Transcript Classification, Diagnosis, & Assessment

Assessment, Interviewing, &
Observation in Clinical Psychology
Dr. Kline
Florida State University
I. Clinical Assessment: Questions
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1. What are goals of assessment?
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2. How is assessment carried out?
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3. What types of data are obtained?
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4. How does assessment allow us to make
inferences regarding treatment?
Why do Clinicians make assessments?
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While most individuals speculate why people behave the way
they do, they aren’t formally trained to make assessments
regarding others’ actions & motives.
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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.
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By conducting assessments, Clinicians can determine an
individual’s diagnosis and the best course of action to treat
the disorder/problem.
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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.
The Clinical Assessment Process
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Clinicians gather information (data) on individuals in a formal
systematic fashion to determine the problem & subsequent
treatment plan.
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At each stage in the assessment process, the Clinician faces
challenges such as:
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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?
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Schematic view of Clinical Assessment Process
Planning Data
Collection
Procedures
Collecting
Assessment
Data
Data
Processing &
Hypothesis
Formation
Communicating
Assessment Data
A. Clinical Assessment Issues:
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1. Planning for Assessment
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Before conducting a clinical assessment, we have to two issues
to address.
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a. What do we want to know?
b. How do we find out about it?
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The answer to both questions hinges largely on the specific
approach (psychodynamic, behavioral, humanistic, etc.) the
Clinician is likely to adopt.
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The Clinician’s approach may have a large impact on the type of
data they want to gather for their assessment.
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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.
Case Study Guide-provides a general overview of the client
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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.
Factors Guiding Assessment Choices
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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.
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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.).
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2. Diagnoses are also influenced by the theoretical approach
the Clinician is adopting.
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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.)
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3. Research on the reliability & validity of assessment methods
are used to determine which types of data are gathered.
Issues in Testing:
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A. Reliability—consistency with which a
test measures what it purports to measure.
Types of reliability:
 *inter-rated reliability
 *test-retest reliability
B. Validity
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Types of validity:
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*content validity-does test measure content
area?
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*face validity—on surface does test
measure what it’s supposed to.
Validity contd.
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Concurrent validity-does the index being
used to measure a type of abnormal
behavior agree with another index used to
measure the same behavior.
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Predictive validity-does measure
accurately predict the occurrence of some
event.
Goals of Clinical Assessment: 3 goals
1. Diagnostic Classification- Determining the
diagnosis for the problem behavior. What is it?
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2. Description- understanding the social,
cultural, & physical context of behavior.
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3. Prediction- What will people do in a variety
of settings based on their past behavior?
Why an “accurate diagnosis” is so
important in Clinical psychology?
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1. The appropriate treatment plan cannot be implemented
until we have an accurate definition of what is wrong
with the client.
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2. Research into causes of psychological disorders
requires reliable & valid identification of disorders &
accurate differentiation of one disorder from another
(Nietzel et al., 2003).
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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).
Diagnostic standard in Clinical Psychology
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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.
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Clinicians currently use the fourth edition of the DSM or The
DSM-IV. This version was published in 1994 and revised in
2000. Plans for a DSM-V are in the works!!
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The DSM-IV is based on a multi-axial classification system.
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Each individual is rated on 5 separate dimensions or axes.
Axis I: Psychiatric disorders, excludes
personality disorders & mental retardation.
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Axis II: Personality disorders & mental
retardation.
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Axis III: General medical conditions
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Axis IV: Psychosocial & environmental
problems.
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Axis V: Current level of functioning: Global
Assessment Scale
Axes I & II comprise the classification of
abnormal behavior.
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Most individuals consult a clinician for an
Axis I condition (e.g., depression).
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Clinician must examine if Axis II disorder is
also present.
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Axis II disorders make treating Axis I
disorders more complicated.
Axis I Disorders
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1. Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence
*separation anxiety
 *attention-deficit/hyperactivity disorder
 *autism
2. Mood disorders-disturbances
in emotion and behavior.
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*Major Depression (unipolar depression)
 *Mania
 *Bipolar disorder (Manic Depression)
 *Cyclothymia (Chronic mood disorder)
 Dysthymia
3. Schizophrenia-disturbances of
thought, emotions, and behavior.
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Different types:
Paranoid Schizophrenia
 Catatonic Schziophrenia
 Undifferentiated Schizophrenia
4. Anxiety disorders
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Generalized anxiety disorder (GAD)
 Phobias
 Panic Disorder
 Obsessive-compulsive disorder (OCD)
 Post-traumatic stress disorder (PTSD)
 Acute Stress Disorder
5. Sexual disorders
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Gender Identity disorder
 Transvestism
 Pedophilia
 Voyeurism
 Exhibitionism
 Sadism/Masochism
 Rape trauma
Axis II: personality disorders
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Schizoid PD—person is aloof, has few friends,
& is indifferent to praise/criticism.
