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Assessment, Interviewing, & Observation in Clinical Psychology

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1 Assessment, Interviewing, & Observation in Clinical Psychology
Dr. Kline Florida State University

2 I. Clinical Assessment: Questions
1. What are goals of assessment? 2. How is assessment carried out? 3. What types of data are obtained? 4. How does assessment allow us to make inferences regarding treatment?

3 Why do Clinicians make assessments?
While most individuals speculate why people behave the way they do, they aren’t formally trained to make assessments regarding others’ actions & motives. Clinical psychologists are trained to systematically & formally examine behaviors of people to determine if there are mental problems, behavior problems, family dysfunctions, & evidence of psychopathology. By conducting assessments, Clinicians can determine an individual’s diagnosis and the best course of action to treat the disorder/problem. Unfortunately, while Clinicians may be more objective than lay individuals, they have their biases as well which effect the assessment tools they use to examine an individual & possibly the treatment plan as well.

4 The Clinical Assessment Process
Clinicians gather information (data) on individuals in a formal systematic fashion to determine the problem & subsequent treatment plan. At each stage in the assessment process, the Clinician faces challenges such as: How do we gather the data? How much information is enough? What kinds of data are important (valuable)? How can we eliminate inaccurate/useless information? How do we put the information together to form a diagnosis? How do we avoid our own biases coming into the picture? Who gets to see the results of the assessment & for what purposes? How will the assessment results effect the clients? How do we ensure confidentiality of the assessment?

5 Schematic view of Clinical Assessment Process
Data Processing & Hypothesis Formation Planning Data Collection Procedures Collecting Assessment Data Communicating Assessment Data

6 A. Clinical Assessment Issues:
1. Planning for Assessment Before conducting a clinical assessment, we have to two issues to address. a. What do we want to know? b. How do we find out about it? The answer to both questions hinges largely on the specific approach (psychodynamic, behavioral, humanistic, etc.) the Clinician is likely to adopt. The Clinician’s approach may have a large impact on the type of data they want to gather for their assessment. Furthermore, the amount of data that could be obtained is vast (from biological to life record) & so it would be difficult to know just how much data is necessary to make an accurate assessment. A. Clinical Assessment Issues:

7 Case Study Guide-provides a general overview of the client
Levels of Assessment & Some Representative Data from Each 1. Somatic- Blood type, RH factor, autonomic stress response pattern, kidney & liver function, genetic data, basal metabolism, vision, toxicology, neuroimaging data (fMRI, Cat, Pet). 2. Physical- Ht, wt, sex, eye color, hair color, body type 3. Demographic- Name, age, address, phone#, occupation, education, income, marital status, # of children. 4. Overt Behavioral- Reading speed, eye-hand coordination, frequency of fighting with others, conversational skill, interpersonal assertiveness, occupational competence, smoking habits. 5. Cognitive- Response to intelligence test items, reports on thoughts, performance on tests of information processing or cognitive complexity, response to tests of reality perception and structuring. 6. Emotional- Reports of feelings, responses to tests measuring mood states, physiological responsiveness. 7. Environmental- Location& characteristics of housing; # & description of cohabitants, job requirements & characteristics; physical & behavioral characteristics of family, friends, & coworkers; nature of specific cultural or subcultural standards & traditions; general economic conditions; geographical location.

8 Factors Guiding Assessment Choices
1. Often Case Study Guides are associated with a particular theoretical approach to clinical psychology. This influences the kinds of questions & data the Clinician will pursue. E.g., a Clinician with a heavy biological orientation, will want to obtain biological data (fMRI, Pet, toxicology, etc.) to see if the behavior is related to an organic cause (brain infection, tumor, stroke, dementia, drug use, etc.). 2. Diagnoses are also influenced by the theoretical approach the Clinician is adopting. E.g., A Clinician with a cognitive-behavioral approach will not only make assessments regarding client’s thinking skills, thought patterns, & the maladaptive thoughts, but will tend to make diagnoses based on this paradigm as well (changing the client’s maladaptive thoughts to reduce the problem behaviors.) 3. Research on the reliability & validity of assessment methods are used to determine which types of data are gathered.

