Assessment in Clinical Psychology

  • 1960's and 1970's—Decline in assessment measures and focus more on therapy.
  • Clinical Assessment: Evaluation of an individual or family's strengths and weaknesses, conceptualization of the problem and prescription for alleviating it.
  • Our capacity to understand a problem is based on our skill to diagnose it (diagnose before treatment).
  • Referral Question: Take into consideration what question was asked by the referral source and what the referral source is seeking. (e.g. from parent, teacher, psychologist).

What Influences How the Clinician Addresses the Referral Question?

  • The type of information asked is often based on the clinician's theoretical approach (ex: psychodynamic clinician may ask about childhood experiences but a behavioral clinician may ask about daily life).
  • Assessment Interview: Most basic and serviceable data gathering tools. It has a wide range of application and adaptability, but this again depends on the clinician's skills.

General Characteristics of Interview

An Interaction

  • Interaction between at least 2 people in which each person contributes to the process and influences the other's response.
  • Involves face-to-face interaction but the conversation is based on a specific set of goals in mind.
  • One characteristic that interviews have that conversation does not—the interexchange is not based on personal satisfaction or prestige (used to gather data and information).

Interviews Versus Tests

  • More purposeful but less formalized than standardized psychological tests.
  • Psychological tests—collection of data under standardized conditions using structured procedures.
  • Interviews can use an individualized approach and are more flexible.

The Art of Interviewing

  • Except for diagnostic interviews have a degree of freedom to their structure.
  • Clinician slowly learns to respond to patients cues over time.

Computer Interviewing

  • Asks all the questions that are assigned and has 100% reliability.
  • May be less uncomfortable for patient to answer in private (dehumanizing to an extent).
  • Clarification of interview questions is not possible and there is no flexibility room.
  • Computers can't assess non-verbal cues (ex: facial expression), can't assess free-form responses, can't apply clinical judgment to patients.

Interview Essentials and Techniques

The Physical Arrangements

  • The setting needs to consider privacy and protection from interruptions.
  • Soundproofing may be necessary to ensure privacy (ex: remove hallway noise).
  • Most clinicians prefer a neutral office setting.

Note Taking and Recording

  • Few key note phrases will aid the clinician in recalling client's responses.
  • Most patients assume that some form of note-taking will occur, but may request note­taking not occur for certain sensitive topics of discussion
  • Verbatim notes; except during a structured interview as it prevents from noticing non­verbal or subtle cues.
  • Audio or videotaped interviews must be done with patient's full consent.

Rapport

Definition and Functions

  • Rapport: Characterize the relationship between patient and clinician, involving comfortable atmosphere and mutual understanding of the purpose and goals of interview.
  • Establishing a positive relationship will determine the type and amount of information the clinician will acquire from the patient.

Characteristics

  • Requires attitude of acceptance, understanding, respect for patient's integrity.
  • Does not require the clinician to like or be friends with the patient.
  • Allows for probing and confrontation once rapport has been established.

Special Considerations

  • Difficult in establishing rapport with multiple individuals during family or marriage counseling.
  • Similar situations may occur with child and adolescents where rapport must be established with both patient and parent(s).

Communication

Beginning a Session

  • Using general topics like the weather or difficulty about finding a parking space are good starters.
  • Establishes the clinician as a real person and removes them from being related to as a “shrink”. Helps relax the patient.

Language

  • Initial estimation of patients age, background and educational level to determine what language to use.
  • Using proper language to establish oneself as a professional but also being cognizant of the client's needs “not using teenager language like LOL”.

The Use of Questions + Silence

  • Questions may become more structured over time—open ended, facilitative, confronting.
  • Assess meaning and functions of the silence—organizing thought, deciding what to say.

Listening

  • Listen and appreciate the emotions that the patient is conveying.
  • If the clinician is concerned about impressing the client, or guided by other motivations therapy will not be effective.

Gratification of Self

  • Clinicians must resist temptations to think about their own problems and concerns; but instead focus on the patient.
  • Clinicians should avoid discussing their personal lives with the patient.

The Impact of the Clinician

  • The type of therapist that a patient has—tall, thin and muscular vs. very feminine female will elicit different responses from their patients.
  • The clinician must thus have a degree of self-insight to consider the possible impact they can have.

