INTRODUCTION TO CLINICAL PSYCHOLOGY

Chapter 8 The Clinical Interview

The Clinical Interview

• Assessment is closely linked with the identity of clinical psychologists

– No other mental health profession incorporates assessment into their work as clinical
psychologists do

• Clinical interviews are the most frequent assessment tool

– More than any specific test

– Vast majority of practicing clinical psychologists use interviews

Essential Qualities of Assessment Techniques

• All assessment techniques (including interviews) should have adequate:

– Validity—measures what it claims to measure

– Reliability—yields consistent, repeatable results

– Clinical utility—benefits the clinician and ultimately the client

Validity, Reliability, and Clinical Utility

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.

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Internal reliability consists of items that are consistent with one another.

Clinical utility improves delivery of services or client outcome.

Feedback

• Common to all kinds of psychological assessment

• Provide results of tests or interviews

• May be face-to-face, a report, etc.

The Interviewer

• General skills

– Quieting yourself

• Minimize excessive internal, self-directed thoughts that detract from listening

– Being self-aware

• Know how you tend to affect others interpersonally, and how others tend to relate to
you

– Develop positive working relationships

• Can segue into psychotherapy

• Respectful and caring attitude is key

• Specific behaviors

– Listening—the primary task of the interviewer, consisting of numerous building blocks

• Eye contact

• Body language

• Vocal qualities

• Verbal tracking

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 • Referring to client by proper name

Components of the Interview

• Rapport

– Positive, comfortable relationship between interviewer and client

– How an interviewer is with clients

• Technique

– What an interviewer does with clients

– Directive vs. nondirective styles

Specific Interviewer Responses

• Open-ended and closed-ended questions

– Open-ended questions

• Allow individualized and spontaneous responses from clients

• Elicit long answers that may or may not provide necessary info

– Closed-ended questions

• Allow less elaboration and self-expression by the client

• Yield quick and precise answers

• Clarification

– Question to make sure the interviewer accurately understands the client’s comments

• Confrontation

– For discrepancies or inconsistencies in a client’s comments

• Paraphrasing

– Restatement of client’s comments to show they have been heard

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• Reflection of feeling

– Echo client’s emotions, even if not explicitly mentioned

• Summarizing

– Tie together various topics, connect statements that may have been made at different
points, and identify themes

Pragmatics of the Interview

• Note-taking

– Little consensus about note-taking

– Provide a reliable written record, but can be distracting to client and interviewer

• Audio- and Video-recording

– Also provide a reliable record, but can be inhibiting to clients

– Must obtain permission

• The Interview Room

– Professional yet comfortable

• Confidentiality

– Explain confidentiality and its limits to clients (e.g., child abuse, intention to harm)

Types of Interviews

• Intake interviews

– To determine whether to “intake” the client into the agency or refer elsewhere

• Diagnostic interviews

– To provide DSM diagnosis

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 – Structured interviews often used

• Minimize subjectivity, enhance reliability

• SCID is an example – Currently being revised for DSM-5

• Semi-structured interviews include some structure but also some flexibility or

opportunities to improvise

• Mental status exam

– Typically used in medical settings

– To quickly assess how a client is functioning at that time

• Crisis interviews

– Assess problem and provide immediate intervention

– Clients are often considering suicide or other harmful act

Cultural Components

• Appreciating the cultural context

– Knowledge of the client’s culture, as well as the interviewer’s own culture

– For behavior described or exhibited during interview

• Acknowledging cultural differences

– Wise to discuss cultural differences rather than ignore

– Sensitive inquiry about a client’s cultural experiences can be helpful

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 Chapter 9 Intellectual and Neuropsychological Assessment

Assessment Overview

• Tests described in this chapter are related to cognitive functioning in some way

– Intelligence tests measure intellectual abilities

– Achievement tests measure accomplishments in academic areas

– Neuropsychological tests focus on cognitive dysfunction, often from brain injury or illness

Intelligence Testing

• Theories of intelligence

– Is intelligence one thing or many things?

