Clinical interviewing and hypothesis building - summary of chapter 1 of Conducting psychological assessment by Wright

Conducting psychological assessment
Chapter 1
Wright, A. J. (2011)
Clinical interviewing and hypothesis building

The first focus of the hypothesis testing model of psychological assessment is building hypotheses.
The primary source is the clinical interview.
The purpose of the psychological assessment is to identify what is likely causing impairment in the individual’s functioning.

The first step is to figure out in what way the individual’s functioning is impaired.
This issues reported by either

• The individual himself or herself
• Whoever referred him or her for the assessment are most often at least part of what is impaired in or impairing his or her functioning

Most often, what is reported at first is only part of what is actually disturbing the individual or is merely the result of something else that he or she is not even aware of.
Practitioners should be both open to the original presenting complaint and ready to consider the possibility of impediments the individual is not aware of.

The nature of the presenting problem most often becomes apparent through the process of the clinical interview, the collection of background information, and your own clinical observations.

The clinical interview

The clinical interview has three major components:

• The presenting problem (and its history)
• A symptomatic evaluation
• A psychosocial evaluation

Presenting problem and its history

The presenting problem is related to the issues that constitute the reason for the assessment, as well as the history of these issues.
Many clients are unclear when discussing their presenting problem.

Presenting problem

The presenting problem includes whatever complaint the individual identifies as the reason for the assessment.
The presenting problem is at times realtively straightforward, but sometimes factors can get in the way of its being clear, including

• Guardedness on the part of the client
• A client’s lack of psychological mindedness and insight
• A diffuse client presentations

At times, the presenting problem needs to be reassessed at the end of the interview, once a client becomes more comfortable and more disclosing with the assessor.

History of presenting problem

The assessor should always work to develop a detailed history of the problem, including

• When it began
• If there was a precipitating event
• How continuous the problem has been
  When and how it got worse or better during the tie the struggle began
• Any previous assessment conducted
  Gain a prior clinician’s perspective on the history of the problem in addition to that of the individual being assessed
  • Consulting with the prior clinician provides potentially rich data and cross-verification and provides the individual you are assessing with a sense of continuity and coherence to the his or her ongoing assessment and care

Symptomatic evaluation

This is important in understanding the actual content of the problem, including the symptomatic and medical features of what may be impairing the client’s functioning.
Assessors should ask specific questions about symptoms related to different psychiatric diagnoses, as well as observe them during the clinical interview and the entire assessment.
In order to fully understand what is going on for a client, an assessor must inquire about family history, medical history and substance history.

Developmental history

The assessment of developmental history can be seen as a crossover between the symptomatic evaluation and the psychosocial evaluation, as it has some components that are physiological and some that are environmental and interpersonal.
It begins with specific questions about

• The early developmental environment
  Including if there were any known problems during pregnancy of the individual’s mother, as well as during labour and delivery.
• Significant events during infancy and childhood
  Including developmental milestones
• Any childhood behavioural problems
  Significant accidents
  Traumas

Psychiatric history

Extremely important for understanding the actual course of the individual’s problems.
You should be sure to collect information on

• Any past hospitalizations
• Past harm of threat of harm to self or others
• Any psychotropic medications taken in the past

If there were previous treatments, you should obtain a release of information to get the records of these treatments or, at the very least, speak with the previous treating clinicians.

Alcohol/substance use history

Both past and present use of alcohol and other drugs should be explored.
Even social use.
Included in the assessment of alcohol or other substance should be

• The type(s) of substance
• The onset of use
• The length of time and duration of use
• The amount of use
• Any previous treatments of use
• Whether the individual feels that his or her use of substances has caused any type of impact, positive or negative, on his or her life.
  • Attitudes about using and quitting can be extremely useful later on in the assessment process

Medical history

Both present and past medical status should be explored

• Any serious medical illness
• Hospitalizations
• Medications taken currently or in the past
  Make sure to not for how long they have been taken
  For what they were prescribed
  Any changes in dosage or administration that have occurred during their use
• Any temporal relationships between changes in the medical history and changes in presenting problem symptomatology
• The data and results of the individual’s last comprehensive physical examination
  Serves as an indicator of the individual’s investment in self-care as well as his or her level of awareness of health status.

Medical history and status can significantly affect current psychological functioning.

Family medical and psychiatric history

Because of what is known about the heritability of both medical and psychiatric illness, and about children being raised by parents with medical illness, it is important to ask about any significant medical and psychiatric illness in both the immediate and distant family of the individual being assessed.
Knowing this information about someone who has come in for an assessment can alert the assessor to possible symptoms or to view problems in a different light.
It may be important to point out to the client that psychiatric illnesses are often undiagnosed.

The topics to assess related to family medical and psychiatric history are the same as when assessing the client’s own medical and psychiatric history, with the addition of discussing possible undiagnosed illnesses in family members.

Psychological evaluation

The psychosocial evaluation is designed to examine the context of the individual’s world, with both its intrapsychic and interpersonal demands.
The scope of the presenting problem often reaches beyond individual symptoms.
It is essential to consider that symptoms are manifested within a larger context of relating to others.
They will likely be affecting interpersonal functioning, educational and work functioning, and many other areas of life.

Family history

Note both current and past family structure.
Any significant history within the family should also be included.

Educational/vocational history

A thorough assessment of educational history should be discussed.