The Clinician's Values and Background

  • Clinicians must examine their own assumptions before making judgements about others; some misconceptions may essentially be a part of the other person's culture.
  • Gender differences or different frame-of-references can sometimes elicit the same response of disconnect from the patient.

The Patients and Clinicians Frame of Reference

  • Being sensitive to the patient's initial perceptions and expectations in necessary to establish rapport.
  • The clinician needs to be prepared and should know everything there is to know about that patient before the first meeting.

o The clinicians should also be clear about the purpose of the interview, and clear about the nature of what is required if it is for a referral.

Varieties of Interviews

  • Interviews first differ in terms of purpose, and second in terms of whether it is unstructured (clinical interview) or structured.
  • Unstructured Interview: Clinicians are allowed to ask any questions that come to mind in any order.
  • Structured Interview: Verbatim set of standardized questions in a specific sequence.

The Intake-Admission Interview

  • Helps determine why the patient has come to the hospital or clinic and judge whether the facilities resources will meet the patients' needs and expectations.
  • Conducted by a psychiatric social worker.
  • Can be done face to face or via phone.
  • Informs patients of clinicians fees, policies, procedures.

The Case-History Interview

  • A complete personal and social history is taken—concrete facts and dates and a patient's feelings about them.
  • Broad history and context in which the patient and problem can be placed.
  • Gathering historical-developmental context so that diagnostic significance and implications can be determined.
  • Can also use outside sources (e.g. parents, teachers, peers).

The Mental Status Examination Interview

  • Conducted to assess cognitive, emotional and behavioral problems.
  • Very unreliable because they are unstructured in nature.
  • One of the primary modes of assessment for a variety of mental health issues.

The Crisis Interview

  • Hotline interviews for people fearful of abusing their children or abusing drugs.
  • Rules of interviewing are blurred but the basics remain.
  • Purpose is to meet the problem as it occurs and provide immediate resource of relief.

The Diagnostic Interview

  • Evaluation against DSM-IV criteria; historically it used a free form unstructured interview.
  • Structured diagnostic interviews: Standard set of questions and follow up questions in a specific sequence. Allows for greater inter-rater reliability.
  • Very few clinicians used these structured interviews in daily life (only 15%).

Reliability and Validity of Interviews

  • Interrater Reliability: Level of agreement between two raters who evaluate the same patient. Quantified using the kappa coefficient or the intraclass correlation coefficient.
  • Kappa Coefficient: To determine how reliable rater judge the presence or absence of a feature of a diagnosis. Between .75 and 1.00 *best inter-rater agreement level.
  • Validity concerns how well an interview measures what it intends to measure.
  • Predictive validity: Scores from a measure, correlated (“predicted”) future events relevant to that construct.

Reliability

  • Structured interviews are more reliable than unstructured (reduce information and criterion variance)
  • Information Variance: Variation in the questions that clinicians ask, observations made and the method integrating that information.
  • Criterion Variance: Variation in the scoring threshold among clinicians. Clear cut scoring criteria is better.
  • DSM-III and structured interviews to assess DSM criteria made diagnostic interviews more reliable.
  • Test-Retest Reliability: Consistency of scores or diagnosis across time (retaken).

o Goes down over longer time periods—years or months.

Validity

  • Content Validity: Measures comprehensiveness in assessing the variable of interest (does it measure all areas of the construct of interest).
  • Criterion-Related Validity: Ability of a measure to predict (correlate with) scores on other relevant measures.
  • Concurrent Validity: Type of criterion-related validity. Extent to which interview scores correlate with scores on other relevant measures given at the same time.
  • Predictive Validity: Type of criterion-related validity. Extent to which interview scores correlate with scores on other relevant measures, at some point in the future.
  • Discriminant Validity: Extent to which interview scores do not correlate with measures that are not theoretically related to the construct being measured. E.g. no reason phobia of spiders should relate to intelligence.
  • Construct Validity: Extent to which interview scores demonstrates all aspects of validity.

Suggestions for Improving Reliability and Validity

  • Use a structured interview, or consider developing one.
  • Interview skills that are essential: establish rapport, being a good communicator, listener, knowing when to remain silent and ask questions, observe verbal and non-verbal cues.
  • Be aware of patients motives and expectations for the interview.
  • Be aware of your own (clinicians) expectations, biases and cultural values.
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