Garb 1998, for an extensivereview of the use of heuristics in clinical psychol-ogy). Using short cuts in reasoning is not uncom-mon in other fields. Research on solving chess andmedical problems showed that chess players and

physicians do not always adhere strictly to theoreti-cal problem-solving models to solve the problemsthey face (Boshuizen & Schmidt, 1992; Patel, Arocha,& Zhang, 2005). Several studies have compared thetheoretical problem-solving approach with the actualpractice of chess players (see Ericsson & Lehmann,1996, for a review). Results showed that successfulchess players do not extensively search for possiblemoves, as prescribed by the theoretical model butrather selected moves based on cued recall frommemory. In the medical field, it was assumed thatphysicians use some form of hypothesis testing indiagnostic problem solving (Elstein & Schwarz,

2002). However, empirical studies showed thatphysicians diagnostic reasoning is also influencedby rapid pattern-recognition processes (Lesgold etal., 1988). Deviations from a theoretical model arerelated to clinical experience. The reasoning strate-gies used by experienced professionals differ fromthose used by novices (Shanteau, 1988). Reasoningstrategies, thus, seem to change as clinical experi-ence increases and new ways to cope with time andcognitive limitations are created.

Empirical studies suggest that the same is truefor clinical psychologists. As experience increases,clinical psychologists approach the psychodiagnos-

tic process in a more flexible way, based on theclinical knowledge they have acquired in practice(Brammer, 1997; Bus & Kruizenga, 1989; Hillerbrand& Claiborn, 1990). Bus and Kruizenga (1989) showedthat diagnosing a client becomes a routine process.They expected that the diagnostic process wouldfollow the same procedure as scientific problemsolving. However, the psychologists in their studyseemed to gather information without any hypoth-eses or explicit goal. Also, recommendations couldnot be traced back to the diagnoses the psycholo-gists formulated. This finding was confirmed byWitteman and Koele (1999), who found that there

was no relation between the psychologists argu-ments and the treatment proposals. Hillerbrand andClaiborn (1990) claimed that this routine process ofpsychologists is based on their knowledge organi-zation. They argued that the psychologists orga-nization of their knowledge base changes throughclinical knowledge they acquire in practice, whichwould result in clearer and more accurate problemrepresentations. A more accurate problem represen-


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258 M. Groenier et al.


tation could increase diagnostic accuracy. A studyby Brammer (1997) confirms these findings. It foundthat more experienced psychologists asked fewerquestions but that these questions were more oftenrelated to diagnostic categories. Brammer arguedthat these questions were based on implicit theo-

ries psychologists had formed about the clients andthat they used these questions to fill up the gaps intheir theories. However, in these studies, it remainsunclear which steps are actually performed in thediagnostic process.

We aim to fill in the gap in the existing knowledgeabout clinical psychologists diagnostic reasoningby comparing their actual diagnostic process, fromregistration to treatment selection, with the activi-ties described in the theoretical models they aretaught during training. The little research there ishas mainly focused on the personal descriptionsof psychologists about their diagnostic process,

for example through verbal protocols (De Kwaad-steniet, Krol, & Witteman, 2008; Witteman & Kunst,1997). A drawback of these studies is that the termsused by the psychologists to describe their diag-nostic activities cannot be directly compared. Pro-viding psychologists with a common language asa frame of reference has been advocated by Beutler(1991) to overcome these limitations. This is whatwe undertake in this study. To be able to identifyand compare the diagnostic activities, we used listsof diagnostic activities prescribed by theoreticalmodels as frames of reference for the psychologiststo make their diagnostic process explicit.

The current study aims to establish which diag-nostic activities clinical psychologists judge to betheoretically necessary and which activities theyintend to actually perform themselves. A distinc-tion is made between judgements of the necessityof diagnostic activities and the intention to actu-ally perform these activities to control for possiblesocial desirability effects. Several review and meta-analytical studies (Ajzen, 2001; Ajzen & Fishbein,1977; Glasman & Albarracn, 2006) have shown thatthere is a difference between what people considernecessary and what they actually do. Althoughmeasuring the intention to perform activities is

not equal to measuring the actual behaviour, itapproximates the actual behaviour best.

METHOD

Participants

Participants for both questionnaires were 313members of the Dutch Institute of Psychologists

(NIP) mental health care division. The mean age ofthe participants was 44.29 years (Standard Devia-tion [SD] =11.21, range =2379 years). The major-ity of the participants had completed post-graduateeducation (87%), were registered mental healthcare psychologists (32%), had a BIG-registration1

(78%), worked part time (53%) and were employedin mental health care (48%). The theoretical ori-entation of the majority of the participants wascognitivebehavioural (55%). They worked withadult clients (50%) and with clients with personal-ity disorders. On average, the participants spentmost of their time treating clients, next on diagnos-ing clients, then on executive tasks, and they spentleast time on scientific research.

