Clinical-Psych 2.docx

**[LESSON 3: Diagnosis and Classification of Psychological Problems]\ What Is Abnormal Behavior?** - **[Clinical psychology]** is usually thought of as an **[applied science]**. Clinicians attempt to ***apply empirically supported psychological principles*** to problems of adjustment...

**[LESSON 3: Diagnosis and Classification of Psychological Problems]\ What Is Abnormal Behavior?** - **[Clinical psychology]** is usually thought of as an **[applied science]**. Clinicians attempt to ***apply empirically supported psychological principles*** to problems of adjustment and abnormal behavior. - This involves ***finding successful*** ways of **changing the behavior**, **thoughts**, and **feelings of clients**. - **[Applied science]** refers to the practical application of scientific knowledge and principles to solve real-world problems or improve existing processes. It involves using scientific findings and theories to develop technologies, products, or methods that address specific needs or challenges in various fields. **[Abnormal behavior is so difficult to define]** are (a) no ***single descriptive feature*** is shared by all forms of abnormal behavior, and no one criterion for **"abnormality**" is sufficient; and (b) no discrete boundary exists between normal and abnormal behavior. **[Proposed definitions of abnormal behavior: ]** - \(a) statistical infrequency or violation of social norms, - \(b) the experience of subjective distress, and - \(c) disability, dysfunction, or impairment. - [*DSM*-*5,* mental disorder is defined as a **"*clinically significant disturbance*" in "cognition, emotion regulation, or behavior"** that indicates **a "*dysfunction" in "mental functioning*"** that is "usually associated with significant distress or disability" in work, relationships, or other areas of functioning (American Psychiatric Association, 2013, p. 20) ] - **Abnormal Psychology --** Disorders - **Clinical Psychology --** How to be a Clinical Psychologist ***How to say a person is Abnormal? (5D)*** **1. Deviation** When behavior is not commonly usual. **2. Discomfort or Distress** When the person feels he is not comfortable with the way he feels. **3. Dysfunctional** -- sudden changes in the behavior that affects interpersonal and occupational. ***Ex. Avoiding others*** **4. Danger** --Dangerous to self and others ***Ex. Suicidal ideations*** **5. Diagnosis** -- confirmation if appears to the DSM 5 or 5-TR [\ **The DSM-5(5-TR)**] **Before the DSM** - Hippocrates (460--377 BCE) wrote extensively about abnormality, but unlike most of his predecessors, he did not offer **[supernatural explanations]** such as possession by demons or gods. Instead, his theories of **[abnormality emphasized natural causes.]** Specifically, he pointed to an **imbalance of bodily fluids** (***blood, phlegm, black bile, and yellow bile***) as the underlying reason for various forms of mental illness (Blashfield, 1991; Butcher et al., 2007). **DSM---Earlier Editions (I and II)** - ***DSM-I (***1952) - ***DSM-II (***1968) - *DSM-I* and *DSM-II* contained only three broad categories of disorders: ***psychoses*** (which would contain today's schizophrenia), ***neurose***s (which would contain today's major depression, bipolar disorder, and anxiety disorders), and ***character disorders*** (which would contain today's personality disorders; Blashfield, Flanagan, & Raley, 2010; Horwitz, 2015). - The first **two *DSM*** editions reflected the ***psychoanalytic approach*** to understanding people and their problems. **DSM---More Recent Editions (III, III-R, IV, and IV-TR)** ***DSM-III (1980)*** - It relied to a much greater extent on empirical data to determine which disorders to include and how to define them. - It used specific diagnostic criteria to define disorders. Whereas the ***DSM-III* retained some descriptive paragraphs** (and in fact augmented them for most disorders), these paragraphs were followed by specific criteria---checklists, basically---that delineated in much greater detail the symptoms that must be present for an individual to qualify for a diagnosis. - It **dropped any allegiance to a particular theory of therapy or psychopathology.** As a result, the psychoanalytic language of previous editions was replaced by terminology that reflected no single school of thought. - It introduced the **[multiaxial assessment system]** that remained in *DSM\ *through the next several editions but **[was dropped in *DSM-5*]**. When multiaxial assessment was in place, the psychiatric problems were described on each of five distinct axes. **[Axis I]** included disorders thought to be ***more episodic*** (likely to have beginning and ending points), and **[Axis II]** included disorders thought to be **more stable or long-lasting**. **[Axes III and IV]** offered clinicians a place to **list medical conditions** and **psychosocial/environmental problems**, respectively, relevant to the mental health issues at hand. And Axis V, known as the Global Assessment of Functioning (GAF) scale, provided clinicians an opportunity to place the client on a 100-point continuum describing the overall level of functioning. - **Axis I** - Included episodic disorders. - **Axis II** - Included stable, long-lasting disorders. - **Axis