Clinical and Counseling Assessment

Clinical psychology is that branch of psychology that has as its primary focus the prevention,
diagnosis, and treatment of abnormal behavior. Clinical psychologists receive training in
psychological assessment and psychotherapy and are employed in hospitals, public and
private mental health centers, independent practice, and academia.
Like clinical psychology, counseling psychology is a branch of psychology that is concerned
with the prevention, diagnosis, and treatment of abnormal behavior. Clinical psychologists
tend to focus their research and treatment efforts on the more severe forms of behavior
pathology, whereas counseling psychologists focus more on “everyday” types of concerns
and problems such as those related to marriage, family, academics, and career.
Members of both professions strive to foster personal growth in their clients.
Therefore, the tools employed in the process of assessment in counselling and clinical
psychology overlap considerably, including the interview, which is the focus of this class
today
Overview
Psychological assessment may be undertaken for various reasons and to answer a variety of
important questions. For the clinical psychologist working in a hospital, clinic, or other
clinical setting, tools of assessment are frequently used to clarify the psychological problem,
make a diagnosis, and/or design a treatment plan.
Does this patient have a mental disorder?
and If so, what is the diagnosis?
are typical questions that require answers.
In many cases, tools of assessment, including an interview, a test, and case history data, can
provide those answers.
Overview
Counseling psychologists who do employment counseling may use a wide variety of
assessment tools to help determine not only what occupations a person might enjoy but
also which occupations would be sufficiently challenging yet not overwhelming.
School psychologists and counseling psychologists working in a school setting may assist
students with a wide variety of problems, including those related to studying.
Here, behavioral measures, including self-monitoring, might be employed to better
understand exactly how, when, and where the student engages in study behavior.
The answer to related questions such as Why am I not doing well in school? may in part be
found in diagnostic educational tests, such as those designed to identify problem areas in
reading and reading comprehension.
Another part of the answer may be obtained through other tools of assessment, including
the interview, which may focus on aspects of the student’s motivation and other life
circumstances.
Overview of the Interview Structure
Although the format, content, and flow of the interview are determined by the type of
interview (refer to Korchin – diagnostic with MSE, intake,social-history or case history,
informants, screening, pre-testing interview etc), all clinical interviews share common
elements.
Variations in the structure of interviews have been proposed (e.g., Foley & Sharf, 1981;
Shea, 1998), but there is general agreement that assessment sessions consist of an opening,
body, and closing.
Prior to the session, several preliminary steps set the stage for a successful interview.
Initial Steps
The assessment process begins at the moment of first contact with the client, often at the
time of scheduling the appointment.
Whether conducted by administrative personnel or by the individual carrying out the
interview, this is the first step in developing rapport; therefore, it should be done in a
professional and collaborative manner.
Managing first impressions is critical at the beginning of the inter- view. As the clinician
presents his or her credentials, it is an opportunity to establish authority, instill confidence,
and set boundaries for the remainder of the session.
This can be particularly challenging for clinicians or counsellors-in-training. Generally,
clinicians/counsellors are advised to use their first and last name when introducing
themselves and to follow this with a brief description of their credentials (e.g., “Hello, my
name is Pat Smith; I am a psychology intern here at Clinic X, and my supervisor is Dr. Brown,
a licensed clinical psychologist”).
Students are encouraged to present their credentials in a confident and straight- forward
manner; however, they should be careful not to overstate or misrepresent their
qualifications, as this constitutes an ethical violation (Sommers- Flanagan & Sommers-
Flanagan, 2009).
Students should be direct and honest in their presentation of their experience and current
status (e.g., “I am in my second year of a master’s degree in clinical psychology and this is
my second psychology place- ment”; “I am in the third year of a doctoral program in clinical
psychology, and I am working here at Clinic X as part of my training”).
Initial Steps
Many clinicians in the early stages of their training may not be sure how to address their
client. The most prudent approach is to address clients by their title and last name (as in,
“Mr. Jones” or “Ms. Lee” BUT MIZO??), rather than addressing them immediately by their
first name. Some clients may readily indicate that they would prefer to be called by their
first name, while others may not. Clinicians can ask clients about their preferences if they
are uncertain (e.g., “Would you prefer that I address you as Ms. Lee, or Sam?”).
The physical space also contributes to a client’s first impression of the upcoming session.
Although the physical space will be determined in large part by the clinical setting, some
features of the room may facilitate the interview process. At the very least, privacy is
crucial, and interruptions should be avoided. This reaffirms the confidentiality of the
procedure and increases client self-disclosure (Sommers-Flanagan & Sommers-Flanagan,
2009).
In addition, the interviewer should have control of the environment, in order to establish
professional boundaries, although the client should have minor choices such as seating
arrangements (Sommers-Flanagan & Sommers-Flanagan, 2009). Some recommend a 90-to-
120degree angle seating arrangement (Sommers-Flanagan & Sommers- Flanagan, 2009),
which allows for flexible eye con- tact for both parties. Others prefer a face-to-face
arrangement for the intake interview, with a desk between the interviewer and client, thus
differenti- ating an assessment from a therapy session.
Opening
The goals of the opening phase of the interview are to convey essential information (such as
confidentiality), to obtain informed consent, to alleviate anxiety, to develop rapport, and to
set the tone of the interview.
Confidentiality is a right afforded to all clients as mandated by law, and clinicians are not
permitted to disclose information obtained during the assessment without the client’s
consent.
However, there are conditions under which the clinician is ethically and legally obligated to
break confidentiality. The specific conditions are established by one’s professional governing
body (e.g., American Psychological Association [APA], 2002) and legislative guidelines.