• Charles Spearman—”g” for general (single) intelligence

• Louis Thurstone—intelligence is plural abilities that may not relate to each other

• Hierarchical models of intelligence blend singular and plural theories

• More contemporary theories of intelligence

– James Cattell—two separate intelligences

• Fluid intelligence—ability to reason when faced with novel problems

• Crystallized intelligence—body of knowledge accumulated through life experiences

– John Carroll—three-stratum theory

• “g,” 8 broad factors, 60 specific abilities

Wechsler Intelligence Tests

• Originally created by David Wechsler in early 1900s

• Currently, there are three Wechsler IQ tests

– Wechsler Adult Intelligence Scale—Fourth Edition (WAIS-IV) – age 16-89

– Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV) – age 6-16

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 – Wechsler Preschool and Primary Scale of Intelligence— Third Edition (WPPSI-III) –
age 2-7

• Similarities among the three Wechsler IQ tests:

– Yield a single full-scale intelligence score

• Also yield 4 index scores: Verbal Comprehension, Perceptual Reasoning, Working

Memory, Processing Speed

• Also yield about a dozen specific subtests scores

– One-to-one, face-to-face administration

– Share a core of subtests:

• Vocabulary • Similarities

• Information • Comprehension

• Block Design • Picture Completion

• Matrix Reasoning • Coding

• Symbol Search

– Mean of 100 for full scale and index scores, and 10 for subtests

– Large sets of normative data

– Impressive psychometric data to support reliability and validity

– Approach to interpretation: full scale IQ first, followed by increasingly specific scores

and patterns

Stanford-Binet Intelligence Scales—5th Edition (SB5)

• Dominated in early 1900s until Wechsler’s tests began to compete

• Like Wechsler tests in many ways

– Face-to-face, one-to-one administration

– Single overall IQ score, 5 factor scores, many more subtest scores

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 – Mean score is 100

• Unlike Wechsler tests in some ways:

– One test covers whole lifespan (ages 2-85+)

– Subtests include extensions at high and low end (useful for assessing giftedness or
mental retardation)

– Different subtests and factors

– Has become less commonly used than Wechsler tests, but still highly regarded and
used

Cultural Fairness in Intelligence Tests

• Some subtests may place people from minority cultural groups at a disadvantage

– Verbal subtests especially

– Both Wechsler tests and Stanford-Binet have made improvements in recent editions

• Universal Nonverbal Intelligence Test (UNIT)

– Recently created (1996)

– Entirely language free

– No speaking necessary for test administrator or test taker

• All instructions are hand gestures

• All responses are manual, not verbal

– Some drawbacks: only for kids age 5-17, limited psychometric data, more limited
range

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Achievement Testing

• Intelligence is what a person can accomplish intellectually

• Achievement is what a person has accomplished, especially reading, spelling, writing, or math

• Achievement tests typically produce standard scores that can be easily compared to scores
from intelligence tests (e.g., mean = 100)

– A significant discrepancy between a person’s achievement and expected levels of

achievement is the basis for specific learning disorder

• They also typically produce age- or grade- equivalency scores

• Some achievement tests are specific to math, reading, or other abilities

• Others are more global

– Wechsler Individual Achievement Test—Third Edition (WIAT-III)

• For ages 4-50

• Administered face-to-face and one-on-one

• Reading, math, written language, oral language

Neuropsychological Testing

• Measure cognitive functioning or impairment of the brain and its specific components or
structures

• Additional purposes: to make prognosis, plan rehab, determine eligibility for accommodations,
etc.

• Often used after a head injury, a brain illness, or prolonged alcohol or drug use

• Some neuropsychological tests are lengthy and comprehensive; others are brief and targeted

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Halstead-Reitan Neuropsychological Battery (HRB)

• Comprehensive battery of 8 neuropsychological tests

• Primary purpose is to identify people with brain damage and, to the extent possible, provide
detailed information or hypotheses about any brain damage identified

• Some of 8 tests involve sight, hearing, touch, motor skills, and pencil & paper tasks

• A similar comprehensive battery of tests is the LuriaNebraska Neuropsychological Battery

(LNNB)

– Similarly long and comprehensive

– Emphasizes qualitative data in addition to quantitative data

Brief Neuropsychological Measures

• Bender Visual-Motor Gestalt Test – Second Edition

– Most commonly used neuropsychological screen among clinical psychologists

– ~6 minutes to administer

– Simple copying test using 9 geometric designs

– A quick “check,” followed by more tests as necessary

– Can suggest brain damage in a diffuse, but not specific, way

• Rey-Osterrieth Complex Figure Test

– Brief pencil-and-paper drawing task, but unlike Bender-Gestalt, involves just a single,
more complex figure

– Also includes a memory component (recall figure and draw it again from memory)

• Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

– Neuropsych screen focusing on a broader range of abilities than Bender-Gestalt or

Rey-Osterrieth

– 12 subtests in less than half hour

• Wechsler Memory Scale – Fourth Edition (WMS-IV)

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 – Assesses memory problems due to brain injury, dementia, substance abuse, etc.