III** - Listed relevant medical conditions. - **Axis IV** - Listed psychosocial and environmental problems **DSM-5: The Current Edition** - In May 2013, ***DSM-5*** was published (*substantial revision of the manual in about 20 years*) - David Kupfer and Darrel Regier,(Led by two prominent mental health researchers ), it involved hundreds of experts from over a dozen countries contributing their time and expertise over a 12-year period. - It involves ideas for adding, eliminating, combining, splitting, or revising the definitions of disorders. - Throughout the process, the *DSM-5* authors tried to coordinate their efforts with those of the World Health Organization (WHO), which publishes the *International Classification of Diseases* (*ICD*). - ***DSM-5*** authors, the fact that not every proposal is adopted, and changes that may be reconsidered for future editions of the manual. 1\. The authors of *DSM-5* considered significantly overhauling the manual to emphasize ***neuropsychology,*** or the ***biological roots***, of mental disorders. - Although there are many mental disorders that involve biological factors, those disorders lack definitive, reliable **["biological markers"---]** the kinds of things that indicate that a person "**tests positive**" or **"tests negative"** in a conclusive way. 2\. A dimensional approach was also seriously considered for a particular subset of mental disorders: personality disorders. The ***DSM-5* authors** proposed a specific way of ***understanding personality disorders dimensionally***, but the proposal ***was rejected*** as being too complex and ***not clinically useful enough***. 3\. The ***DSM-5* authors** considered removing ***5 of the 10 personality disorders*** previously included in that section, a change that would have significantly reshaped that category. The **five** that were on the ***chopping block at one point*** were paranoid, schizoid, histrionic, dependent, and narcissistic personality disorders***. The DSM-5 authors ultimately decided to retain all of them*** (American Psychiatric Association, 2011; Pull, 2013). - There were numerous proposals for specific **new disorders** that were considered but rejected. **"Emerging Measures and Models"** *1.**Attenuated psychosis syndrome***. which features the hallucinations, delusions, and disorganized speech characteristic of schizophrenia but in much less intense and more fleeting forms, and in which the person doesn't lose touch with reality in a pervasive way (American Psychiatric Association, 2013; Frances, 2013a; Tsuang et al., 2013; Wakefield, 2013a) *2. **Mixed anxiety-depressive disorder***, which features some symptoms of anxiety, some symptoms of depression, but not enough of either to qualify for any existing disorder (such as generalized anxiety disorder or major depressive disorder; American Psychiatric Association, 2013; Frances, 2012a) *3. **Internet gaming disorder***, which features excessive and disruptive Internet game-playing behavior (Bean, Nielsen, van Rooij, & Ferguson, 2017; King & Delfabbro, 2014a, 2014b). To a lesser extent, the *DSM-5* authors also considered other disorders based on various nonsubstance addictive-related behaviors such as shopping, exercise, work, and sex (American Psychiatric Association, 2013; Frances, 2013a; G. Greenberg, 2013; Kafka, 2013; King & Delfabbro, 2013; Petry & O'Brien, 2013; Wakefield, 2013a). **New Features in DSM-5** - The manual is not *DSM-V*, but *DSM-5* - Traditional **Roman numerals** **Arabic numerals** - The reason for this shift is to enable more frequent **minor updates** that will be named just as changes to **computer operating systems** and applications are often named: ***DSM-5.1, DSM-5.2***, et cetera. - This naming change is ***not merely superficial***. It suggests that *DSM* is a ***["living document"]*** that, in the future, will be more quick to respond to new research that improves our understanding of mental disorders. - The ***multiaxial assessment system***---a central feature of *DSM* since its introduction in *DSM-III* in 1980---***was dropped altogether from DSM-5***. - This removal brings a number of important changes to the way clinicians diagnose clients. - The tradition of separate **axes** for disorders that **tend to persist long-term** (such as developmental disorders and personality disorders, formerly on **Axis II**) from disorders that tend to be more **short-term or episodic** (such as major depression, formerly on **Axis I**) is now gone. - **Axis V**, the Global Assessment of Functioning (GAF) scale, is now eliminated, so there is **no longer a single numeric scale on which clinicians can describe their clients' level of functioning across all disorders** **New Disorders in DSM-5** 1\. ***[Premenstrual dysphoric disorder]** (*PMDD)-a ***severe version of premenstrual syndrome (PMS***), including a combination of ***at least five emotional*** and ***physical symptoms*** occurring in most menstrual cycles during the last year that cause clinically significant distress or interfere with work, school, social life, or relationships with others 2**[. *Disruptive mood dysregulation disorder* ]**(DMDD), which is essentially frequent temper tantrums in ***children 6 to 18 years old*** (***[at least three tantrums per week]*** over the course of a year) that are clearly below the ***expected level of maturity*** and occur in at least two settings (e.g., home, school, or with friends) along with ***irritable or angry mood between the temper tantrums.