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From Last Class

Clinical Interviewing (Chapter 6) PSYC 4500: Introduction to Clinical Psychology Brett Deacon, Ph.D. October 3, 2013. From Last Class. Experience and clinical judgment Broken leg exceptions Implications of problems with clinical judgment for evidence-based practice in psychology.

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From Last Class

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  1. Clinical Interviewing(Chapter 6) PSYC 4500: Introduction to Clinical PsychologyBrett Deacon, Ph.D.October 3, 2013

  2. From Last Class • Experience and clinical judgment • Broken leg exceptions • Implications of problems with clinical judgment for evidence-based practice in psychology

  3. Clinical Interviewing • How does interviewing differ from chatting with a friend? • 1. Different role (professional) • 2. Different setting • 3. One-sided exchange • 4. Has a purpose

  4. Intake Interview • Intake interview (usually first meeting) • Goals • 1. Determine nature of problem • 2. Determine whether you can help • 3. Determine how you can help • 4. Establish rapport

  5. Four Key Questions (for all Clinical Services) • 1. Who is the patient? • 2. What are they seeking? • 3. What is my role in helping them? • 4. How will I know when I am done?

  6. Informed Consent • APA ethics code • Aspects of informed consent: • 1. Knowledge (confidentiality, fees, goals of therapy, procedures used, prognosis, alternatives) • 2. Freedom to choose • 3. Capacity

  7. APA Ethics Code: Informed Consent for Therapy http://www.apa.org/ethics/code/index.aspx?item=13 10.01 Informed Consent to Therapy(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. (b) When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available and the voluntary nature of their participation. (c) When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.

  8. Informed Consent • Imagine that a therapist wishes to provide thought field therapy to help a client manage his ADHD. Does the APA ethics code mandate, or at least strongly suggest, that the therapist inform the client that thought field therapy has no scientific evidence to support its use as a treatment for ADHD, and that alternative, evidence-based treatments for ADHD exist?

  9. Informed Consent among EMDR Therapists (our unpublished data) • Among therapists who use EMDR for the following disorders, the percentage who reported informing clients about the existence of alternative, more evidence-based treatments was: • OCD: 42.2% • Substance use disorders: 42.4% • Panic disorder: 40.5% • Anorexia nervosa: 30.0% • Depression: 28.6% • ADHD: 13.3%

  10. Informed Consent • Imagine that you are a therapist. You believe research shows that all therapies are equally effective, the therapeutic relationship is what makes therapy work, and that scientifically conducted clinical trials of psychotherapy are neither valid nor relevant to your clinical practice. Imagine that you wish to provide thought field therapy to help a client overcome his ADHD. What information would you feel obligated to provide to the client to satisfy informed consent?

  11. Informed Consent • Imagine that a therapist wishes to provide thought field therapy to help a client cope with adjustment to a life stressor as opposed to a DSM-defined mental disorder. There are no science-based guidelines for treating adjustment problems. What information should be conveyed to the client satisfy informed consent?

  12. Other Issues in Intake Assessment • Feedback on diagnosis • Feedback on case conceptualization • Contracting for treatment and goals

  13. Mental Status Exam • Method of organizing behavioral observations • Covers the following areas (not inclusive): (a) general appearance and behavior, (b) speech and thought, (c) affect, (d) memory, and (e) insight and judgment • Does not include diagnostic impressions • Examples

  14. Example Mental Status Exam Mr. X arrived on time for his appointments with this writer on 6/20 and 6/21. He presented as an overweight veteran who appeared to be his stated age. His grooming and hygiene were appropriate. His mood was mildly dysphoric, and his affect was labile. He made good eye contact. His speech was generally clear, coherent, goal-directed, and congruent with his affect. He denied homicidal ideation, suicidal ideation, hallucinations, and delusions. Mr. X presented himself as both highly virtuous and seriously impaired. On numerous occasions he rather dramatically pointed out that he “doesn’t ever give up if I believe in something,” “doesn’t take no for an answer,” and even that he has never told a lie. His demeanor changed from friendly to guarded and confrontational during the second interview when we discussed signing releases for his medical records and the several inconsistencies in his story about the events on March 14th. He reported that he felt like he was being attacked and was being called a liar when I asked for his records in order to substantiate his story. It was at this point that he began to refuse to disclose information about his medical care. He offered to sign a release for the interviewer to speak with his supervisor and stated that he might make additional records available after this individual had been contacted. He also asked me if I had ever met anyone as straightforward and intimidating as himself, and he threatened to “go over [my] head” if he felt like I wasn’t being straightforward with him.

  15. Mental Status Exam • Practice Administration: The Folstein Mini-Mental Status Exam • Scoring: < 24 considered abnormal

  16. Diagnostic Interviewing • Two basic approaches: unstructured vs. semi-structured interviews • The “unstructured” interview • Possible sources of inaccuracy using this approach?

  17. Semi-Structured Interviews • Questions follow DSM diagnostic criteria for specific mental disorders • Standardized administration, initial questions read verbatim, examiner may follow-up with own questions to determine whether criteria are met • Example: the Structured Clinical Interview for DSM-IV (SCID)

  18. Semi-Structured Interviews • Advantages of semi-structured interviews • Improved diagnostic reliability • More comprehensive • Improve adherence to diagnostic rules • Disadvantages? • Take a long time to administer • What if the DSM symptoms are vague, diagnostic rules are arbitrary, and DSM diagnoses are neither reliable nor valid?

  19. Structured Interviews • Fully standardized administration, can be administered by laypersons • Often used in research settings • Example: the Composite International Diagnostic Interview (CIDI) • Advantages and disadvantages

  20. Establishing Rapport • Begins at first contact with patient • How can rapport be established? • Carl Rogers’ three conditions: • 1. Empathy • 2. Genuineness • 3. Unconditional positive regard

  21. Establishing Rapport • How to establish rapport: http://www.youtube.com/watch?v=m30jsZx_Ngs

  22. Establishing Rapport • How not to establish rapport: http://www.youtube.com/watch?v=G0yU-YJ6sjY

  23. Communication Strategies - Verbal • Open-ended vs. closed-ended questions • Funnel analogy • Learning to tolerate silence • Learning which patient verbalizations to follow up on, and how to do so

  24. Verbal Communication Pitfalls • Asking, then answering, questions • Always filling silence by asking questions • Slavish attention to diagnostic criteria • Use of jargon • Don’t apologize • Be yourself

  25. Communication Strategies - Nonverbal • Read patient’s nonverbal behavior • Be attentive to own nonverbal behavior • SOLER • Squarely face the patient • adopt Open posture • Lean toward patient • Eye contact • Relax

  26. Nonverbal Communication Pitfalls • Appearing distracted • Appearing to react negatively to something the client tells you about themselves • Incongruence between verbal and nonverbal messages • Note taking?

  27. Listening Skills • Listening in therapy is like a duck in water • Active listening • 1. Clarification • 2. Paraphrase • 3. Reflection • 4. Summarization

  28. Listening Skills Practice • “I just can’t seem to get going anymore. I’m always tired and it’s a struggle to accomplish anything productive during the day. There are some days where I only leave my bed to eat or use the bathroom. The scary part is that I find myself not even caring about life anymore. I know I can’t keep living like this. I want things to go back to the way they were.” • For this patient verbalization, generate a clarification, paraphrase, reflection, and summarization.

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