– Ages 16-90

– Assesses visual and auditory memory, immediate and delayed recall

Chapter 10 Personality Assessment and Behavioral Assessment

Multimethod Assessment

• No measure of personality or behavior is perfect

• It is best to use multiple methods

– Tests – Interviews

– Observations – Other sources

• Convergent conclusions can be made with more confidence

Evidence-Based Assessment

• Assessment based on “what works” empirically

• Similar to movement regarding “what works” in therapy, but data is not quite as abundant yet

• Typically tied to particular disorders

– Ex. SCID and BDI-II for assessing depression

Culturally Competent Assessment

• Every culture has its own definitions of “normal” and “abnormal”

• Culturally competent clinical psychologists are aware of this, and of the influence of their own
cultural perspective

• Especially important not to overpathologize

– View as abnormal what is culturally normal

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Objective Personality Tests

• Include unambiguous test items, offer clients a limited range of responses, and are objectively
scored

• Typically self-report questionnaires

• Typically a series of brief statements or questions to which clients respond in a true/false or

multiple choice format

Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

• Most popular and most psychometrically sound objective personality test

– Used worldwide; translated into dozens of languages

• Pencil & paper format

• 567 self-descriptive sentences

• Client marks true or false for each

• Original MMPI was published in 1943

– Primary authors were Starke Hathaway and J. C. McKinley

– Empirical criterion keying was used as test construction method

• Revised edition, MMPI-2, was published in 1989

– Better norms

– Less outdated wording of items

• MMPI and MMPI-2 feature 10 clinical scales

– 1—Hypochondriasis

– 2—Depression

– 3—Hysteria

– 4—Psychopathic Deviate

– 5—Masculinity/femininity

– 6—Paranoia

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– 7—Psychasthenia

– 8—Schizophrenia

– 9—Mania

– 0—Social Introversion

• Also feature supplemental scales and content scales for additional clinical information

• MMPI and MMPI-2 also feature validity scales

– To measure test-taking attitudes

– Can identify clients who “fake good” or “fake bad,” or clients who respond randomly

• MMPI-A (for adolescents, age 14-18) was published in 1992

– Similar clinical scales, validity scales, and administration

• MMPI-2-RF—most recent edition—briefer, less overlap between clinical scales

• Strengths include psychometrics (established reliability and validity) and comprehensiveness

• Limitations include length, reading requirement, attention requirement, and emphasis on

pathology/abnormality

• Therapeutic Assessment

– Interesting use of MMPI-2, developed by Stephen Finn and colleagues

– MMPI-2 feedback used as a brief therapeutic intervention

– What psychologists intend as assessment clients can experience as therapeutic

Millon Clinical Multiaxial Inventory (MCMI-III)

• Originally created by Theodore Millon

• Like the MMPI-2 in some ways

– Comprehensive objective personality test

– Self-report, pencil & paper format

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• Main difference: MCMI-III emphasizes personality disorders

– Its clinical scales are based on DSM personality disorders (e.g., antisocial, borderline,
narcissistic, paranoid)

NEO Personality Inventory—Revised (NEO-PI-R)

• Originally created by Paul Costa and Robert McCrae

• Another objective personality test

– Pencil & paper, self-report format

• Main distinction: measures “normal” personality traits (not pathologies)

– Based on Five Factor model of personality

– Neuroticism, Extraversion, Openness, Conscientiousness, Agreeableness

• Lacks validity scales, and of limited help with clinical diagnosis

California Psychological Inventory-III (CPI-III)

• Another objective personality test

– Pencil & paper, self-report

• Like NEO-PI-R, doesn’t emphasize pathology

• Emphasizes positive attributes of personality— strengths, assets, internal resources

