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The Process of Assessment in Clinical Psychology

His primary physician referred John to a clinical psychologist after several episodes of sudden violence and rage. John claimed to have limited or no memory of the incidents. His mother described him as typically being a shy, quiet, and even withdrawn adolescent. This was the 15-year-old’s first psychological evaluation. During one of John’s episodes, his anger was so out of control that he broke dishes, punched holes in the wall, and did hundreds of dollars of damage to his room. His mother worried that John’s anger might soon turn to violence against himself or others. She further described him as having low energy, sometimes being sullen, and wanting to sleep a lot. He was unhappy in school, falling far behind his classmates, and in danger of repeating the ninth grade.

What do you think the clinical psychologist would want to know about John to help him with his problems?

The clinical assessment process consists of the following six steps:

1. deciding what we want to know
2. planning data collection procedures
3. collecting assessment data
4. interpreting the data and formulating hypotheses
5. making recommendations and decisions based on the data
6. communicating information from the assessment data

How the Clinical Psychologist Proceeded in the Case of John

Step 1. Deciding what we want to know

• Is John depressed?
• Could there be a neurological problem contributing to the episodes?
• What factors in his environment might be contributing to his problems?
• Might John have a learning disorder that causes his difficulties in school?

Step 2. Planning data collection procedures

• Choose appropriate personality assessment tests such as the MMPI-A to assess for depression or other psychopathology.
• Choose cognitive tests of aptitude (e.g., WISC-V) and achievement (e.g., WJ-IV) to rule out the possibility of a learning disorder.
• Refer John for a neurological examination to rule out medical problems (e.g., seizure activity).

Step 3. Collecting assessment data

• Conduct a thorough clinical interview.
• Administer and score tests.

Step 4. Interpreting the data and formulating hypotheses

• Medical tests ruled out neurological problems.
• Cognitive testing ruled out learning disorders and found average intelligence.
• Personality testing as well as information and behavioral observations from the clinical interview indicated clinical depression.

Step 5. Making recommendations and decisions based on data

• John was referred for psychotherapy and a medication evaluation to treat his depression.
• It was recommended that John be monitored for suicidal or homicidal ideations because of his episodes of violence.
• John may be referred for an inpatient evaluation if therapy and medication fail to improve his condition.

Step 6. Communicating information from the assessment

The clinical psychologist conducted a feedback session with John and his mother communicating the impressions and recommendations gained from the assessment. She then referred John to an appropriate therapist for psychotherapy and a psychiatrist for medication evaluation. Finally, the psychologist documented the diagnosis (i.e., major depressive disorder) and wrote a formal report summarizing data, impressions, and recommendations to communicate information to other mental health professionals.

Referrals and the Referral Question

The assessment process generally begins with a referral, meaning someone such as a doctor, teacher, parent, or judge asks a question for the psychologist to answer. In John’s case, the referral came from his primary physician. The referral question was, “What is causing John to have episodes of rage and violence?” The psychologist answered this question by conducting a clinical interview and gathering data from several psychological tests. Several possibilities (e.g., learning disorder, seizure activity) had to be ruled out. Hence, a clinical psychologist must use both inferential reasoning (collect and assess various forms of data) and deductive reasoning (operate with a working hypothesis—in this case, the referral question—and eliminate competing explanations).

Ultimately, the answer to the referral question in the case of John was clinical depression. Some referral questions may be difficult or impossible to answer. For example, in John’s case the question, “Will he become violent toward people?” may have been very difficult to answer. Sometimes, psychologists may ask the referral source to rephrase or change their referral question to a more reasonable, more answerable question.

The Clinical Interview

Interview Variations

The type of clinical interview conducted varies with the situation. These types are summarized below.