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Borderline PD—erratic behavior, impulsivity,
and instability in relationships/ mood, & selfimage.
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Narcissistic PD—people who have malignant
grandiosity of their own self-importance.
Axis II (contd.)
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Histrionic PD- marked by an overly
dramatic display of behavior that is for
show (no real substance underneath).
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Antisocial PD—marked by violent acts &
lack of empathy for others.
2. Collecting Assessment Data: Four main
sources
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1. Interviews- Clinicians may simply ask the client questions to
find out what is happening in his or her life.
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Advantages of interviews:
*Allows Clinician to obtain a sample of the client’s verbal & nonverbal behavior in a social interaction.
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*No equipment is necessary to conduct an interview.
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*Interviews are flexible.
2. Observations –Clinicians may want to
observe non-verbal behaviors in a variety of
situations.
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The goal here is to look at what the client is
“doing” rather than what he/she is saying.
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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?
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3. Tests- Clinicians may administer tests to
assess a variety of abilities, functions, traits,
& aptitudes.
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Advantage of tests
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*Tests may be more reliable than interviews.
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*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.
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*Responses on tests can be quantified, providing
more objective data with which to make a more
accurate assessment.
4. Life Records – Clinicians obtain data
about a client from this life history.
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Our life history may provide useful information about our past
behavior.
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Examples of life records:
Academic transcripts, driving record, financial records,
diaries/journals, occupational history, etc.
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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.
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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.
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This is easier said than done, as clinical
inference can be tricky.
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Again, the theoretical approach of the
clinician plays a large role in how they
interpret the assessment data they’ve
obtained.
Three main ways Clinicians view Assessment
Information:
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1. Samples- Clinicians may examine the raw behavior
of the client (E.g., What the client did?)
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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).
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3. Signs- The raw behavior sample may be viewed as
a sign of other less obvious client traits
(characteristics).
1. Sample behavior
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“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.”
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The incident is the sample in this case. On this data alone the Clinician might
infer the following:
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*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.
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Problems—No effort is made by the Clinician to
ascertain “why” the client made the attempt in the first
place.
2. Correlates- The client’s behavior may be
viewed for its correlation with other
individuals’ behaviors.
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*The client is likely to be elderly, single, divorced, or widowed and lives alone
with a physical ailment.
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*The client is or has been depressed.
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*The client has little support from family & friends.
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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.
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Inferences are more accurate when more information is known about the
relationships between variables.
3. Signs- The suicide attempt may be viewed
as a sign of other lesser known client traits.
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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.
4. Communicating Assessment Data
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Once the Clinician as assessed the data they
write up a detailed report for other Clinicians
and professionals to view.
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This report needs to be clear, relevant to the
treatment outcomes proposed, and efficient for
the treatment to be implemented.
II. Clinical Interviews:
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Clinicians have a conversation with the client
with the purpose of learning more about the
client.
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This allows the Clinician to both observe
verbal & non-verbal behavior in a social
interaction (providing two sources of
information).
A. Types of Clinical Interviews:
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1. Intake interviews- are the most common form of interviews
in which clients come to clinicians because of a problem they are
having.
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Clinicians try to determine several things from intake
interviews:
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*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?
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2. Problem-Referral Interviews:
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In these interviews, the client has been referred to the Clinician
from another sources or agency (psychiatrist, court, school,
employer, social service agency, etc.).
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These individuals are sent to the Clinician to address a
specific referral issue.
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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?
3. Orientation Interviews:
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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.)
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.
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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!!)
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.
B. Interview Structure: the most fundamental part
of an interview is its structure.
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Structure refers to the degree to which the interviewer
determines the content and course of the
conversation.
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There are two basic kinds of structure for interviews:
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1. Nondirective interviews -in which the clinician
does a little as possible to stop the natural flow of the
conversation with the client.
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2. Structured interview -the interview is carefully
planned with a systematic format.
Structured interviews
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To make reliable and valid diagnoses, clinicians
need to gather standardized information on
patients.
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SCID (Structured Clinical Interview)- a
structured interview for Axis I of the DSM.
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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.
C. Stages in the Interview: Basic format
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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.
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.
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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?”
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This puts onus on client & allows them to direct
the flow of the conversation.
Active Listening
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Is a non-directive tactic where the clinician responds to the client’s
speech in ways that indicate understanding & facilitate further
communication.
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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.
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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.
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Rogers called “paraphrasing” reflection.
Reflection examples:
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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.
Directive techniques:
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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.
Stage 3: Closing the Interview
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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.
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The clinician may reiterate what was covered in the
interview for clarification and for the chance to ask
more questions before closing the interview.
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This allows the clinician to summarize the interview
content and to make sure nothing was misunderstood
or omitted.