9 Issues in Testing: A. Reliability—consistency with which a test measures what it purports to measure. Types of reliability: *inter-rated reliability *test-retest reliability

10 B. Validity Types of validity:
*content validity-does test measure content area? *face validity—on surface does test measure what it’s supposed to.

11 Validity contd. Concurrent validity-does the index being used to measure a type of abnormal behavior agree with another index used to measure the same behavior. Predictive validity-does measure accurately predict the occurrence of some event.

12 Goals of Clinical Assessment: 3 goals
1. Diagnostic Classification- Determining the diagnosis for the problem behavior. What is it? 2. Description- understanding the social, cultural, & physical context of behavior. 3. Prediction- What will people do in a variety of settings based on their past behavior?

13 Why an “accurate diagnosis” is so important in Clinical psychology?
1. The appropriate treatment plan cannot be implemented until we have an accurate definition of what is wrong with the client. 2. Research into causes of psychological disorders requires reliable & valid identification of disorders & accurate differentiation of one disorder from another (Nietzel et al., 2003). 3. Classification allows multiple Clinicians to discuss a client’s case or cases based on a given disorder accurately & efficiently (i.e., standardized of diagnosis).

14 Diagnostic standard in Clinical Psychology
In 1952, The American Psychiatric Association published its first official classification system, the “Diagnostic and Statistical Manual of mental disorders.” Several revisions have been made to the DSM over the years. Clinicians currently use the fourth edition of the DSM or The DSM-IV. This version was published in 1994 and revised in Plans for a DSM-V are in the works!! The DSM-IV is based on a multi-axial classification system. Each individual is rated on 5 separate dimensions or axes.

15 Axis I: Psychiatric disorders, excludes personality disorders & mental retardation.
Axis II: Personality disorders & mental retardation. Axis III: General medical conditions Axis IV: Psychosocial & environmental problems. Axis V: Current level of functioning: Global Assessment Scale

16 Axes I & II comprise the classification of abnormal behavior.
Most individuals consult a clinician for an Axis I condition (e.g., depression). Clinician must examine if Axis II disorder is also present. Axis II disorders make treating Axis I disorders more complicated.

17 Axis I Disorders 1. Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence *separation anxiety *attention-deficit/hyperactivity disorder *autism

18 2. Mood disorders-disturbances in emotion and behavior.
*Major Depression (unipolar depression) *Mania *Bipolar disorder (Manic Depression) *Cyclothymia (Chronic mood disorder) Dysthymia

19 3. Schizophrenia-disturbances of thought, emotions, and behavior.
Different types: Paranoid Schizophrenia Catatonic Schziophrenia Undifferentiated Schizophrenia

20 4. Anxiety disorders Generalized anxiety disorder (GAD) Phobias
Panic Disorder Obsessive-compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Acute Stress Disorder

21 5. Sexual disorders Gender Identity disorder Transvestism Pedophilia
Voyeurism Exhibitionism Sadism/Masochism Rape trauma

22 Axis II: personality disorders
Schizoid PD—person is aloof, has few friends, & is indifferent to praise/criticism. Borderline PD—erratic behavior, impulsivity, and instability in relationships/ mood, & self-image. Narcissistic PD—people who have malignant grandiosity of their own self-importance.

23 Axis II (contd.) Histrionic PD- marked by an overly dramatic display of behavior that is for show (no real substance underneath). Antisocial PD—marked by violent acts & lack of empathy for others.

24 2. Collecting Assessment Data: Four main sources
1. Interviews- Clinicians may simply ask the client questions to find out what is happening in his or her life. Advantages of interviews: *Allows Clinician to obtain a sample of the client’s verbal & non-verbal behavior in a social interaction. *No equipment is necessary to conduct an interview. *Interviews are flexible.

25 2. Observations –Clinicians may want to observe non-verbal behaviors in a variety of situations.
The goal here is to look at what the client is “doing” rather than what he/she is saying. Clinicians may observe: client’s eye contact how distractible is the client Does the client seem comfortable or agitated Is the client coherent or rambling Does client keep changing topic in social interaction?