• Intake interviews: This, the most common type of interview, is used when a client first comes in for an evaluation. The main goal is to establish the nature of the presenting problem. The information gathered may help the interviewer to make appropriate recommendations and referrals. Intake interviews may also lay the foundation for therapy by establishing rapport and a therapeutic relationship.
• Diagnostic interviews: Sometimes psychiatrists, courts, schools, or other agencies refer clients to clinical psychologists to get diagnostic impressions or to answer referral questions or both. In such cases, the interview will not necessarily lead to treatment by the psychologist but to a diagnosis to be given to the referring agency. The goal of the interview is to answer the referral question or to provide a clinical diagnosis or both.
• Orientation interviews: These interviews help people learn what to expect when they undergo psychological testing or treatment. These interviews help clients feel more comfortable and knowledgeable about the procedures (assessment, treatment, or research) they will be undergoing. In these interviews, the client is encouraged to ask questions or make comments, which can then be discussed.
• Termination interviews: These interviews take place at the end of a clinical relationship, for example, with people completing psychotherapy or with those who have undergone an extensive assessment process. The interview helps answer questions, tie up loose ends, and helps the client transition to the next step. In research, these interviews are called debriefing and include an explanation of the project in which the person has participated.
• Crisis interviews: If a person’s problems are intense and pressing, there may not be as much time to conduct interviews and assessments. For individuals in crisis, it is important to provide support, collect information, and provide intervention, all in a short period of time. Those who work at crisis hotlines or suicide prevention agencies may conduct such interviews.

Components of the Clinical Interview

The goal of most clinical interviews is to obtain as much information as possible to help formulate diagnoses and plan treatment. The clinical psychologist should identify the client’s chief complaint (i.e., presenting problem), gather information or observations to make a specific diagnosis, and record the client’s medical, family, personal, and social history, and any history of suicide attempts, violence, or substance abuse. Clients may be uncomfortable sharing such information, especially if they are seeking psychological help for the first time. The following components of interviewing can offer reassurance and thereby facilitate gathering the most complete and accurate information.

• Rapport: Most clinical psychologists would agree that rapport is very important for successful clinical work. Rapport, which is based on trust, confidence, and genuineness, helps to generate a good working relationship between the psychologist and the client. There are many techniques for generating rapport during the initial interview, including greeting the client in a warm and friendly manner, making good eye contact, and displaying empathy and genuine concern for the client.
• Verbal encouragement: The interviewer’s goal is to facilitate information flow. Verbal encouragement helps keep the client talking and demonstrates that the interviewer is listening to him or her. Types of verbal encouragement may be a simple yes or mm-hmm, clearly indicating an understanding of what the client is saying. Other verbal techniques that encourage the client to open up include repeating his or her last word or two with a rising inflection to make a question, or simply saying, “Tell me more about that.” Briefly summarizing what the client has just said also shows that the interviewer is listening.
• Nonverbal encouragement: The interviewer can also encourage the client to share more information by using nonverbal cues. Maintaining eye contact is very important, and a simple smile or nod can indicate, “I understand” or “I am listening.” Interviewers can also lean a little closer to demonstrate interest in what the client is saying. Maintaining an open body position (e.g., no crossed arms) is also important to show that the interviewer is attentive and encouraging.
• Offering reassurance: Reassuring the client helps him or her have confidence in sharing what might be difficult information. It also indicates you are interested in the client and can help build rapport. Certain body language such as a nod or a smile can be reassuring, as can normalizing a painful experience (“Many people suffer from depression, but there are ways to help”). Focusing on a client’s strengths and emphasizing positive characteristics (“I see you are a devoted mother”) is also reassuring.

Interviewing Special Populations

Interviewing certain populations, such as children and adolescents, presents a different set of circumstances for the interviewer. For example, the parent or guardian will most likely be the one interviewed about the presenting problem. Because of differences in cognitive development, language skills, and interpersonal skills, the techniques used to interview adults may not be as effective with children. Children require concrete questions for which they can offer simple answers. Children may provide better information through art or play.

Some interviewers may use behavior checklists that the primary caretaker fills out to get information (e.g., the Child Behavior Checklist) or projective interview techniques with the child. An example of a projective interview technique would be a sentence-completion task. The child is given a series of sentence stems and asked to complete the sentences (e.g., Sometimes I think about. . . , School is. . . , I get mad when. . . ). The child’s responses typically reflect his or her own thoughts and feelings. Interviewing children requires flexibility and resourcefulness, and the clinician must demonstrate genuine enthusiasm to keep a child interested in the interview.