Chapter 7 – Assessment, Formulation, and Goal Setting

A set of vocabulary flashcards summarizing key terms and definitions from Chapter 7 on assessment, formulation, and goal setting.

Assessment

The systematic process of gathering and organizing information about a client for understanding, planning, and intervention.

Process of Assessment

The logistical questions of why, who, what, how, where, and when the assessment is conducted.

Content of Assessment

The substantive information gathered—participants, problems, strengths, contexts, timelines, and resources.

Formal Clinical Assessment

A structured evaluation used for diagnosis, treatment planning, or research that considers problems, strengths, relationships, spirituality, and social forces.

Technology-assisted Assessment

Use of computers or other devices to collect, score, interpret, or report assessment data.

Methods of Assessment

Four primary data-gathering approaches: interviews, observations, testing, and review of life records.

Assessment Interview

A conversation aimed at collecting clinical data; it may be unstructured, semistructured, or structured.

Unstructured Interview

Flexible interview allowing the clinician to follow the client’s lead with minimal predetermined questions.

Semistructured Interview

Interview guided by a checklist of content areas while still allowing conversational flexibility.

Structured Interview

Interview consisting of standardized questions asked in a fixed order to ensure consistency.

Observation (Clinical)

Direct evaluation of a client’s behavior and interactions in natural or clinical settings.

Informal Observation

Unsystematic watching of behavior without pre-identified target behaviors or antecedents.

Formal Observation

Systematic recording of clearly defined target behaviors along with their antecedents and consequences.

Assessment Testing

Administration of standardized instruments measuring symptoms, intelligence, personality, neuropsychology, or aptitudes.

Reliability

The consistency of an assessment measure across time, raters, or diagnostic decisions.

Validity

The degree to which an assessment accurately measures what it intends to measure.

Test-retest Reliability

Stability of test results when the same instrument is administered to the same person over time.

Inter-rater Reliability

Agreement between different clinicians scoring or interpreting the same assessment data.

Diagnostic Reliability

Consistency with which different clinicians assign the same diagnosis using a classification system.

Review of Life Records

Examination of previous treatment notes, school records, medical reports, and online information with client consent.

Eco-map

Graphic depiction of a client’s social and environmental systems, highlighting strengths and stressors.

Life Chart

Visual timeline summarizing major life domains, values, and purpose across the lifespan.

Strength-based Genogram

Family diagram emphasizing intergenerational strengths, resources, and positive patterns.

Conceptualization

Integration and analysis of assessment data to form hypotheses about the client’s situation.

Formulation

A concise summary explaining the meaning of assessment data and guiding future intervention.

Multidisciplinary Team

Group of professionals from various fields collaborating on assessment and formulation.

Levels of Inference

The degree of speculation when interpreting data: low (data-close), moderate (correlational hunches), high (theory-based interpretations).

Low-level Inference

Staying close to the raw data with minimal interpretation.

Moderate-level Inference

Forming hypotheses based on correlations among observed behaviors.

High-level Inference

Interpreting data through broader theoretical models involving greater speculation.

Diagnostic and Statistical Manual (DSM)

APA’s classification system providing a common language for mental disorder diagnosis.

International Classification of Diseases (ICD)

WHO’s global system for coding medical and mental health conditions.

Culture-bound Syndrome

A mental or emotional condition that appears unique to a specific cultural group.

Cultural Formulation Interview

DSM-5 tool for assessing cultural factors affecting distress and care.

Cultural Universalism

View that mental disorders are fundamentally similar across cultures.

Cultural Relativism

View that mental disorders are shaped by cultural context and vary across groups.

Stigma (in Diagnosis)

Negative labeling and stereotyping that can follow a diagnostic classification.

Psychological Report

Written summary of assessment findings required by insurers or agencies; should be clear, factual, and client-inclusive.

Clinical Record

File containing assessment data, formulation, treatment plans, progress notes, HIPAA releases, and external reports.

Goal Setting

Collaborative process of defining desired outcomes for change in therapy.

Short-term Goal

Objective that can be accomplished quickly, often a step toward a larger aim.

Long-term Goal

Outcome requiring extended effort and time to achieve.

Positive Goal

Statement of what the client wants to attain or increase rather than eliminate.

Negative Goal

Goal framed around stopping or reducing an undesired behavior.

Partializing

Breaking overarching goals into smaller, manageable objectives.

Prioritizing Goals

Ordering objectives from simple to complex or urgent to less urgent to build momentum.

Operationalize (Goals)

Translating goals into specific, observable behaviors and contexts.

Stakeholders (in Goal Setting)

Individuals or groups—client, family, professionals—who have an interest in the goals established.

Attainable Goal

A realistically achievable objective within available resources and constraints.