26 3. Tests- Clinicians may administer tests to assess a variety of abilities, functions, traits, & aptitudes. Advantage of tests *Tests may be more reliable than interviews. *Tests that have been standardized, allow Clinicians to obtain data on a client or multiple clients that can be compared with individuals in the general population. *Responses on tests can be quantified, providing more objective data with which to make a more accurate assessment.

27 4. Life Records – Clinicians obtain data about a client from this life history.
Our life history may provide useful information about our past behavior. Examples of life records: Academic transcripts, driving record, financial records, diaries/journals, occupational history, etc. Advantages of Life records: *Easy to obtain *You don’t have to worry about memory problems or biases in obtaining this type of data. *Allows you to summarize a client’s behavior over a long span of time.

28 3. Processing Assessment Data
Once the Clinician has obtained data on a client, they have to make an inference regarding the client’s diagnosis & subsequent treatment plan. This is easier said than done, as clinical inference can be tricky. Again, the theoretical approach of the clinician plays a large role in how they interpret the assessment data they’ve obtained.

29 Three main ways Clinicians view Assessment Information:
1. Samples- Clinicians may examine the raw behavior of the client (E.g., What the client did?) 2. Correlates- The sample of a client’s raw behavior may be viewed as a correlate to other aspects of their life (Neitzel et al., 2003). 3. Signs- The raw behavior sample may be viewed as a sign of other less obvious client traits (characteristics).

30 1. Sample behavior “A person overdoses on pain medication in a hotel room one night before going to bed. Fortunately, the individual is saved after being discovered by the hotel maid and is rushed to the hospital.” The incident is the sample in this case. On this data alone the Clinician might infer the following: *Conclude the client had access to lethal meds. *Client did not wish to be saved as no one was warned of the suicide attempt. *Under similar situations, the client may attempt suicide again. Problems—No effort is made by the Clinician to ascertain “why” the client made the attempt in the first place.

31 2. Correlates- The client’s behavior may be viewed for its correlation with other individuals’ behaviors. *The client is likely to be elderly, single, divorced, or widowed and lives alone with a physical ailment. *The client is or has been depressed. *The client has little support from family & friends. With the correlates method, the Clinician may look at the facts related to the client’s individual behavior as well as the how this behavior is related to the Clinician’s knowledge base of factors associated with suicide attempts. Inferences are more accurate when more information is known about the relationships between variables.

32 3. Signs- The suicide attempt may be viewed as a sign of other lesser known client traits.
Inferences made from sign perspective (Neitzel et al., 2003) *The client’s aggressive impulses have been turned against the self. *The client’s behavior reflects intrapsychic conflicts. *The pill taking may be an unconscious cry for help. Here a Clinician with a psychodynamic approach makes inferences well beyond the scope of the assessment data in determining why the individual made the suicide attempt. Caution– the sign approach may lead to inaccurate inferences regarding a client’s motives, actions, traits, etc. This is one of the fundamental problems using such a method. Nevertheless, sometimes Clinicians go with a “hunch” in explaining why a person behaved a given way.

33 4. Communicating Assessment Data
Once the Clinician as assessed the data they write up a detailed report for other Clinicians and professionals to view. This report needs to be clear, relevant to the treatment outcomes proposed, and efficient for the treatment to be implemented.

34 II. Clinical Interviews:
Clinicians have a conversation with the client with the purpose of learning more about the client. This allows the Clinician to both observe verbal & non-verbal behavior in a social interaction (providing two sources of information).

35 A. Types of Clinical Interviews:
1. Intake interviews- are the most common form of interviews in which clients come to clinicians because of a problem they are having. Clinicians try to determine several things from intake interviews: *Can I help this person? *Is this client’s problem within my area of expertise? *Will this person benefit from treatment? *Can I make a diagnosis of the problem? *Can I establish a rapport with this person to treat them?

36 2. Problem-Referral Interviews:
In these interviews, the client has been referred to the Clinician from another sources or agency (psychiatrist, court, school, employer, social service agency, etc.). These individuals are sent to the Clinician to address a specific referral issue. Examples include: Is the person stand to fit trial? Is the person psychotic? Is the person mentally retarded or developmentally delayed? Is the parent fit for custody? Is the parent in the best interest of the child?