*** 3\. ***[Binge eating disorder]*** (BED) Binges must take place at least once per week for 3 months and be accompanied by a lack of control over the eating as well as other symptoms like rapid eating, eating until overly full, eating alone to avoid embarrassment, and feelings of guilt or depression afterward *4. **[Mild neurocognitive disorder ]***(mild NCD) a ***less intense version of major neurocognitive problems*** like dementia and amnesia. It requires modest decline in such cognitive functions as memory, language use, attention, or executive function, but nothing serious enough that it interferes with the ability to live independently. 5**[. *Somatic symptom disorder*]** (SSD), which involves a ***combination of at least one significantly disruptive bodily (somatic) symptom*** with excessive focus on that symptom (or symptoms) that involves perceiving it as more serious than it really is, experiencing high anxiety about it, or devoting excessive time and energy to it **Revised Disorders in DSM-5** 1. **"bereavement exclusion"** The rationale for the exclusion was that the ***sadness that commonly comes with such loss*** should not be confused with the mental disorder of major depression. 2. **Asperger's disorder**, - *autism spectrum disorder*. The reason for consolidating these disorders is that, according to *DSM-5* authors, ***they represent various points on the same spectrum of impairment***, defined by ***social communication problems*** and ***restrictive*** or ***repetitive behaviors*** and ***interests.*** 3. 3\. criteria for **Attention-deficit/hyperactivity disorder** (ADHD), the age at which **symptoms must first appear** was changed **from 7 to 12 years old**, and the number of symptoms required for the diagnosis to apply to **adults was specified as five** (as opposed to six for kids) 4. 4\. In the criteria for **Bulimia nervosa**, the frequency of binge eating required for the disorder was dropped from ***twice per week to once per week***. In the diagnosis of **Anorexia nervosa**, the requirement that ***menstrual periods stop has been omitted***, and the definition of ***low body weight has been changed from a numeric definition*** 5. 5\. **Mental retardation** was renamed ***[Intellectual disability]** (intellectual development disorder)*, and learning disabilities in reading, math, and writing were combined into a single diagnosis with a new name: *specific learning disorder.* **Controversy Surrounding DSM-5** - *DSM-5* arrived in May 2013 - The majority of the commentary surrounding *DSM-5* was critical, and the most vocal critic was **Allen Frances** - The risks that *DSM-5* will mislabel normal people, promote diagnostic inflation, and encourage inappropriate medication use. 1**. *[Diagnostic overexpansion]****.* its diagnoses ***cover too much of normal life***---in other words, too often it takes difficult or inopportune life experiences and labels them as mental illnesses 2\. ***[Transparency of the revision process]**.* they shared information throughout the revision process, including proposals for changes to the manual, some critics argued that t***hey were vague and selective about what they shared,*** that too many of their ideas and decisions were eventually made behind closed doors. 3**[. *Membership of the work groups.* ]**Undoubtedly, they understand the disorders in their area of expertise in terms of designing and conducting empirical studies, but some of them ***do not practice at all***, and those who do may only ***do so minimally***, so their ability to assess the impact of *DSM* changes on ***full-time clinicians practicing in real- world clinics, hospitals, and private practices may have been lacking*** **Cultural Issues** - Cultural concepts of ***distress,*** or terms used by various cultural groups to describe specific psychological conditions - The paragraphs describing schizophrenia, *DSM-5* contains several paragraphs on cultural issues, including such statements as "Ideas that appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another" - Few of the empirical studies considered by the authors of the current *DSM* have focused sufficiently on ethnic minorities, ***which suggests that the DSM still may not reflect minority experiences*** - The implicit values of ***Western culture*** have been the focus of some *DSM* critics as well. They argue that these values are embedded in the *DSM* and that they ***don't encompass the values of many people from [non-Western] societies*** **Causes of Abnormal Behavior and Mental Illness** - *What factors may cause abnormal behavior and mental illness?