A total of 175 psychologists filled in the Ques-tionnaire Necessary Activities (the NA-group) and138 psychologists filled in the Questionnaire Per-formed Activities (the PA-group; see Materials).

Except for clinical setting, with more psychologistsworking in a hospital in the NA-group than in thePA-group (c2= 16.70, degree of freedom = 7, p=0.019), the groups did not differ in any other back-ground variable.

Procedure

By email we invited all members of the NIP mentalhealth care division to take part in the study. Par-ticipants who accepted the invitation were sent asecond email with a hyperlink to one of the twoweb-based questionnaires (see Materials; Cope,1993). The participants were randomly assignedto one of the two questionnaires.

Psychodiagnostic Model

Lists of diagnostic activities used in this study asframes of reference for responding were derivedfrom the DC (De Bruyn et al., 2003). The DC waschosen because it provides a clear specification ofthe diagnostic activities that a psychologist oughtto perform. The wording used in the DC is basedon generic terms recognizable both for partici-

pants educated with the DC and for participants

1The Individual Health Care Professions Act, known throughthe Dutch acronym as the BIG Act, regulates the provision ofcare by health care professionals. Only registered individu-als may use the legally protected title. The register enablesthe expertise of the registered practitioners to be recognizedby all.


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educated before the DC was introduced. Also, thewording is similar to that in other Dutch theoreti-cal models used in educational programmes, suchas the diagnostic model proposed by Vertommenet al. (2005).

Based on De Bruyn et al.s (2003) DC, we dis-

tinguished six main categories and 63 diagnosticactivities within the main categories (see Appen-dix A). The first main category, Registration (11activities), has the objective of deciding whetherthe assessment process is continued. The goal ofthe second main category, Complaint analysis(11 activities), is to identify and summarize theclients complaints and describe them in behav-ioural terms. In the third main category, Problemanalysis (10 activities), the problematic behaviourof the client is explored and the problem is statedin objective, testable terms. In the fourth main cat-egory, Explanation analysis (11 activities), alterna-

tive diagnostic hypotheses are generated and testedso that an integrated picture of the client with anexplanation for the problem can be formed. Afterthat, a method of treatment is selected in the fifthmain category, Indication analysis (15 activities).The final and sixth main category, Diagnostic sce-nario (5 activities), has the objective of formulatinga plan to answer the clients diagnostic questions.

Materials

We developed two web-based questionnaires.One questionnaire asked participants to judge the

necessity of the diagnostic activities derived fromthe DC (the Questionnaire Necessary Activities),and the other questionnaire asked participants toselect the diagnostic activities they actually intendto perform in diagnosing a client (the Question-naire Performed Activities), to be referred to as theNA-group and the PA-group, respectively.

Each questionnaire started with a description ofthe purpose of the study and the structure of thequestionnaire. Then a case description was pre-sented (see Appendix B). This case was selectedto be recognizable for every participant and waschecked with three experienced psychologists. The

participants had to keep this particular client inmind while filling in the questionnaires. The par-ticipants could also consult a list with explanationsof the concepts used in the questionnaire.

The next part was different for the two ques-tionnaires. The main categories and the diagnos-tic activities within the main categories were bothpresented in a fixed randomized order to the par-ticipants. The NA-group was asked to indicate, for

each activity, to what extent you deem that activitynecessary in diagnosing the client described in the casevignette on a four-point Likert scale ranging fromabsolutely unnecessary to absolutely necessary.The PA-group was asked to select the diagnosticactivities from each main category that you actually

intend to perform with the client described in the casevignette. Activities the participants did not intendto perform could be skipped.

Both questionnaires contained 14 open-end andmultiple-choice questions about the backgroundand job characteristics of the participant. Thesequestions asked about gender, age, work experi-ence, BIG-registration, part-time/full-time appoint-ment, clinical setting, theoretical orientation, clientpopulation, specialization in disorders, post-graduate education, and time spent on diagnosis,treatment, executive tasks, and scientific research.Each questionnaire ended with a request to partici-

pate in future research and a statement thankingthe participants for their cooperation.

Analysis

To facilitate the comparison of the results of thetwo questionnaires, the measurement scale of theQuestionnaire Necessary Activities was adjusted.For this purpose, the response options absolutelyunnecessary and unnecessary were recoded into(absolutely) unnecessary. Likewise, absolutelynecessary and necessary were recoded into(absolutely) necessary.

To establish which diagnostic activities psychol-ogists considered necessary and which activitiesthey intended to actually perform, percentageswere calculated. An independent samples t-testwas performed to test for differences between theanswers on the two questionnaires. To test fordifferences between main categories within eachquestionnaire, analyses of variance (ANOVAs)were performed. A Bonferroni procedure was usedto maintain an overall significance level of 0.05.

