CLINICAL PSYCHOLOGY to their clients.

Simply put, the voice in the interviewer’s own

CHAPTER 7: CLINICAL INTERVIEW mind should not interrupt or drown out the voice of the client.

 Being Self-aware
THE INTERVIEWER – The most pivotal element of The type of self-awareness that should be maximized is the
a clinical interview is the person who conducts it. A skilled interviewer’s ability to know how he or she tends to affect
interviewer not only is a master of the technical and practical others inter personally and how others tend to relate to him or
aspects of the interview but also demonstrates broad-based her.
wisdom about the human interaction interviewing entails.
 Developing Positive Working Relationships

There is no formula for developing positive working

GENERAL SKILLS relationships during an interview; however, attentive listening,
appropriate empathy, genuine respect, and cultural sensitivity
Before leaping into any interview, the interviewer should have
play significant roles. Positive working relationships are always
acquired some general skills to serve as a foundation for
a function of the interviewer’s attitude as well as the
interviewing in any context. These general skills focus on the
interviewer’s actions
interviewer’s own frame of mind rather than any particular set
of techniques. Sommers-Flanagan and Sommers-Flanagan
(2009) describe several such requirements: quieting yourself, SPECIFIC INTERVIEWERS
being self-aware, and developing positive working
relationships. When interviewers succeed in quieting themselves, knowing
themselves, and developing good working relationships, they
have laid the groundwork for conducting successful interviews.
 Quieting Yourself
The next task is to master the tools of the trade, the specific
The term quieting yourself does not simply mean that the behaviors characteristic of effective interviewers. As mentioned
interviewer shouldn’t talk much during the interview (although earlier, a primary task of the interviewer is to listen. Listening
rambling by the interviewer is usually not a good idea). Rather may seem like a simple enough task, but it can be broken
than the interviewer’s speech, what should be quieted is the down into even more fundamental building blocks of attending
inter viewer’s internal, self-directed thinking pattern. To the behaviors (many described in Ivey, Ivey, & Zalaquett, 2010).
extent that interviewers are pre occupied by their own
Eye Contact – Interviewers must realize the connection
thoughts, they will struggle in the fundamental task of listening
between attentive listening and eye contact. Eye contact not
only facilitates listening, but it also communicates listening. Ms. Washington as “Latrice”) are presumptuous mistakes that,
That is, when the client notices the interviewer’s continuous, for some clients, can jeopardize the sense of comfort with the
appropriate eye contact, the client feels heard. interviewer

As with eye contact, culture can shape the connotations of Observing Client Behaviors
body language. A few general guidelines for the interviewer
That behavior can vary widely: Some clients are calm while
include facing the client, appearing attentive, minimizing
others are nervous; some are easygoing while others are
restlessness, and displaying appropriate facial expressions.
hostile; some stay on task while others stray in random
Vocal Qualities – Skilled interviewers have mastered the directions; some are emotional while others are stoic; and so
subtleties of the vocal qualities of language—not just the on. Observing client behaviors during the interview allows the
words but how those words sound to the client’s ears. They psychologist to consider not only what the client said but how
use pitch, tone, volume, and fluctuation in their own voices to the client said it, and that “how” component can offer important
let clients know that their words and feelings are deeply information to the psychologist about responding during the
appreciated. And these interviewers also attend closely to the interview and understanding the client.
vocal qualities of their clients.