* **Major Models of Psychopathology** 1. **[Diathesis-Stress Model ]** The diathesis-stress model of psychopathology: The diathesis-stress model ***is not wedded to one school of thought*** and can incorporate ***[biologica]***l, ***[psychological]***, and ***[environmental factors]***. - A ***[diathesis]*** refers to a ***vulnerability or predisposition*** to possibly develop the disorder in question. - **[BIOLOGICAL]** (e.g., a genetic predisposition, a deficit or excess in neurotransmitter functioning) - **[PSYCHOLOGICAL]** (e.g., maladaptive cognitive schema, maladaptive personality style). - A diathesis is necessary but *[not sufficient]* to produce a mental disorder. - Predispositions, whether they are biological or psychological, do not guarantee that people develop psychological disorders - According to the diathesis- stress model, the ***[combination]*** of a predisposition and stress (or stressors) may produce psychological problems. **[Diathesis-Stress Model ]** - Two other features of this model are important to note as well. 1\. it is important to recognize that a diathesis or predisposition, be it biological or psychological, ***can influence the perception of stress.*** Stress is, after all, subjective in nature. The same event may be perceived and experienced as much more stressful by one person than another person who has a different level of the diathesis or vulnerability. 2\. one's predisposition is likely to **influence a person's own life course and choice of experiences.** In other words, individuals' choices of life experience and their preferences are likely guided, at least in part, by the diathesis. This makes some sense, if we think about it for a moment. Our experiences are influenced by a number of preferences and decisions we make. **The Value of Classification** - Classification systems are necessary; otherwise, our experience and our consciousness become a chaotic array of events. By ***abstracting*** the ***similarities*** and the ***differences*** among the events of our experience***, we can establish categories of varying width and purpose that allow us to generalize and predict.*** - All of us have, and will continue to have, some disagreement with the *DSM 5* or any other diagnostic system. Diagnostic systems have their advantages and disadvantages, and the criteria for individual mental disorders are fallible (Widiger & Trull, 1991). - However, we hope that you are convinced that **diagnostic formulations are important** because these formulations have ***communication value***, have potential ***treatment implications***, and ***facilitate psychopathology research.*** **[LESSON 4: Clinical Interview]** **Clinical Interview** - Any assessment technique used by a clinical psychologist should possess the qualities of validity, reliability, and clinical utility (Hogan & Tsushima, 2016; J. M. Wood et al., 2007). - **Validity -** "Does this really measure what it says it measures?" - **Reliability - I**t yields consistent, repeatable results - **Clinical utility -** technique is used in clinical settings. - An element common to all kinds of psychological assessment is ***feedback***. In other words, ***clinical psychologists provide their clients with the results of tests or interviews that have been conducted*** (American Psychological Association, 2002). - Most psychologists believe that clients find their ***feedback to be helpful and positive***, even before any type of ***intervention*** (e.g., psychotherapy) is implemented (S. R. Smith, Wiggins, & Gorske, 2007). - Clinical psychologists ***rely most frequently on the clinical interview.*** The **vast majority of clinical psychologists use interviews**, and few assessments are conducted without an interview of some kind (Norcross, Hedges, & Castle, 2002; Watkins, Campbell, Nieberding, & Hallmark, 1995). **\ Defining Validity, Reliability, and Clinical Utility for Assessment Methods** **Validity** - measures what it claims to measure. - **Content validity** - has content appropriate for what is being measured. - **Convergent validity** - correlates with other techniques that measure the same thing. - **Discriminant validity** - does not correlate with techniques that measure something else. **Reliability** - yields consistent, repeatable results. - **Test-retest reliability** - yields similar results across multiple administrations at different times. - **Interrater reliability** - yields similar results across different administrators. - **Internal reliability** (e.g., split-half reliability) - consists of items that are consistent with one another. **Clinical utility** - improves delivery of services or client outcome. **\ \ THE INTERVIEWER** - the interviewer should have acquired some general skills to serve as a foundation for interviewing in any context. - **Sommers-Flanagan and Sommers-Flanagan (2009) describe several such requirements:** **1. Quieting Yourself -** the interviewer shouldn't talk much during the interview. Rather than the interviewer's speech, what should be quieted is the inter- viewer's internal, self-directed thinking pattern. 