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Article Excerpt
Because mental health counselors typically rely on confirmatory or supportive questions to gain initial impressions about their clients' presenting concerns, they tend to search for differential diagnostic information less frequently (e.g., Haverkamp, 1993: Parmlev, 2007). There has been little empirical attention given to the potential mechanisms for confirmatory questions. Accordingly, this study used multilevel modeling to analyze 772 confirmatory and disconfirmatory questions generated by 97 mental health counselors in training. Mental health counselors in this study, as in previous research, generated more confirmatory questions that supported their initial diagnostic impression than disconfirmatory questions; confirmatory questions were rated as having more diagnostic clarity and as being more specific. Further, confirmatory questions were more likely to be elicited from the initial case data presented to the counselor These findings suggest that the ability of mental health counselors to generate questions that support their initial impressions may surpass their ability to formulate questions that adequately test differential diagnoses. Implications for training and practice are offered.
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Diagnostic assessments provide the foundation for the goals of therapy, which can ultimately impact its course. Accordingly, to develop an accurate diagnostic impression, mental health counselors should consider a wide variety of assessment information about their clients' relational systems, personality factors, individual stressors, and cultural views (Kaslow, 2004; Krishnamurthy et al., 2004). In the process counselors use both confirmatory evidence to rule in potential diagnoses and disconfirmatory information to test the viability of alternative diagnoses (Pepinsky & Pepinsky, 1954; Spengler, Strohmer, Dixon, & Shivy, 1995). Confirmatory assessment strategies are commonly defined as questions (or other assessment strategies) that elicit information from the client to support a mental health counselor's initial diagnostic impression; disconfirmatory approaches are questions that seek to expand or test alternative hypotheses about the client's concerns (e.g., differential diagnoses) (Haverkamp, 1993). Clinically, balancing the use of confirmatory and disconfirmatory approaches is optimal.
However, mental health counselors use confirmatory more than disconfirmatory assessment approaches to formulate clinical impressions (Haverkamp, 1993; Morran, Kurpius, Brack, & Rozecki, 1994; Osmo & Rosen, 2002; Pfieffer, Whelan, & Martin, 2000; Snyder &Swann, 1978; Strohmer & Shivy, 1994; Strohmer, Shivy, & Chiodo, 1990). Confirmatory approaches would not be problematic if they were correct or at minimum congruent with the client. However, confirmatory assessment approaches have been associated with incomplete or incorrect decisions (e.g., Dawes, 1994; Koehler, Brenner, & Griffin, 2002; Parmley, 2007) and lower client ratings of therapeutic alliance (Morran et al., 1994). Therefore, as clients and mental health counselors strive to agree on the goals for therapy--a component of the working alliance--confirmatory approaches may hamper the process.
Most studies to date have examined how often mental health counselors use confirmatory or disconfirmatory assessment approaches with clients who endorse different clinical syndromes, such as depression or anxiety (Haverkamp, 1993; Pfieffer et al., 2000; Strohmer & Shivy, 1994). However, many questions can arise about the nature of confirmatory and disconfirmatory assessment strategies (e.g., How are the strategies similar or different? What elicits the use of confirmatory or disconfirmatory strategies?). This study examines three aspects--(a) source, (b) diagnostic clarity, and (c) structure (e.g., specificity)--of counselors' confirmatory and disconfirmatory questions during the initial assessment.
The Initial Assessment Process
At the start of the assessment process, clients present cursory details about their concerns and mental health counselors elicit additional information through a variety of approaches, such as asking questions. While the initial information can be helpful for formulating a diagnostic impression, counselors should be cautious about drawing firm conclusions too soon; some clients are reluctant about the therapy process and may not fully disclose their situation to the therapist (Constantine, 2007; Mahalik, Good, & Englar-Carlson, 2003). Simply, counselors might miss important information if they foreclose on a diagnostic impression too early in the assessment process.
The tendency to focus on information that is readily available is often referred to as the availability heuristic (Faust, 1986; Gambrill, 2005). In their assessments, mental health counselors have been found to form quick impressions (e.g., within three minutes; Sandifer, Hordern, & Green, 1970) and then derive conclusions, at times with little information (see Ambady & Rosenthal, 1992; Ambady, Bernieri, & Richeson, 2000, for reviews). Moreover, initial impressions can dictate future perceptions and evaluations (Chapman & Johnson, 2002). For instance, Parmley (2007) found that counselors did not adjust their judgments when they were presented with evidence that disconfirmed their initial impression, even when they were educated about clinical biases. Consequently, initial impressions that rely primarily on cursory information may ignore other essential narratives about, for example, a client's relational or cultural history, and the diagnostic impression is likely to guide future interaction regardless of accuracy.
As the assessment continues, mental health counselors gain new information using questions as well as other assessment techniques; they must then weigh the merits of these data compared to their initial impression. However, not all assessment questions are equal in their diagnostic clarity or ability to generate meaningful information. For instance, to rule out or in major depressive episode, a counselor might start by asking a confirmatory question such as "Have you been feeling sad most of the time? ... every day?" (DSM-IV-TR, 2000). The same counselor might also ask a disconfirmatory question, "Do you experience some...
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