Verbal Tracking – Effective interviewers are able to repeat

key words and phrases back to their clients to assure the COMPONENTS OF THE INTERVIEW
clients that they have been accurately heard. Interviewers
I. Rapport refers to a positive, comfortable relationship between
don’t do this in a mechanical way; instead, they weave the
interviewer and client.
clients’ language into their own. In addition, interviewers skilled
at verbal tracking monitor the train of thought implied by How can an interviewer establish good rapport with
clients’ patterns of statements and are thus able to shift topics clients?
smoothly rather than abruptly.
1. First, interviewers should make an effort to put the
Referring to the Client by the Proper Name client at ease, especially early in the interview session.
2. Second, interviewers can acknowledge the unique,
It sounds simple enough, but using the client’s name correctly
unusual situation of the clinical interview. From the
is essential (Fontes, 2008). Inappropriately using nicknames or
client’s perspective, the interview experience is unlike
shortening names (e.g., calling Benjamin “Benji”), omitting a
any other inter action: They are expected to discuss
“middle” name that is in fact an essential part of the first name
(e.g., calling John Paul “John”), or addressing a client by first private, difficult, often emotionally charged issues with
a person they just met and know very little about.
name rather than a title followed by surname (e.g., addressing
Letting clients know that you recognize their position
 and appreciate their willingness to participate Although nondirective interviewing can facilitate rapport, it can
communicates empathy and enhances rapport. fall short in terms of gathering specific information.
3. Third, interviewers can enhance rapport by noticing Interviewers who are overly nondirective may finish an
how the client uses language and then following the interview without specific data necessary for a valid diagnosis,
client’s lead. Interviewers should pick up on the client’s conceptualization, or recommendation.
vocabulary and, as much as possible, speak in similar
terms
SPECIFIC INTERVIEWER RESPONSES
II. Technique is what an interviewer does with clients. These
are the tools in the interviewer’s toolbox, including questions, interviewing technique consists of what the interviewer chooses to
responses, and other specific actions. say. The interviewer’s questions and comments can span a
wide range and serve many purposes. There are numerous
common categories of interviewer responses: open- and
DIRECTIVE VERSUS NONDIRECTIVE STYLES closed ended questions, clarification, confrontation,
paraphrasing, reflection of feeling, and summarizing.
Directive Style – interviewers get exactly the information they need Open-Ended Questions – allow for individualized and
by asking clients specifically for it. Directive questions tend to spontaneous responses from clients. (“What more can you tell
be targeted toward specific pieces of information, and client me about the eating problems you mentioned on the phone?”)
responses are typically brief, sometimes as short as a single
word (e.g., “yes” or “no”). Closed-Ended-Questions – allow for far less elaboration and
self-expression by the client but yield quick and precise
Nondirective Style – allow the client to determine the course answers. (“How many times per week do you binge and
of the interview. Without direction from the inter viewer, a client purge?”)
may choose to spend a lot of time on some topics and none on
others. Clarification – Clarification questions not only enhance the
interviewer’s ability to “get it,” they also communicate to the
Both directive and nondirective approaches have client that the interviewer is actively listening and processing
shortcomings as well, especially when an interviewer relies what the client says.
too heavily on either one. Sometimes, directive approaches
can sacrifice rapport in favor of information. In other words, Confrontation – Interviewers use confrontation when they
interviewers who are overly directive may leave clients feeling notice discrepancies or inconsistencies in a client’s comments.
as though they didn’t have a chance to express themselves or Confrontations can be similar to clarifications, but they focus
explain what they thought was important. on apparently contradictory information provided by clients.
Paraphrasing – is used simply to assure clients that they are TYPES OF INTERVIEWS
being accurately heard. When interviewers paraphrase, they