2\. **Being self-aware-** The type of self-awareness that should be maximized is the ***interviewer's ability to know how he*** or ***she tends to affect others interpersonally*** and how others tend to relate to him or her. 3\. **Developing positive working relationships with clients-** There is ***no formula*** for developing positive working relationships during an interview; however, ***attentive listening, appropriate empathy***, ***genuine respect***, and ***cultural sensitivity play significant roles***. Positive working relationships are always a function of the interviewer's attitude as well as the interviewer's actions (Sommers-Flanagan & Sommers-Flanagan, 2009). **Specific Behaviors** - A primary task of the interviewer is to listen. **Listening** may seem like a simple enough task, but it can be broken down into even more fundamental building blocks of **attending behaviors** 1[. **Eye Contact** ] - Eye contact not only facilitates listening, but it also communicates listening. - Inconsistent eye contact may be viewed by some clients as inattentive or insulting. Like so many other aspects of the clinical inter- view, eye contact is a specific behavior that requires cultural knowledge and sensitivity on the part of the interviewer, both as the sender and receiver of eye contact. - **Eye Contact -**culture plays a significant role in the meaning of eye contact. In some cultures, eye contact that lasts too long or is too intense may communicate threat, seduction, or other messages that an interviewer would be wise to avoid 2\. **Body Language** - A few general guidelines for the interviewer include facing the client, **appearing attentive**, **minimizing restlessness**, and **displaying appropriate facial expressions.** - the client's body language can be misinterpreted by an interviewer whose knowledge of the client's cultural background is deficient. 3\. **Vocal Qualities** - Skilled interviewers have mastered the subtleties of the **vocal qualities** of language---**not just the words** **[but]** how those words sound to **the client's ears**. They use **pitch**, **tone**, **volume**, and **fluctuation in their own voices** to let clients know that their words and feelings are deeply appreciated... vocal qualities of their clients. 4\. **Verbal Tracking** - Effective interviewers are able to repeat key words and phrases back to their clients to assure the clients that they have been accurately heard. - Interviewers skilled at **verbal tracking [monitor the train of thought]** implied by **[clients' patterns of statements]** and are thus able to shift topics **smoothly** rather than **abruptly**. 5\. **Referring to the Client by the Proper Name** - It sounds simple enough, but using the **client's name correctly is essential** (Fontes, 2008). - **Inappropriately** using **nicknames** or **shortening names** (e.g., calling Benjamin "Benji"), **omitting a "middle**" name that is in fact an essential part of the first name (e.g., calling John Paul "John"), or **addressing a client by first name rather than a title followed by surname** (e.g., addressing Ms. Washington as "Latrice") are presumptuous mistakes that, for some clients, can jeopardize the sense of comfort with the interviewer. **6. Observing Client Behaviors** - Many other important decisions the interviewer makes, can be informed by *behavioral observations* of the client by the interviewer (Kamphaus & Dever, 2016). - When psychologists write a **[report summarizing]** the results of an assessment (including the clinical interview), that report contains **at least a brief section describing the behavior of the client during the process.** **Example:** - Some clients are calm while others are nervous; some are easygoing while others are hostile; some stay on task while others stray in random directions; some are emotional while others are stoic; and so on **Note:** The interviewer should carry out all these attending behaviors naturally and authentically (Ivey et al., 2010). **\ \ COMPONENTS OF THE INTERVIEW** **Rapport** - **Rapport** refers to a positive, comfortable relationship between interviewer and client. - When clients ***feel a strong sense of rapport*** with interviewers, they feel that the interviewers have **["connected"]** with them and that the interviewers empathize with their issues. **Problems:** 1\. Some Patients have had past experiences that will not easily permit theme to accept even genuine overtures for a professional relationship. 2\. In the cases that involve more than one individual (family therapy or couples, Child and adolescent-parents) **Some specific efforts interviewers can make to enhance the client's experience of rapport.** **1. Interviewers should make an effort to put the client at ease, especially early in the interview session.** **Example:** - *"Did you have any trouble finding the office?" or "I haven't been outside in a while---is it still cold out?"* **2. Interviewers can acknowledge the unique, unusual situation of the clinical interview.** ***Example:*** - *Inviting clients to ask questions about the interview process provides them with a sense of knowledge and control, which can also improve their comfort level.* **3. Interviewers can enhance rapport by noticing how the client uses language and then following the client's lead.** - Interviewers should pick up on the client's vocabulary and, as much as possible, speak in similar terms (Othmer & Othmer, 1994). **Example:** (When a client uses a metaphor, the interviewer can extend it) - ***Client:** It's like I'm juggling, and I can't keep all the balls in the air," the interviewer might establish better rapport by asking.* - ***Interviewer:** "What if one of the balls fell?"* **Technique** - **Technique** is *what* an interviewer *does* with clients. 