It is the responsibility of the interviewer to be familiar with these before initiating any
dialogue with the client, and to convey this information at the outset of the assessment. In
fact, an honest discussion of confidentiality may contribute to the validity of the
assessment. Research indicates that clients are more likely to disclose per- sonal and
potentially critical diagnostic information when confidentiality, and its limits, are clear
(Kremer & Gesten, 1998).
Opening
Informed consent refers to sufficient disclosure of information about the nature of the
assessment so that a competent person can make a voluntary decision to continue (APA,
2002). This is frequently provided both orally and in writing, using clear and understandable
language. Informed consent is not only mandatory, but also facilitates the interview process.
Clients become actively engaged in the assessment because they are aware of what to
expect, the potential risks and benefits, and they agree to accept shared liability and
responsibility for the interview (Beahrs & Gutheil, 2001).
Moving from communicating standard information to discussing the client’s presenting
problems signals a transition to the information collection phase of the interview.
Most interviews begin with an open-ended question and then proceed with more direct
questions throughout the session to obtain targeted information.
Often, the interviewer is interested in hearing, in the client’s own words, what led him or
her to seek counselling or therapy at that time (e.g., “Tell me what brings you to therapy at
this time”; Sommers-
Flanagan & Sommers-Flanagan, 2009, p. 155). This puts the client at ease, and allows the
interviewer to make important behavioral observations, regarding such variables as the
client’s ability to organize his or her thoughts, tone of voice, energy level, body language,
and interpersonal style (Sommers-Flanagan & Sommers-Flanagan, 2009).
Although this may be done with varying degrees of formality depending on the type and
structure of the interview, in essence, this portion sets the tone for the remainder of the
assessment
Body
The body of the interview is generally the most variable section, defined by the depth,
breadth, and structure of the assessment.
It is a process of information gathering, in which hypotheses are formed and refined, and a
complete picture of the client is developed.
The format of this section is based almost entirely on the type of interview conducted. Some
interviews may cover a breadth of psychological disorders, whereas others will focus on a
specific area of interest in some depth
The body of the interview will also depend on the degree of structure. Structured interviews
contain primarily closed questions with specified response options. On the other hand,
unstructured interviews often allow the client to describe difficulties in his or her own
words.
Body
Throughout the interview, the psychologist should be aware of inconsistencies in reported
symptoms and behavior.
The implicit assumption is that the client and interviewer work together to obtain complete
and accurate information.
However, some clients may adopt response styles that interfere with this process. For
example, a client may over-endorse symptoms in an effort to “fake bad,” as in malingering,
or provide socially desirable responses in order to “fake good” (Rogers, 2001).
Interpreting these inconsistencies may be more difficult with unstructured interviews, as
they may be an artifact of the question form or sequence (Rogers); however, it is the task of
the interviewer to resolve the discrepancies when making diagnostic conclusions and
treatment recommendations.
Several strategies may be useful, such as using counterbalanced and neutral questions,
seeking corroborative data, and using clinical judgment to assess the plausibility of the client
self-reports (Rogers, 2001).
Closing
At the end of the session, the interviewer should reserve time to summarize the main
themes of the assessment, address any questions or concerns, and discuss the next steps,
like testing etc.
In most jurisdictions, communicating a diagnosis is considered a controlled act requiring a
minimum level of professional competence; therefore, when summarizing and organizing
reported symptoms, the interviewer should be mindful of relevant legal restrictions.
Once the information has been summarized and presented to the client, the client should
always have an opportunity to confirm the conclusions.
Occasionally, the interviewer may recommend treating a different problem than the client
wishes to focus on in treatment. Unless the client is at risk of endangering himself or herself,
or someone else, the client is ultimately responsible for determining the course of
treatment.
Often, the clinician will provide some basic psychoeducation regarding the nature of the
client’s difficulties as well as treatment options.
The interview typically concludes with a clear description of the next steps in the process,
such as when and how results and recommendations will be communicated to both the
referral source and the client, and resolution of payment, as established at the outset of the
session.
Behavioral Observations
Behavioral observations are an important part of any psychological interview.
During the interview, assessors will typically take note of the client’s appearance, behavior,
mood and affect, motor activity, and quality of thought and speech.
Such observations are made in an unobtrusive manner and provide important information
over and above client self-reports.
The client’s verbal and nonverbal behavior during the assessment can provide corroborating
information for reported symptoms, but may also alert the clinician to inconsistencies. For
example, a client who reports being deeply depressed yet displays positive affect and
normal motor activity may suggest the possibility of low insight or malingering.
The mental status examination (MSE) is a system by which clinicians can categorize their
observations. The MSE is used primarily to make inferences about cognitive functioning.
Generally, MSEs include the following categories of observations (Sommers- Flanagan &
Sommers-Flanagan, 2009):
Appearance (e.g., grooming, weight)
Physical movements (e.g., avoidance of eye contact)
Attitude toward the assessor (e.g., hostile, cooperative)
Behavioral Observations
Mood and affect (e.g., euphoric, irritable)
Thought and speech (e.g., flight of ideas, tangential speech)
Delusions and hallucinations
Orientation and consciousness (i.e., awareness of who one is, where one is, and what day it
is)
Memory and intelligence (e.g., memory for facts, problem-solving ability)
Reliability (e.g., vague self-report; inconsistency across multiple assessments),
judgment (e.g., impulsive decision-making),
and insight (e.g., belief that one’s psychological problems are due exclusively to a medical
problem)
Behavioral observations can be quite subjective. The clinician is comparing the client’s
presentation to a prototype that has been developed through clinical experience