typically restate the content of clients’ comments, using similar Intake Interviews – The purpose of the intake interview is
language. essentially to determine whether to “intake” the client to the
Reflection of Feeling – echoes the client’s emotions. setting where the interview is taking place.
Reflections of feeling are intended to make clients feel that In other words, the intake interview determines whether the
their emotions are recognized, even if their comments did not client needs treatment; if so, what form of treatment is needed
explicitly include labels of their feelings.
(inpatient, outpatient, specialized provider, etc.); and whether
Summarizing – usually involves tying together various topics the current facility can provide that treatment or the client
that may have been discussed, connecting statements that should be referred to a more suitable facility (Sommers-
may have been made at different points, and identifying Flanagan, 2016).
themes that have recurred during the interview.
Diagnostic Interviews (to diagnose) – If the purpose of the
Conclusions – In some cases, the conclusion can be diagnostic interview is to produce a diagnosis, it would make
essentially similar to a summarization. Or the interviewer might sense for the diagnostic interview to include questions that
be able to go a step further by providing an initial relate to the criteria of DSM disorders.
conceptualization of the client’s problem that incorporates a
greater degree of detail than a brief summarization statement.
In some situations, the conclusion of the interview may consist
STRUCTURED VERSUS UNSTRUCTURED
of a specific diagnosis made by the interviewer on the basis of
the client’s response to questions about specific criteria. Or the INTERVIEW
Structured Interview – is a predetermined, planned sequence
conclusion may involve recommendations.
of questions that an inter viewer asks a client. Structured
interviews are constructed for particular purposes, usually
diagnostic.
PRAGMATICS OF THE INTERVIEW
Advantages:
 Note Taking
 Structured interviews produce a diagnosis based
 Audio and Video Recordings
 The Interview Room explicitly on DSM criteria, reducing reliance on
 Confidentiality subjective factors such as the interviewer’s clinical
judgment and inference, which can be biased or
otherwise flawed.
  Structured interviews tend to be highly reliable, in that The mental status exam is employed most often in medical
two interviewers using the same structured interview settings. Its primary purpose is to quickly assess how the client
will come to the same diagnostic conclusions far more is functioning at the time of the evaluation. The mental status
often than two interviewers using unstructured exam does not delve into the client’s personal history, nor is it
interviews. Overall, they are more empirically sound designed to determine a DSM diagnosis definitively.
than unstructured interviews.
The format of the mental status exam is not completely
 Structured interviews are standardized and typically
standardized, so it may be administered differently by various
uncomplicated in terms of administration.
health professionals; two interviewers who use the mental
Disadvantages: status exam may ask different questions within the same
category.
 The format of structured interviews is usually rigid,
which can inhibit rapport and the client’s opportunity to
elaborate or explain as he or she wishes. CRISIS INTERVIEW
 Structured interviews typically don’t allow for inquiries
into important topics that may not be directly related to The crisis interview is a special type of clinical interview and
DSM criteria, such as relationship issues, personal can be uniquely challenging for the interviewer.
history, and problems that fall below or between DSM
Crisis interviews have purposes that extend beyond mere
diagnostic categories.
assessment. They are designed not only to assess a problem
 Structured interviews often require a more
demanding urgent attention (most often, clients actively
comprehensive list of questions than is clinically
considering suicide or another act of harm toward self or
necessary, which lengthens the interview.
others) but also to provide immediate and effective intervention
Unstructured Interview – involves no predetermined or for that problem.
planned questions. In unstructured interviews, interviewers
Crisis interviews can be conducted in person but also take
improvise: They determine their questions on the spot, seeking
place often on the telephone via suicide hotlines, crisis lines,
information that they decide is relevant during the course of
and similar services.
the interview.