1\. **Directive Versus Nondirective Styles** **[Directive questions ]** - It tends to be targeted toward ***specific pieces of information,*** and client responses are ***typically brief***, sometimes as short as a single word (e.g., "**yes**" or "**no**"). - **Direct questioning** can provide **crucial data** that clients may not otherwise choose to discuss: important ***historical information***, the ***presence or absence of a particular symptom of a disorder***, ***frequency of behaviors***, and ***duration of a problem.*** ***Example*** - Dr. Molina interviewing Raymond, a client whose presenting problem is depressive in nature. If Dr. Molina directly inquires about symptoms and duration---"When did you first notice these feelings of sadness? Has your weight changed during that time? Do you feel fatigued? Do you have trouble concentrating?"---Dr. Molina will be sure to gather information essential for diagnosis. **[Nondirective questions]** - Style allow the client to ***determine the course of the interview***. Without direction from the interviewer, a client may choose ***to spend a lot of time on some topics*** and none on others. - Indirect questioning, conversely, can provide ***crucial information*** that interviewers may not otherwise know to inquire about. ***Example*** - Dr. Molina asks Raymond, "Can you tell me more about your feelings of sadness?" Raymond's response may not specifically mention how long the symptoms have been present or refer to each individual criterion for major depression, dysthymia, or other related disorders. However, Dr. Molina's indirect question does allow Raymond to expand on anything he believes is essential, including symptoms, duration, background data, or other elements that may prove to be extremely relevant (J. Morrison, 2008). **\ ** **Specific Interviewer Responses** 1**. Open- and Closed-Ended Questions** - **[Open-ended question] -** allow for individualized and ***spontaneous responses from clients***. These responses tend to be ***relatively long***, and although they may include a ***lot of information relevant to the client***, they may lack details that are important to the clinical psychologist. - Indeed, open-ended questions are the ***building blocks of the nondirective interviewing style,*** whereas the directive interviewing style typically consists of closed-ended questions. ***Example*** - What more can you tell me about the eating problems you mentioned on the phone?" - **[Closed-ended question] -** allow for far ***less elaboration and self-expression*** by the client but yield quick and precise answers. ***Example:*** - "How many times per week do you binge and purge?" - "Which purging methods do you use---vomiting, exercise, nausea?" - "Have you been diagnosed with an eating disorder in the past?" **2. Clarification** - **Clarification** question is to make sure the interviewer has an ***accurate understanding of the client's comments.*** - Clarification questions ***not only enhance the interviewer's ability*** to "get it," they also communicate to the ***client*** that the interviewer is ***actively listening and processing what the client says.*** ***Example:*** - The interviewer may at one point say, "You mentioned that a few months ago you started exercising excessively after eating large amounts of food but that you've never made yourself vomit---do I have that right?" or "I want to make sure I'm understanding this correctly---did you mention that you've been struggling with eating-related issues for about 6 months?" 3\. **Confrontation** - Interviewers use **confrontation** when they notice discrepancies or inconsistencies in a client's comments. - Confrontations can be similar to clarifications, but they ***focus on apparently contradictory information provided by clients.*** ***Example:*** - An interviewer might say to Brianna, "Earlier, you mentioned that you had been happy with your body and weight as a teenager, but then a few minutes ago you mentioned that during high school you felt fat in comparison with many of your friends. I'm a bit confused." 4\. **Paraphrasing** - **Paraphrasing** is used simply to assure clients that they are being accurately heard. - When interviewers paraphrase, they typically restate the content of clients' comments, using similar language. - A paraphrase usually doesn't break new ground; instead, ***it maintains the conversation*** by assuring the client that the interviewer is paying attention and comprehending. ***Example*** "I only binge when I'm ***alone,***" the interviewer might immediately respond with a statement such as, "You only binge when ***no one else is around***." **5. Reflection of Feeling** - Reflections of feeling are intended to make clients feel that their emotions are recognized, even if their comments did not explicitly include labels of their feelings. - Unlike paraphrasing, reflecting a client's feelings ***often involves an inference by the interviewer about the emotions underlying the client's words.*** Example "I only binge when I'm alone" was delivered with a tone and body language that communicated ***shame***---her hand covering her face, her voice quivering, and her eyes looking downward---the ***interviewer*** might respond with a statement such as "***You don't want anyone to see you bingeing---do you feel embarrassed about it?"