• The highest level of school completed
• General functioning within schools
• Educational aspirations
• Whether there is a history of any academic difficulties
• Information on current and past occupational functioning

Criminal/legal history

Note any history of legal problems.
It is absolutely necessary to assess past legal involvement.

Be aware of subtle and slight reactions on your part.
To elicit the most honest and open responses from the client, you have to work hard to appear non-judgmental and difficult to shock when discussing illegal activity.

Social history

A history of socialization should be evaluated

• Current number of friends and the quality of these friendships
• The kinds of social networks and social activities that the individual participated in while growing up
  They may illustrate some of the reasons behind current difficulties
• Whether or not the individual has a best friend
• Any history of interpersonal difficulties
• Any current significant relationships
  Including length and quality

Psychiosexual history

Psychosexual functioning: all of the psychosocial issues related to sexuality. Including

• History of romantic and sexual behaviour and exploration
• Sexual adjustment and attitudes
• Gender identification
• Sexual orientation

It is important to rule out the possibility that psychosexual issues may be affecting an individual’s current psychological functioning.

Included in this evaluation should be

• A history of sexual development
• Any history of sexual violence or molestation

It is important to approach inquiry about psychosexual history in as straightforward and unapologetic a manner as possible.

Multicultural evaluation

It is impossible to understand an individual without understanding the cultural environment in which he or she is functioning.
Include in this section of the evaluation specific facts if there is one.

• The individual’s cultural, racial and spiritual/religious identify

Mental status evaluation

One of the most important tools for evaluating a person’s current functioning is clinical observation.
The mental status evaluation (MSE) is a useful way of organizing clinical observation data.

Appearance and behaviour

How someone appears and behaves.

• Clothing
• Grooming
  How adequate someone’s hygiene is
• The level of motor activity and coordination

Behaviour refers to both any abnormal or repetitive behaviours, and the individual’s relatedness toward you.

Appearance and behaviour can, even before testing, clue you in the possibility of some reasons for functional impairment.
Behaviour is significant clinical data that must be used or explained by the results of the assessment.

Speech and language

A person’s language functioning critically affects your ability to adequately assess him or her in all other domains of functioning.
Language should be evaluated separately for

• Receptive elements
  Language comprehension
• Expressive elements
  The individual’s actual use of language to make his or her point known

Aspects of speech should be evaluated separately from the language itself

• Volume
• Rate
• Tone

Difficulty understanding language would impair interpersonal relationships, educational and occupational functioning, ect.
It informs what alterations your testing battery may need to be made.

Difficulties with receptive language can be related to several things.

Mood and affect

Mood: the current emotional state of the individual as reported by the client him- or herself.
Affect: the observed emotional state of the individual.

It is important to decide whether both

• Are appropriate for the situation
• Are appropriate to each other
  Mood-affect congruence (it is appropriate).

Thought process and content

Evaluating the thought process and content can provide you with extremely useful pieces of data when you create a picture of what may be going on for an individual.
Thought process: how an individual thinks.

Tangential thought process: constantly going off topic in an seemingly stream-of-consciousness delivery
Circumstnatial thinking: will eventually veer back onto the point and answer the question, though in a roundabout way.

Thought content: what the individual thinks about.
We are most interested in abnormal thought and perceptual content.

Depressive, manic, aggressive, suicidal, homocidial, hallucinations should be noted.

Cognition

Clinical impressions of different domains of cognitive functioning should be noted from the interview, so that any suspected abnormalities can be included in the hypotheses generated later.
Additional testing may be required as a result of these noted abnormalities.

• Alertness
• Attention
• Concentration
• Memory

Prefrontal functioning

Those higher-order skills and functions associated with the functioning of the prefrontal cortex area of the brain.
These domains are complex and difficult to assess. It is nevertheless useful to evaluate them broadly.

• Judgment
• Planning
• Insight
  Is the person aware that he or she has difficulties and needs support or help
  Is the person aware that he or she plays a part in his or her own problems
  Is the persona aware of the specific issues that need addressing

Hypothesis building

Once data have been gathered it is time to ask what could be going on for this person.
To answer this question effectively, you need clear and comprehensive knowledge of psychodiagnosis.
For assistance, there is the DSM.
Also important is a thorough knowledge of cognitive, personality, and emotional functioning form whichever theoretical perspective you subscribe to.

You should generate hypotheses for all the likely causes of the functional impairment.
One hypothesis should always be that the individual’s functioning is normative and functional – that nothing is wrong.
This is the null hypothesis.

Identify impairments

The first task in the process of hypothesizing is to clearly lay out the precise impairments in functioning.
This often requires some degree of simplification.

The first step is to list the impairments in functioning.

Eliminate possible causes

The next step is to try to enumerate all the logical possible causes for each of the broad areas of impairment in functioning.
First we must consider the fact that there may be nothing abnormal occurring.
The alternative generates several other hypotheses.
Take into consideration the prior functioning, the duration of symptoms and many other factors.

There are tow hypotheses that must be ruled out across the board

• Substance-related disorder
  This is not exclusive
• The impairment in functioning is due to a general medical condition

When generating hypotheses you want to try to be as expansive as possible, enumerating as many possibilities as you can come up with for each impairment in functioning.
Many of these will be ruled out quickly and easily in the testing process, but each will help inform what tests you choose for the assessment battery.