MENTAL STATUS EXAM

CLINICAL PSYCHOLOGY Why Clinical Psychologists Should Prescribe
CHAPTER 3: CURRENT CONTROVERSIES
 Shortage of psychiatrists
AND DIRECTIONS IN CLINICAL PSYCHOLOGY
 Clinical psychologists are more expert than
primary care physicians – When it comes to
PRESCRIPTION PRIVILEDGES The roots of
expertise in mental health problems, clinical psychologists’
the movement were established in the 1980s, but in the 1990s
training is more extensive and specialized than physicians’;
and 2000s, it rose to the level of a high-profile, high-stakes
therefore, clinical psychologists could be better able to
debate. The American Psychological Association published
diagnose problems correctly and select effective
numerous articles endorsing prescription privileges and
medications.
offering suggestions for training of psychologists to become
proficient in the knowledge necessary to prescribe safely and  Other nonphysician professionals already have
effectively (American Psychological Association, 1996a). prescription privileges – Dentists, podiatrists,
optometrists, and advanced practice nurses are among the
THE PROMINENT INDIVIDUALS who promoted the
professionals who are not physicians but have some rights
movement toward prescribing:
to prescribe medication to their patients; clinical
Patrick H. DeLeon – a former president of the American psychologists must use their specialized expertise for the
Psychological Association. purpose of prescribing.
Morgan T. Sammons – a widely recognized expert on  Convenience for clients – with prescription
psychopharmacology and 1 of 10 psy chologists who took part privileges, clients could get both their therapy and
in the first experimental pilot program of psychologists medication from the both sources; it requires the two busy
prescribing medication. mental health professionals to communicate consistently
with each other.
Robert McGrath – training director of the
 Professional autonomy – with prescription privileges,
Psychopharmacology Postdoctoral Training Program in the
their ability to treat the physical and psychological aspects
School of Psychology at Fairleigh Dickinson University and
former president of the American Society for the Advancement of their clients’ difficulties autonomously, without relying on
of Pharmacotherapy (American Psychological Association, psychiatrists or other physicians, is greatly increased.
Division 55).  Professional identification
 Evolution of the profession
 Revenue of the profession
 ADVANTAGES of Evidence-Based
Why Clinical Psychologists Should NOT Prescribe
Practice/Manualized Therapy
 Training issues – Psychologists should not prescribe  Scientific legitimacy – A more scientific, empirical
without extensive medical training, specifically a approach to the treatment of depression, or any other
pharmacological training for psychologists. disorder, requires that the discipline of clinical psychology
 Threats for psychotherapy – prescribing may lead determine a beneficial treatment for the disorder and that
to a prioritization of medication over therapy. members of the discipline uniformly practice that treatment.
 Identity confusion  Establishing minimal levels of competence
 Training improvements
 The potential influence of the pharmaceutical
 Decreased reliance on clinical judgement – Clinical
industry – Allowing psychologists to prescribe
judgment can be susceptible to bias and, as a result, quite
medications may expose them to influence from
flawed.
pharmaceutical companies.
DISADVANTAGES of Evidence-Based
Practice/Manualized Therapy
EVIDENCE-BASED
 Threats to the psychotherapy relationship – therapy
PACTICE/MANUALIZED THERAPY manuals tend to focus on techniques, they may overlook the
importance of how therapists relate to their clients.
Evidence-based practice refers to the integration of the best  Diagnostic complication
 Restriction on practice
available research evidence with clinical expertise and patient
 Debatable criteria for empirical evidence
values/preferences in making decisions about healthcare.
Manualized therapy involves the development and use of
detailed treatment manuals that specify therapeutic techniques
and procedures in a standardized manner, aiming to ensure
consistency and effectiveness in therapeutic interventions.
 PAYMENT METHODS: THIRD-PARTY EFFECT ON DIAGNOSIS

PAYMENT VERSUS SELF-PAYMENT Health insurance and managed-care companies often require a
diagnosis for treatment coverage, potentially leading
Health insurance companies increasingly recognized the worth
of clinical psychologists’ practices and included them in their psychologists to assign diagnoses differently based on payment
coverage. So today, although some clients still pay for therapy method. Studies indicate that psychologists may be more likely
on their own, many use their health insurance/managed care to diagnose clients when they pay through managed care
benefits to pay for therapy, at least partially. The presence of compared to self-payment, especially for mild symptoms, which
this third-party payer in the therapy relationship has numerous could result in differences in treatment accessibility and the
consequences (Reich & Kolbasovsky, 2006).
perception of clients' symptom severity.

EFFECT ON THERAPY

THE INFLUENCE OF TECHNOLOGY:

The method of payment for therapy, whether through third-party
payment like insurance or self-payment, can significantly impact the TELEPSYCHOLOGY
quality and nature of therapy. Research suggests that therapists in
private practice often perceive managed care negatively, as it can
lead to constraints on clinical decisions, increased administrative Telepsychology – This use of technology, and particularly the
Internet, by clinical psychologist; also called telehealth,
burdens, and compromises in confidentiality. Clients may experience
telemental health, and cybertherapy
lower-quality therapy due to these influences, and informing them
about these potential drawbacks can affect their perceptions of
therapy. However, self-payment allows for greater autonomy in
therapy decisions but may be financially inaccessible for many
APPLICATION OF TECHNOLOGY
IN CLINICAL PSYCHOLOGY
individuals, highlighting the complex dynamics between payment
methods and the quality of therapy received.
Today, technologically savvy clinical psychologists can use:

 videoconferencing (similar to Skype or FaceTime) to

interview or treat a client;
 e-mail or text (in chat-room or one-on-one formats) to
provide psychotherapy to a client;
 interactive Internet sites to educate the public by CLINICAL PSYCHOLOGY
responding to questions about mental health concerns; CHAPTER 5: ETHICAL AND PROFESSIONAL ISSUES
 online psychotherapy programs to diagnose and treat IN CLINICAL PSYCHOLOGY
specific conditions;
 virtual-reality techniques in which clients undergo
therapeutic experiences, such as virtual exposure to
AMERICAN PSYCHOLOGICAL
feared objects; ASSOCIATION’S CODE OF ETHICS
 computer-based self-instructional programs designed
as specific components of a treatment that is otherwise
American Psychological Association (APA) published its
provided face to face; and Web Link 3.5 Psychotherapy
first code of ethics in 1953.
via videoconference
 apps and biofeedback sensors on handheld devices
(e.g., smartphones, tablets) to monitor clients and Aspirational and Enforceable
interact with them on a regular or random basis
between meetings with the psychologist APA ethical code features two distinct sections:

 General Principles – section are aspirational. In

other words, they describe an ideal level of ethical
functioning or how psychologists should strive to
conduct themselves. They don’t include specific
definitions of ethical violations; instead, they offer more
broad descriptions of exemplary ethical behavior.

 Ethical Standards – section of the ethical code

includes enforceable rules of conduct. Thus, if a
psychologist is found guilty of an ethical violation, it is a
standard (not a principle) that has been violated. These
standards are written broadly enough to cover the great
range of activities in which psychologists engage. It can
be understood as a source of inspiration for ethical
behavior of the highest order.
 1. Remedial approach to ethics would involve doing
just enough to avoid any trouble that might come from a
violation of ethical standards.

Psychologists with a remedial approach to ethics might do the

bare minimum to make themselves competent for a particular
activity (e.g., taking courses, getting supervision)

2. Positive approach to ethics would involve making

every effort to ensure that one’s professional behavior was as
consistent with ethical principles as possible.

Psychologists with a positive approach to ethics will strive to

become as competent as possible (e.g., additional courses,
extra supervision, self-study, self-care).

Ethical Decision Making

Celia Fisher – who served as chair of the American
Psychological Association’s Ethics Code Task Force, the
Categories of American Psychological Association Ethical committee responsible for creating the 2002 revision of the
Standards: ethical code. In her book Decoding the Ethics Code, Fisher
1. Resolving Ethical Issues (2017) proposes a model for ethical decision making.
2. Competence
3. Human Relations
4. Privacy And Confidentiality Psychologists’ Ethical Beliefs
5. Advertising And Other Public Statements
6. Record Keeping And Fees Sex with clients or former clients, socializing with current
7. Education And Training clients, and disclosing confidential information without cause
8. Research And Publication or permission—are viewed as blatantly unethical.
9. Assessment
10. Therapy

Knapp and VandeCreek (2006) Two Approaches to Ethics:

Shaking hands with clients, addressing clients by first name, Duty to warn – a duty to protect, which could involve
and breaking confidentiality if clients are suicidal or homicidal something other than a direct warning by the therapist.
— are viewed as unquestionably ethical.
When the Client is a Child or Adolescent
CONFIDENTIALITY
One particular challenge center on the fact that for many
It is specifically mentioned among the general principles (in children and adolescents, the establishment of a close,
Principle E: Respect for People’s Rights and Dignity) and trusting relationship with a clinical psychologist depends on the
in numerous specific ethical standards—including Standard extent to which the psychologist reveals details of one-on-one
4.01, “Maintaining Confidentiality,” which begins, conversations with the child’s parents.
“Psychologists have a primary obligation and take reasonable
Kids might choose to withhold rather than discuss important
precautions to protect confidential information” (American
personal issues if they know that their psychologists will
Psychological Association, 2002, p. 1066).
subsequently share the information with the kids’ parents.
Confidentiality is not absolute. As there are some
Effective clinical practice to keep parents actively engaged in a
situations arise in which psychologists are obligated to
child’s therapy.
break confidentiality.
Separate confidentiality issue for clients who are minors
involves child abuse. Every state has laws requiring mental
Tarasoff and the Duty to Warn health professionals to break confidentiality to report known or
suspected child abuse.
Tarasoff case – case set the legal precedent, clinical
psychologists (and other therapists) have understood that
there are limits to their confidentiality agreements with clients INFORMED CONSENT
and that they have a duty to warn or protect people toward
whom their clients make credible, serious threats. A written information about the study first, and only after you
provided consent by signing your name did the research
“The confidential character of patient-psychotherapist
begin.
communications must yield to the extent to which disclosure is
essential to avert danger to others. The protective privilege The informed consent process presents the clinical
ends where the public peril begins”. psychologist the chance to begin to establish a collaborative
relationship with the client.
 Boundaries of competence: “Psychologists provide services,
teach, and conduct research with populations and in areas
BOUNDARIES AND MULTIPLE RELATIONSHIPS only within the boundaries of their competence, based on their
Multiple Relationships – to know someone professionally— education, training, supervised experience, consultation, study,
as, say, a therapy client or student—and also to know that or profes sional experience”.
person in another way—as, say, a friend, business partner, or
CULTURAL COMPETENCE – an essential component of the
romantic partner. It is unethical.
ethical practice of clinical psychology that can lead to
It can form not only when a psychologist knows one person detrimental consequences for clients when violated.
both professionally and nonprofessionally but also when a
BURNOUT – a state of exhaustion that relates to engaging
psychologist has a relationship with someone “closely
continually in emotionally demanding work that exceeds the
associated with or related to” someone the psychologist
normal stresses or psychological “wear and tear” of the job.
knows professionally.
Factors of Burnout:
Sexual Multiple Relationships – clinical psychologist
becomes a sexual partner of the client. o feeling overcommitted to clients,
o having a low sense of control over the therapy,
“Psychologists do not engage in sexual intimacies with current
o earning a relatively low salary,
therapy clients/patients” (PAP, Code of Ethics, 2002)
o over involvement with clients correlates strongly with
Nonsexual Multiple Relationships – friendships, business or burnout.
financial relationships, coworker or supervisory relationships,
affiliations through religious activities.
ETHICS IN CLINICAL ASSESSMENT

COMPETENCE Test Selection – In code of ethics, it obligates psychologists

to select tests that are appropriate for the purpose of the
Competent clinical psychologists are those who are sufficiently assessment and the population being tested.
capable, skilled, experienced, and expert to adequately
complete the professional tasks they undertake. (Continuing Psychologists must not select tests that have become obsolete
education in order to maintain competencies and or have been replaced by revised editions that are better
increased improvement in a profession.) suited to the assessment questions being addressed

Test Security – Psychologists should make efforts to protect

the security and integrity of the test materials they use.
Test Data – ethical code explains that they are generally 1062), they may be professionally pressured to minimize the
obligated to release test data to clients on request. services they provide to limit the cost of mental health care. In
other words, clinical psychologists may find themselves in a
Test Data refers to the raw data the client provided during the
tug-of-war between the managed-care companies’ profits and
assessment—responses, answers, and other notes the
their clients’ psychological well-being.
psychologist may have made.

ETHICS IN CLINICAL RESEARCH Technology and Ethics

A quick Internet search will yield a wide array of so-called

Clinical psychologists who conduct research are ethically obli
psychological tests of one kind or another, claiming to
gated to minimize harm to participants, steer clear of
measure intelligence, personality, and other variables. Many of
plagiarism, and avoid fabrication of data.
these tests have questionable validity or reliability, and the
The participants in therapy efficacy studies who don’t feedback they provide may be inaccurate and distressing to
receive the treatment being studied are placed in one of clients.
three conditions:

No Treatment – wait-list control

Ethics in Small Communities
Placebo Treatment – some kind of interpersonal interaction
Rural areas and small towns may be the most obvious
with a professional but with presumably therapeutic techniques
examples of small communities, but there are many others as
deliberately omitted
well.
Alternate Treatment – efficacy of which may be unknown
Multiple relationships are a distinctively difficult ethical issue
for clinical psychologists in small communities.
CONTEMPORARY ETHICAL ISSUES
“Nonsexual overlapping relationships are not a matter of if as
much as when in the daily lives of many small- and contained-
Manage Care and Ethics
community psychologists.”
Managed-care companies can put clinical psychologists in a
position of divided loyalty. Although psychologists are ethically
committed to “strive to benefit” and “safeguard the welfare” of
their clients (American Psychological Association, 2002, p.