*** **6. Summarizing** - **Summarizing** usually involves tying together various topics that may have been ***discussed***, ***connecting statements*** that may have been made at ***different points,*** and ***identifying themes*** that have recurred during the interview. - Summarizing lets clients know that they have been ***understood*** but in a ***more comprehensive***, ***integrative way*** than, say, paraphrasing single statements. - An accurate summarization conveys to the client that the ***interviewer has a good grasp on the "big picture."*** ***Example*** - "It seems as though you are acknowledging that your bingeing and purging have become significant problems in recent months, and although you've kept it to yourself and you may feel ashamed about it, you're willing to discuss it here with me and you want to work toward improving it." **7. Conclusions** - The conclusion can take a number of ***different forms***, depending on the type of interview, the client's problem, the setting, or other factors. - The conclusion can be essentially ***similar to a summarization.*** - The conclusion of the interview may ***consist of a specific diagnosis*** made by the ***interviewer on the basis of the client's response to questions*** about specific criteria. Or the conclusion may involve recommendations. - These ***recommendations*** might include outpatient or inpatient treatment, further evaluation (by another psychologist, psychiatrist, or health professional), or any number of other options. **\ ** **PRAGMATICS OF THE INTERVIEW** - Many of these decisions involve the setting in which the interview will take place and the professional behaviors the interviewer plans to use during the interview itself. **Note Taking** - Should an interviewer take notes during an interview? - There are **good reasons** for taking notes - **[Written notes are certainly more reliable than the interviewer's memory. ]** - There are also **drawbacks** to taking notes. The process of note taking can be a **[distraction,]** **both for the interviewer,** who may **[fail to notice]** important client **[behaviors]** while looking down to write, and for the client, who may feel that the interviewer's notebook is an **[obstacle to rapport]**. - In some clinical situations, interviewers may be wise to **[explain their note-taking]** behavior to clients. - **EX**: *In particular, a client- centered rationale for the note-taking behavior---"I'm taking notes because I want to make sure I have a good record of what you have told me"* **Audio and Video Recordings** - Clinical psychologists may prefer to **[audio- or video-record the session.]** Unlike note taking, recording a client's interview requires that the interviewer obtain **[written permission from the client]**. ***Note:*** - Intended use (e.g., review by the interviewer or a supervisor) and a date by which it will be erased or destroyed, is typically appreciated by the client. **The Interview Room** - **What should the interview room look like?** - The size of the room, its furnishings, and its decor are among the features that may differ. As a general rule, "when choosing a room \[for interviews\], it is useful to strike a **[balance between professional formality]** and **[casual comfort]**" (Sommers-Flanagan & Sommers- Flanagan, 2009, p. 31). - The interview room should **[subtly convey the message to the client that the clinical interview is a professional activity]** but one in which **warmth** and **comfort** are high priorities. **Confidentiality** - Interviewers should routinely explain **[policies regarding confidentiality]** as early as possible. Such explanations should be consistent with **law** and **professional ethics** and provided in **writing**, with ample opportunity for oral discussion offered as well. Psychologists who discuss **confidentiality** and its **limits with interview clients demonstrate competent and [ethical practice ]**(American Psychological Association, 2002). **\ TYPES OF INTERVIEWS** **Intake Interviews** - **intake interview** is essentially to **determine whether to "intake"** the client to the setting where the interview is taking place. In other words, the intake interview determines whether the **[client needs treatment]**; if so, **[what form of treatment is needed]** (*inpatient, outpatient, specialized provider, etc*.); and whether the current facility can provide that treatment or the client should be referred to a more suitable facility (Sommers-Flanagan, 2016). 1. ***To determine why the patient has come to the clinic or hospital*** 2. ***To judge whether the agency's facilities, policies, and services will meet the needs and expectations of the patients.