• Consistent with recent positive psychology movement

• Also goes by name CPI-434 (434 items)

Beck Depression Inventory-II (BDI-II)

• Not a comprehensive test of personality, but a brief, targeted measure of one characteristic
(depression symptoms)

• 21 items; takes 5-10 minutes to complete

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• Pencil & paper, self-report format

• Lacks validity scales, and much more limited scope than other tests discussed to this point

Projective Personality Tests

• Based on the assumption that clients will “project” their personalities when presented with
unstructured, ambiguous stimuli and an unrestricted opportunity to respond

• Lack of objectivity in scoring and interpretation

– Considered by many to be empirically inferior to objective tests

– Usage has declined in recent decades

• Advocates claim they are less “fake-able”

Rorschach Inkblot Method

• Created in 1921 by Hermann Rorschach

• 10 inkblots (5 in color, 5 black & white) are presented

• Clients say what they see in each blot (in “response” phase)

• Later (in “inquiry” phase), explain what features of the blot caused them to make their
responses

• Exner’s Comprehensive System is most widely used scoring system

• Scoring emphasizes how the client perceives the blot as well as what the client sees

• Scoring variables include:

– Location (Whole blot, large part, or small detail?)

– Determinants (Form, color, or shading of blot?)

– Form Quality (Conventional? Distorted?)

– Popular (What others see? Idiosyncratic?)

– Content (What kinds of objects appear frequently?)

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• Reliability and validity are questionable and hotly debated

Thematic Apperception Test (TAT)

• Published in 1943 by Henry Murray and Christiana Morgan

• Like Rorschach in that it involves a series of cards with ambiguous stimuli

• Cards feature interpersonal scenes rather than inkblots

• Client tells a story to go along with each scene

• Often, not formally or empirically scored

• Reliability and validity are questionable

Tell-Me-a-Story (TEMAS)

• Recent TAT-style apperception test

• Greater emphasis on cultural sensitivity (via portrayal of diverse individuals in cards)

• Greater emphasis on empirical scoring via normative data

Sentence Completion Tests

• The ambiguous stimuli are not inkblots or interpersonal scenes, but beginnings of sentences

• Rotter Incomplete Sentence Blank (RISB) is most widely used

• Simulated examples: – I enjoy_______________. – It makes me furious_______________. –

My greatest weakness_________.

• Not often formally or empirically scored

• Reliability and validity are questionable

Behavioral Assessment

• Assumes that client behaviors are not signs of underlying issues or problems; instead, those
behaviors are the problems

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• The behavior a client demonstrates is a sample of the problem itself, not a sign of some
deeper, underlying problem

Techniques of Behavioral Assessment

• Behavioral observation is the most essential technique

– Direct, systematic observation of a client’s behavior in the natural environment

– Also known as naturalistic observation

– Requires operationally defining target behavior and measuring its frequency, duration,
or intensity across specified time periods

• Often more accurate than asking client to report on their own behaviors

• When naturalistic observation is not possible, analogue observation is used

– Replicate situation in clinic

• Recording of behaviors is crucial

– Done by parent, teacher, friend, or client

– Enables functionality of behavior to be determined

– This functionality is key concept in behavioral assessment

Technology in Behavioral Assessment

• Laptop computers or handheld devices can be used to record observed behaviors

• Numerous software programs have been created for this purpose

• Clients can use similar technological tools for self-monitoring

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 Chapter 11 General Issues in Psychotherapy

Overview

 This is the first chapter in the section on psychotherapy

 Psychotherapy is the most common professional activity of clinical psychologists

 Upcoming chapters will focus on specific approaches; this chapter focuses on general
psychotherapy issues

Does Psychotherapy Work?

 Through the mid-1900s, most answers to this question came in subjective, non-empirical
forms (few empirical studies)

 Hans Eysenck (1952) concluded that therapy was of little benefit

 His finding has since been overturned, but his study inspired decades of research on therapy
outcome

Who, When, and How Should Researchers Ask?

 Who?

◼ Tripartite (“three party”) model - Hans Strupp

◼ Client ◼ Therapist ◼ Third parties (society, family, insurance company, others)

◼ Ratings by any of these three parties can be informative, but also biased

 When?