Also, background characteristics considered the-oretically relevant were selected and their influ-

ence on the selection of activities was investigated.Work experience, training, theoretical orientationand setting were entered into a multiple regres-sion analysis.

RESULTS

Figure 1 shows the percentage of participants in theNA-group who considered an activity (absolutely)


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necessary (dotted line) and the percentage of par-ticipants in the PA-group who actually intended toperform that activity (straight line).

The percentages of participants differed for the

two questionnaires, as can be seen in Figure 1. Per-centages of the NA-group are, on average, higherthan percentages of the PA-group (76 and 65%,respectively). This means that, for any activity,about three-fourths of the NA-group judges thatactivity (absolutely) necessary, while about two-thirds of the PA-group intends to perform thatactivity.

To compare main categories of activities, resultsfrom Figure 1 were comprised into an overview ofthese categories. Table 1 shows the percentages ofparticipants for each main category, per question-naire.

First, an independent samples t-test with percent-ages of the main categories as dependent variablesand questionnaire type as a grouping factor wasperformed to test for differences between the twoquestionnaires. Significant differences were foundfor Registration (t[299] =6.64,p


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main categories Diagnostic scenario and Explana-tion analysis were judged necessary by the lowestpercentage of participants.

For the PA-group also, a significant effect of maincategory was found (F[5, 8688] =30.34,p


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model of the client with an explanation for theproblem (Explanation analysis) receive much lessattention.

The theoretical diagnostic model used as a frameof reference for the activities to be judged, the DC,assumes that each part of the diagnostic process is

equally important. Results show that the relevanceand intention to actually perform the diagnosticactivities are judged differently.

More specifically, the lack of focus on the Expla-nation analysis is noteworthy. An integrated modelof the client including possible causal explanationsfor the problem behaviour, i.e., the end result ofthe Explanation analysis, is an essential conditionfor further treatment planning (Kendjelic & Eells,2007; Krol, Morton, & De Bruyn, 2004; Kuyken,Fothergill, Musa, & Chadwick, 2005). While thisis true theoretically, explanation does not receivemuch attention from the participants in our

study. A possible explanation could be that psy-chologists do not use causal reasoning to generatepossible explanations of the problem behaviour.Psychologists could be building a schema withexplanations directly upon seeing the symptoms(Mayfield, Kardash, & Kivlighan, 1999). Recogniz-ing the pattern of these symptoms might activatethe schemas of the disorders, which include diag-nostic explanations. Explicit causal analysis aboutexplanations then becomes unnecessary. An alter-native explanation could be that the participantsuse causal analysis implicitly. This explanation issupported by research by Kim and Ahn (2002),

who found that psychologists diagnostic reason-ing is based upon personal, implicit causal theo-ries about disorders. These causal theories maycorrespond to Brammers (1997) implicit theories.Based on a few observations, psychologists appearto form a theory about the clients problem. Theythen use this theory to guide further informationgathering (Brammer, 1997). These implicit theoriespreclude the necessity to explicitly reason caus-ally. Thus, psychologists might use pattern recog-nition to see whether the pattern of complaintsand problem behaviour of a specific client fits theirpersonal, implicit, causal theory. If so, then explic-

itly generating and testing possible explanationswould be redundant.

The regression analysis showed a significantinfluence of the background characteristics on theselection of activities and offers insight into the roleof the psychologists background in the decision-making process. Nevertheless, this result needs tobe regarded with some caution. The psychologistsbackground characteristics do determine the diag-

nostic decision-making process to some extent.However, individual contributions of work expe-rience, training, theoretical orientation and settingto the diagnostic decision-making process werenot determined due to heterogeneity of the pre-dictors used and limitations of the data collected.

The influence of the individual predictors shouldcertainly be explored further in future research.It should be noted that there was a difference

in clinical setting between the NA-group and thePA-group. That there were more psychologistsworking in a (general) hospital in the NA-groupthan in the PA-group may have resulted in differ-ences in the decision-making process. For example,psychologists working in a hospital might beused to diagnosing more complex and severeproblems.

ImplicationsClinical psychologists do not seem to practise whatthey preach. By comparing their diagnostic activi-ties to a theoretical model, the DC, we saw that oneactivity in particular seemed to be neglected: theexplanation analysis. Since proper treatment plan-ning depends on proper explanation, this activ-ity should be the focus of further studies: whendo psychologists engage in explanatory diagnosis,and what are the consequences for treatment plan-ning both when they do and do not explicitly lookfor explanations of their clients problems? Also,more attention could be paid to designing educa-tional aids to training psychologists to follow theprescriptions of a diagnostic process model andspecifically to reason causally about their clientscomplaints.