*** ***Example*** - Julia, a 45-year-old client who arrives for an intake inter- view at an outpatient community mental health center and describes "hearing voices." - frequency, intensity, and duration of Julia's psychotic symptoms.... note any relevant behaviors...personal history so on **Diagnostic Interviews** - The **diagnostic interview** is to diagnose. - The interviewer is able to confidently and accurately assign **[Diagnostic and Statistical Manual of Mental Disorders (DSM]**) diagnoses to the client's problems. - If the **purpose** of the diagnostic interview is to produce a diagnosis, it would make sense for the **[diagnostic interview to include questions that relate to the criteria of *DSM* disorders. ]** - Some clinical psychologists believe that the questions should essentially **[replicate the *DSM* criteria ]** - Other clinical psychologists believe that every question in a **[diagnostic interview need not be coupled with a specific *DSM* diagnostic criterion. ]** **Structured Interviews** - is a **[predetermined]**, **[planned sequence]** of questions that an inter- viewer asks a client. Structured interviews are **[constructed for particular purposes]**, usually diagnostic. ***Advantages of Structured interviews*** - Structured interviews produce a **[diagnosis based explicitly on *DSM* criteria]**, **[reducing reliance]** on subjective factors such as the interviewer's clinical judgment and inference, which can be biased or otherwise flawed. - Structured interviews tend to be **[highly reliable]**, in that two interviewers using the same structured interview will come to the **same diagnostic conclusions far** more often than two interviewers using unstructured interviews. Overall, they are **[more empirically sound than unstructured interviews. ]** - Structured interviews are **[standardized]** and typically [uncomplicated in terms of administration]. ***Example:*** - **Structured Clinical Interview for *DSM-5* Disorders** (**SCID**; First, 2015) ***Disadvantages of Structured interviews*** - The format of structured interviews is usually **[rigid]**, which can **[inhibit rapport and the client's opportunity to elaborate]** or **[explain]** as he or she wishes. - Structured interviews typically **[don't allow for inquiries into important topics]** that may not be directly related to *DSM* criteria, such as ***relationship issues, personal history,*** and problems that fall below or between *DSM* diagnostic categories. - Structured interviews often require a **[more comprehensive list of questions]** than is clinically necessary, which lengthens the interview. **Unstructured Interviews** - involves **[no predetermined]** or **[planned questions]**. In unstructured interviews, interviewers improvise: They determine their questions **[on the spot]**, seeking information that they decide is relevant during the course of the interview **Mental Status Exam** - The **mental status exam** is employed most often in **[medical settings. ]** - The mental status exam **[does not delve into the client's personal history]**, nor is it designed to determine a *DSM* diagnosis definitively. Instead, its yield is usually a **brief paragraph** that captures the **[psychological]** and **[cognitive processes]** of an individual "**[right now]**"--- like a psychological snapshot (Lukas, 1993; J. Morrison, 2008) **Mental status exam -** the following main categories are typically covered (Sommers-Flanagan, 2016): - *Appearance* - *Behavior/psychomotor activity* - *Attitude toward interviewer* - *Affect and mood* - *Speech and thought* - *Perceptual disturbances* - *Orientation to person, place, and time* - *Memory and intelligence* - *Reliability, judgment, and insight* **Crisis Interviews** - The **crisis interview** is a special type of clinical interview and can be uniquely challenging for the interviewer. - They are designed **[not only to assess a problem]** demanding **[urgent attention]** (most often, clients actively ***considering suicide*** or another ***act of harm*** toward self or others) but also to provide **immediate** and **[effective intervention for that problem]** (Sommers-Flanagan & Shaw, 2017). - Crisis interviews can be conducted **in person** but also take place often on the ***telephone via suicide hotlines***, ***crisis lines***, and similar services. **Note:** - *Crisis interviews are unique among clinical interviews because they typically involve not only assessment of the client's problems but immediate intervention as well.* **Crisis Interviews** When interviewing an **actively suicidal person**, **five specific issues** should be assessed (adapted from Sommers-Flanagan & Sommers-Flanagan, 2009): - ***How depressed is the client?*** Unrelenting, long-term depression and a lack of hope for the future indicate high risk. - ***Does the client have suicidal thoughts?*** If such thoughts have occurred, it is important to inquire about their frequency and intensity. - ***Does the client have a suicide plan?*** Some clients may have suicidal thoughts but\ no specific plan. If the client does have a plan, its feasibility (the client's access to the means of self-harm, such as a gun, pills, etc.), its lethality, and the presence of others (family, friends) who might prevent it are crucial factors. - ***How much self-control does the client currently appear to have?*** Questions about similarly stressful periods in the client's past, or about moments when self-harm was previously contemplated, can provide indirect information about the client's self-control in moments of crisis. - ***Does the client have definite suicidal intentions?*** Direct questions may be informative, but other indications such as giving away one's possessions, putting one's affairs in order, and notifying friends and family about suicide plans can also imply the client's intentions. Beatriz Ashley