◼ Immediately after therapy?

◼ Follow-up?

◼ After months? Years?

◼ Before therapy ends?

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 ◼ At certain points, or at every session?

 How?

◼ Questionnaires?

◼ Interviews?

◼ What questions should be asked?

◼ Behavioral observation?

 Who, when, and how researchers ask about psychotherapy can influence results

Efficacy vs. Effectiveness

 Efficacy—the extent to which psychotherapy works “in the lab”

◼ In controlled outcome studies

◼ Therapists’ methods are controlled or manualized

◼ Clients are selected for diagnostic criteria

◼ Better internal validity than external validity

 Effectiveness—the extent to which psychotherapy works “in the real world”

◼ Greater variability in therapists’ methods

◼ Greater variability in clients’ issues and diagnoses

◼ Better external validity than internal validity

 Results of efficacy studies

◼ Overall result: psychotherapy works

◼ Hundreds of meta-analyses and thousands of individual studies support this finding

◼ Average person receiving therapy is better off than 80% of comparable others who
don’t

◼ Benefits last and exceed placebo effect

 Results of effectiveness studies

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 ◼ Not as many studies as efficacy studies, but similar results: psychotherapy works

◼ Consumer Reports study is example of a large scale effectiveness study

◼ Therapy had positive effects

◼ Results lasted over time

◼ Some methodological concerns

◼ Sampling bias

◼ No control group

Alternate Ways to Measure Psychotherapy Outcome

 Neurobiological effects of therapy

◼ Via fMRI, PET neuroimaging, etc.

◼ Therapy changes the brain

 Medical cost offset

◼ Indirect measure of therapy outcome

◼ Successful therapy reduces later medical costs

Which Type of Psychotherapy is Best?

 Supporters of various kinds of therapy have often claimed theirs is superior

 However, comparative outcome studies have consistently reached the same finding: a virtual
tie

◼ Different therapies are equally effective

◼ This finding was nicknamed the “dodo bird verdict” (from Alice in Wonderland)

 How could various therapies be equally effective?

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 ◼ Common factors—shared, fundamental elements of therapy (rather than specific
techniques) are “active ingredients”

◼ Therapeutic relationship/alliance

◼ Hope

◼ Attention

◼ Three-stage sequential model of common factors

◼ Support, learning, action factors (in that sequence)

 The dodo bird verdict has not gone unchallenged

◼ Some researchers (e.g., Dianne Chambless) argue that for specific disorders, some
therapies are demonstrably better

◼ Outcome studies using manualized treatments for specific disorders can lead to a
prescriptive approach to psychotherapy

◼ Certain therapies are “treatments of choice” for specific disorders

◼ This controversy continues today

What Types of Psychotherapy Do Clinical Psychologists Practice?

 Eclectic/integrative therapy was most popular orientation until 2010

◼ Cognitive is now #1

 Psychodynamic therapy has declined since 1960s

What Format of Psychotherapy Do Clinical Psychologists Practice?

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 Individual therapy is most common by far

 A sizable number of clinical psychologists also practice group, family, marital

The Future of Psychotherapy

 Experts expect the future of psychology to include a rise in

◼ Cognitive and behavioral therapy

◼ Culturally sensitive therapy

◼ Eclectic/integrative therapy

◼ Evidence-based therapy

Eclectic and Integrative Approaches

 Both involve multiple approaches

 Eclectic therapy involves selecting the best treatment for a given client based on empirical
data from studies of the treatment of similar clients

 Integrative therapy involves blending approaches in order to create a new hybrid

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 Chapter 12 Psychodynamic Psychotherapy

Psychodynamic Psychotherapy

 This is the first of a series of chapters on specific approaches to psychotherapy

 We begin with psychodynamic for numerous reasons

◼ It came first historically

◼ Many other therapies were reactions against it

◼ Despite a recent decline, it still influences many clinical psychologists

Defining Psychodynamic Psychotherapy

 This textbook uses the term “psychodynamic psychotherapy” to refer broadly to Sigmund
Freud’s approach to therapy and all subsequent efforts to revise and expand upon it