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APPENDIX A: DIAGNOSTIC ACTIVITIES (IN RANDOMIZED ORDER)

Registration

a01 Establish whether people involved are prepared to make arrangements about their contribution.a02 Determine the follow-up procedure in writing.

a03 Establish whether diagnostic examination is necessary.a04 Decide whether the registration procedure can be continued.a05 Check the demands for the length of the treatment.a06 Establish whether the diagnostician can perform the examination.a07 Establish whether the formal positions are in conflict with legal provisions.a08 Determine clients motives and expectations.a09 Make arrangements about the follow-up procedure.a10 Determine who are involved at registration.a11 Determine the follow-up procedure orally.

Complaint analysis

k01 Check whether complaints and diagnostic questions are complete.k02 Formulate the goals of the complaint analysis.k03 Order complaints and diagnostic questions in importance.k04 Explain the importance of the complaint analysis to the client.k05 Go over the arrangements from registration.k06 Record the order of the complaints and diagnostic questions in writing.k07 Check interpretation of the complaints against the clients interpretation.k08 Convert clients experience of the complaints into diagnostic questions.k09 Check that complaints and diagnostic questions are consistent.k10 Formulate the complaints.k11 Explain the methods of the complaint analysis.

Problem analysis

p01 Compare the clients behaviour to dysfunctional behaviour categories in the literature (e.g., DSM).p02 Make an inventory of problem behaviours and the situations in which they occur.p03 Discuss the problem analysis with colleagues.p04 Establish the risk factors of the clients behaviour.p05 Assign disorders to a category with the help of a classification system.

p06 Assess the severity of the problems.p07 Describe the problem behaviour.p08 Explain the classification system to the client.p09 Weigh the positive and negative behaviours.p10 Order the disorders.

Explanation analysis

v01 Operationalize the hypotheses about the problems explanation into testable predictions.v02 Evaluate the results of testing the diagnostic explanations.v03 Test the diagnostic explanations.v04 Split up the diagnostic reasoning schema into testable statements.v05 Check whether there is knowledge that allows the testing of the diagnostic explanations.v06 Determine the degree of certainty about the results of testing the diagnostic explanations.v07 Order causal relations between problems and conditions into a preliminary diagnostic reasoning schema.

v08 Process the results of testing the diagnostic explanations into an integrated model.v09 Perform a literature search on the causal relationships between problems and conditions.v10 Establish the criteria for the testable predictions.v11 Analyse the hypotheses about the explanations of the clients problem.


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APPENDIX B

Case Description

The case description below is based on the firstconversation between a client and the psychologistwho is treating her.

Case Description: Mrs. W.Mrs. W. says that she feels she hasnt gotten over

the death of her mother. Her mother passed away 2years ago. Since a year ago, Mrs. W. often cries sud-denly, she talks to her mother in her thoughts, andshe often visits her mothers grave. Her mothersdeath also keeps her preoccupied in other situa-tions. At work, Mrs. W. finds it hard to distanceherself from the stories she hears about accidents.She notices that she has become more sensitive.She feels that she has lost her joy of living. Further-

more, she talks about the strains of taking care ofher sister who has multiple sclerosis and about theburden of her husbands alcohol addiction. They

Indication analysis

i01 Select the most appropriate treatment(s).i02 Formulate concrete and specific treatment goals.i03 Weigh the costs and benefits of a possible treatment.i04 Check whether treatment is possible.i05 Check the requirements for the length of a treatment.

i06 Consult the literature on treatment instruments and techniques.i07 Ask clients appreciation about treatment proposals.i08 Check whether treatment is necessary.i09 Make an inventory of treatment instruments and techniques.i10 Select type of setting for treatment.i11 Formulate final global treatment goals.i12 Check whether treatment is desirable.i13 Weigh chance of success and failure of a possible treatment.i14 Select a theoretical framework.i15 Choose between a direct or an indirect treatment.

Diagnostic scenario

d01 Explain the follow-up procedure to the client.d02 Rewrite (partial) diagnostic questions briefly.d03 Check sub-questions in diagnostic questions.d04 Identify types of queries and types of diagnostic examinations.d05 Formulate diagnostic sub-questions.

separated 8 years ago but never got a divorce. Shealso feels weighed down by having to take care ofher father after her mothers death.

Three years ago, she was hospitalized in apsychosomatic clinic for 3 weeks because of herproblems with her husband. This did not lead tothe expected relief. Mrs. W. did not open herselfup to the therapeutic possibilities. Mrs. W. is stillmarried, but she does not live together with herhusband, although they have three sons together.The eldest was born in 1972. Two years ago, Mrs.W. started a new relationship but she became lessinvolved with her boyfriend the past few weeks.In the past years, she has been taking Oxazepamin stressful situations because of her restless-ness and sleeping disorders. There is no regularintake.

For the past 15 years, Mrs. W. has been working

in the administration department of a physicaltherapy practice. At the moment, she works 28hours a week.

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Groenier Et Al 2008