37 3. Orientation Interviews:
These interviews are conducted to provide the client with information regarding the assessment, treatment, or research procedures to be implemented. Advantages: 1. Client learns more about assessment & treatment outcomes in his/her situation. 2. Are important for research participants so that we can learn more about assessment & treatment outcomes (e.g., efficacy of therapeutic methods.)

38 4. Termination or Debriefing Interviews
These interviews are conducted once assessment has been completed. Essentially, they allow the Clinician to convey what they “found” during the assessment. E.g., following a problem-referral interview the clinician may have enough information to convey the answer the client regarding the referral question. *Yes, you are fit to stand trial!!)

39 5. Crisis Interviews: If a client is having a crisis (e.g., rape hotline, domestic abuse, etc.) where they need the Clinician immediately, a crisis interview may be conducted. Crisis interviews are designed to provide immediate social & administrative support, collect assessment data, and provide help as quickly as possible. Because this is a crisis, the Clinician needs to be as calm as possible & determine if the client is a danger to themselves or others. The Clinician may also have to determine if the individual needs to be hospitalized for their safety.

40 B. Interview Structure: the most fundamental part of an interview is its structure.
Structure refers to the degree to which the interviewer determines the content and course of the conversation. There are two basic kinds of structure for interviews: 1. Nondirective interviews -in which the clinician does a little as possible to stop the natural flow of the conversation with the client. 2. Structured interview -the interview is carefully planned with a systematic format.

41 Structured interviews
To make reliable and valid diagnoses, clinicians need to gather standardized information on patients. SCID (Structured Clinical Interview)- a structured interview for Axis I of the DSM. Questions are in prescribed order for interviewer to ask. The SCID is a branching interview, which means the patient’s response to one question, will determine the next question asked.

42 C. Stages in the Interview: Basic format
Stage 1: Beginning the Interview – The clinician begins the interview in a comfortable setting, and by trying to establish rapport with the client. This can be done by: *Sitting fairly close to the client (when possible) *Keeping physical barriers between the client & Clinician to a minimum *Start interview with non-threatening small talk to allow the client time to relax *Review client’s referral or background info so the Clinician may have some information on the client before starting the interview. *Provide reassurance and support.

43 Stage 2: The middle of the interview
The clinician should try to make the transition from the beginning to the middle of the interview as smooth as possible. Non-directive tactics: Most Clinicians begin the second stage of the interview with non-directive open-ended questions. E.g., “What brings you here today?” This puts onus on client & allows them to direct the flow of the conversation.

44 Active Listening Is a non-directive tactic where the clinician responds to the client’s speech in ways that indicate understanding & facilitate further communication. E.g., Clinician may say something like, “I see” or “I’m with you,” in response to a major point a client has just made. Related to this concept is “paraphrasing” in which Clinicians restate what their clients say to demonstrate they are listening to them and are willing to give the client a chance to correct the comment if misinterpreted. Rogers called “paraphrasing” reflection.

45 Reflection examples: Example A:
Client: Sometimes I get so mad at my boss, I could just kill him Clinician: You would just like to get rid of your boss altogether. Example B: Client: Sometimes I get so mad at my boss, I could just kill him. Clinician: Your boss really upsets you sometimes. In Example A, the Clinician restates the client’s remark. This does show active listening. In Example B, the Clinician reflects the emotion or feeling made in the client’s remark. Both versions usually will facilitate the client to continue discussing the program.

46 Directive techniques:
Clinicians may also use more directive tactics to determine what’s bothering their clients. This is usually done after a good rapport has been established so as to avoid threatening the client.

47 Stage 3: Closing the Interview
The Clinician closes the interview by making sure they have enough information for assessment as well as continuing to establish a good rapport with the client. The clinician may reiterate what was covered in the interview for clarification and for the chance to ask more questions before closing the interview. This allows the clinician to summarize the interview content and to make sure nothing was misunderstood or omitted.


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