 Similar or overlapping terms include “psychoanalytic therapy” and “neo-Freudian therapy,”

among others

Goal of Psychodynamic Psychotherapy

 The primary goal of psychodynamic psychotherapy is to make the unconscious conscious

◼ “Insight” into thoughts, feelings, and other mental activity previously outside of
awareness

◼ The very presence of the unconscious was a fundamental idea of Sigmund Freud

Accessing the Unconscious

 Free Association

◼ Clients simply say whatever comes into mind without any self-censorship or self-
editing

◼ Not easy to allow self to be absolutely spontaneous

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 ◼ Allows the unconscious to be expressed

 Freudian “slips”

◼ Verbal or behavioral “mistakes” reveal unconscious wishes

 Dreams

◼ Manifest content represents latent content, which contains unconscious wishes

 Resistance

◼ Clients “resist” certain topics in therapy because they touch on certain unconscious
feelings or thoughts

◼ Missed appointments, tardiness, change subject

 Defense Mechanisms

◼ Unconscious techniques created by ego, as an attempt to handle conflict between id

and superego

◼ Repression—keep impulse in unconscious

◼ Projection—attribute impulse to others

◼ Reaction formation—do opposite of impulse

◼ Displacement—redirect impulse

◼ Sublimation—redirect impulse in a way that benefits others

 Transference

◼ Client forms a relationship with therapist in which client unconsciously and

unrealistically expects therapist to behave like important people from the client’s past

◼ Clients bring similar transference issues to the client-therapist relationship, just as

they do to many of the other relationships in their lives

◼ Help clients become aware of their own transference tendencies and the ways in
which these unrealistic perceptions of others affect their relationships and their lives

◼ Interpretation, followed by working through phase

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 ◼ “Blank screen” role of therapist facilitates transference

Psychosexual Stages: Clinical Implications

 Oral stage—birth to 1.5 years old

◼ Key issue is dependency/trust

◼ “Can I trust others to take care of me?”

◼ Underindulgence → distrustful and pessimistic of others

◼ Overindulgence → naive and overly trusting

◼ Of course, blatantly oral behaviors can occur as well (e.g., smoking, overeating)

 Anal stage—1.5 to 3 years old

◼ Key issue is control

◼ Parents impose control on child (toilet training, and other forms of self-control)

◼ Overly-demanding parents → “control freaks,” obsessiveness

◼ Overly-lenient parents →lax about organization, ”slobs,” disorganization

 Phallic stage—3 to 6 years old

◼ Key issue is self-worth/view of self

◼ Children seek to have special, close relationship with parents

◼ If parents respond too positively, child’s sense of self becomes overinflated →

arrogant, egotistical

◼ If parents respond too negatively, child’s sense of self is damaged → insecure,

self-doubting

More Contemporary Forms of Psychodynamic Psychotherapy

 Ego psychology

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 ◼ Emphasizes social relationships over psychosexual stages

 Object relations

◼ Emphasizes relationships between internalized “objects”

 Self-psychology

◼ Emphasizes parental roles in the development of the self, with special attention to
narcissism

 Most recent forms emphasize efficiency or brevity

 Brief Psychodynamic Psychotherapies

◼ Narrow problems, quick alliance, focus on present as well as past, therapists are more
active, pathology is less severe

 Interpersonal Therapy (IPT)

◼ Designed to treat depression in 14-18 sessions

◼ Improving interpersonal relationships will alleviate depression

◼ Emphasis on role expectations

 Time-Limited Dynamic Psychotherapy (TDLP)

◼ Focus on transference and a therapy relationship that doesn’t follow the same
unhealthy, unconscious “script” as previous relationships

◼ Make client aware of script to enable a corrective emotional experience

Outcome Issues

 Very difficult to empirically measure the outcome of psychodynamic psychotherapy

◼ Improvement can’t be objectively measured

◼ Also difficult to manualize, which inhibits empirical study

◼ Regardless, large-scale reviews support its benefits with some disorders, but remains
unproven with others

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 Allegiance effects may influence outcome studies, particularly for psychodynamic therapy

◼ Few empirical outcome researchers are psychodynamic

◼ Researchers’ own orientations may bias the results of their studies

 Empirical support for components of psychodynamic therapy

◼ Interpretation of transference reactions

◼ Interpretation of countertransference reactions

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