Clinical Interviewing and Hypothesis Building - Wright - 2011 - Chapter 1

Summary with Clinical Interviewing and Hypothesis Building - Wright - 2011 - Chapter 1

The clinical interview is the most important part for a researcher to use when he or she wants to set up hypotheses using the hypothesis testing model. The first step in the hypothesis testing model is to find out what is impairing somebody's function, this is what researchers call presenting problem or the referral question. Often it is the case that the presenting problem is just a small part of the overall problem or what is disturbing someone. 

How do you take a clinical interview?

A clinical interview is based upon three components: 

1. The presenting problem
2. A symptomatic evaluation
3. A psychosocial evaluation

What is the presenting problem?

The presenting problem is about the issues that the person has, the reason for assessment, but also the history of these issues. The presenting problem includes everything what the individual identifies or sees as the reason for the assessment. The presenting problem isn't always completely clear, most of all because the individual often doesn't tell the whole story immediately, guardedness or lack of psychological mindedness and insight. 

You also have to make sure to know the history of the presenting problem, the time since the struggle began and previous assessment conducted. You can also always ask previous researchers and clinicians to give information about your client. 

What is the symptomatic evaluation?

During the symptomatic evaluation the clinician tries to get a good understanding of the problem the individual is facing, including all the symptomatic and medical problems. 

The researcher also needs to make sure to know things about the individual's developmental history. This begins with questions about the pregnancy and the labor and delivery of the mother. Furthermore, the developmental milestones (crawling, walking, talking), behavioral problems, significant accidents, and traumas are also very important. 

The psychiatric history is also very important to ask out. You need to collect information about eventually past hospitalizations and harm/threat or psychotropic medications. Also, both the past and present of alcohol and drug use should be explored. For example: an individual who presents as depressed and reports social use of alcohol may not understand how alcohol, a depressant, can influence her symptoms, even in what she considers to be low doses. You also need to ask whether the drug and/or alcohol use influences the life of the individual in a positive or negative way. 

The medical history of the client is important to note because medical conditions can influence the current psychological function. Also, medication can react with each other, so the clinician needs to know what the client is taking. 

In addition to the medical history of the client is the medical and psychiatric history of family members also very important. This because there are a lot of heritable medical and psychiatric illnesses. 

What is the psychosocial evaluation?

The symptomatic evaluation is used to clarify the content of the individual's current functioning. The psychosocial evaluation is used to examine the context of the individual, with the intrapsychic and interpersonal demands. Asking about the family history is the first step in the psychosocial evaluation (think about primary caregiver, siblings, traumas and deaths). 

The educational history of the client is also important to note. You can discuss the highest level of school completed, general functioning, educational aspirations etc. 

The criminal and legal history is next on the list. It is absolutely necessary to assess past legal involvement, probation or parole, because these things can support a potential hypothesis of antisocial or even psychopathic traits. It is also important because you want to know whether the client is capable of harming him/herself or others. As the clinician you really need to make sure to keep your head straight during this kind of conversations. The slightest emotional reaction can trigger the client not to answer as honest or open as you wish they would react. 

The social history of the client includes the current number of friends, quality of these friendships, social networks, social activities, interests etc. 

One of the more delicate topics during a clinical interview has to do with psychosexual history of the individual. This relates to all the psychosocial issues related to sexuality, history of romantic and sexual behavior, sexual adjustment and attitudes, gender identification, and sexual orientation. This isn't always very interesting, because not everybody has sexual related problems that influence the psychological functioning of the client. Additionally, you also have to ask about the history of sexual violation or molestation from or to the client. Then, you also have to make sure you understand the culture, language, environment, and norms the client uses. 

What is the mental status evaluation?

The mental status evaluation MSE is a useful way of organizing clinical observation data, and was designed to identify certain parts of functioning that don't fall in the normal range. 

• Appearance and behavior: appearance isn't only about the ways somebody looks or dresses, but also how somebody moves and coordinates. When somebody looks like he hasn't taken care of himself for a while, these are all signs he must not feeling very well and there might be something wrong. 

• Speech and language: the language a person is speaking can affect the ability to adequately assess the client. Language should be evaluated as (a) receptive, and (b) expressive elements. Repetitive language is about language comprehension, and expressive language is about the individual's actual use of language to make his or her points clear. 

• Mood and affect: mood refers to the emotional state of the individual at this moment reported by the client self, and the affect refers to the observed emotional state of the individual, such as facial expressions and body language. When you look at the mood and affect of the client you have to think about whether (a) the mood and affect are appropriate for the situation, and (b) if the mood and affect are appropriate to each other. The idea is that the client says he/she is 'fine' but shows clearly depressed symptoms. 

• Thought process and content: the thought process is about how the individual is thinking, in a goal-directed/logical way or in a magical, weird way of thinking. This can show signs of schizophrenia, bipolar I and II and depressive symptoms. Also, when somebody has trouble thinking he or she can also have dementia or a psychosis. Thought content is what the individual thinks about, especially the weird abnormal stuff. 

• Cognition: the cognitive functioning will always be assessed in a separate part but you also have to make some time in the clinical interview to get to the cognitive functioning part to make sure you can include this information in the hypotheses. Also when the individual is bad at answering the questions or listening, it can be the case that there is a concentration problem. 

• Prefrontal functioning: this is the last part of the MSE and is about the higher-order functions such as attention and concentration. But the prefrontal cortex has also a lot of influence on the personality of somebody, such as judgement, planning and insight. Insight, for instance, is about (a) how the individual sees she has a problem and needs support and help, (b) that he/she plays a role in his or her own problems, and (c) aware about the specific issues. 

What hypotheses do you need to check?

You, as a researcher, have to ask yourself 'what could be going on for this person?'. For extra assistance, next to clinical interview information and the MSE you can use the DSM-IV, which includes a list of symptoms with all their likely diagnostic causes. 

1. Identify the impairments: you have gathered a lot of information, and you now have to put all the information together and make sure you step back and look at the overall picture to see if you know what is impairing the individual's functioning. 
2. Enumerate possible causes: the first thing you need to think about is that there might be nothing wrong with the individual, but it can also be the case that there is a psychological illness or disorder that causes all the mishaps. You also always have to make sure that the hypothesis 'substance-use disorder' is favored or declined. Another major hypothesis would be a 'personality disorder'.