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The Clinical Interview and Behavioral Observation
Abnormal Psychology · Chapter 10: Psychological Assessment: Tools and TechniquesSection 10.2 · lesson 36 of 9711 min · free with a free account
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In this lesson
Structure, purpose, and the errors that produce no signal at all.
- Compare structured, unstructured and semi-structured formats
- Explain why rapport determines data quality
- Name the mental status examination domains
- Separate observation from inference in a record
Transcript
Everything said in the video, section by section (1,485 words). Read along, or search it.
Psychological Assessment: Tools and Techniques
The Clinical Interview and Behavioral Observation
Most of what a clinician knows about a person came out of a conversation. Which is uncomfortable, because conversations are unreliable. Memory is reconstructive. People present themselves according to the situation. And the interviewer's expectations shape what gets asked, and what gets heard. So this section is about how that method is structured to survive its own weaknesses. We will look at three interview formats, and the trade-off between them. At rapport, which turns out to be a technical matter rather than a courtesy. At the mental status examination, and what it does not license. At observation, and the fact that being watched changes behavior. And at the errors, which share one dangerous property. They produce no signal.
Why Interview
Primary Despite Well-Documented Weaknesses
The clinical interview is a purposeful professional conversation. Conducted to gather assessment information, and every assessment is built around it. So why does it stay primary? Four reasons no other method supplies. Only the person can report their internal experience. Which is a substantial part of what most conditions actually consist of. Only an interview can follow an unexpected answer. A questionnaire cannot ask what it was not written to ask. And it covers history, circumstances, and observation all at once. So the realistic position is not that interviewing is reliable. It is that the weaknesses get addressed by structure and corroboration, rather than replacement. One note first. This material is educational, and is not a basis for assessing anyone.
Three Formats
Reliability and Flexibility Move in Opposite Directions
An unstructured interview has no predetermined questions or sequence. The clinician follows the material as it arises. Its costs are twofold. Reliability suffers, because two clinicians ask different questions. And coverage is uneven in a way that is invisible from inside. What is never asked about is never known to be missing. A structured interview specifies the questions, their order, and the decision rules. Diagnostic agreement improves substantially, which is the whole purpose. Its costs are the mirror image. An unexpected disclosure cannot be followed. Notice that structure does not eliminate the coverage problem. It fixes the coverage in advance, which helps only if the fixed coverage is right here. It specifies the areas to cover, and leaves wording and depth to the clinician.
Intake
Seven Areas, Each Supplying Something the Others Cannot
An intake interview is the initial assessment interview. Each area contributes something the others cannot. The presenting problem, in the person's own account. Including why now, rather than six months ago. Developmental and family history, establishing sequence rather than assigning cause. Medical history, and this one is skipped more often than any other. Several physical conditions and medication effects produce presentations resembling psychological ones. Social and occupational functioning. Work, education, relationships, housing, finances. Non-response to a previous treatment is a substantive finding, not a blank. And current supports, assessed functionally rather than counted.
Rapport
Poor Rapport Presents as an Interview That Went Smoothly
Rapport is a working relationship in which a person can give an accurate account. That is a misunderstanding of what it does. Rapport is a determinant of data quality. And the mechanism is not mysterious at all. People withhold what they expect to be judged for. Someone anticipating disapproval will minimize, omit, or answer a different question. The clinician then receives an account that is fluent, plausible, and wrong. And here is the important part. They have no way of knowing it. Poor rapport does not announce itself as missing data. It presents as an interview that went smoothly. Open questions produce material the clinician did not know to ask for. The common error is reaching for the second too early, which produces a checklist.
Mental Status
A Description of the Present Moment
The mental status examination is a structured description of a person's presentation. At the time of the interview. Two features define it. It covers appearance and behavior, speech, mood and affect. Thought process and thought content. Perception, cognition, insight, and judgment. Now here is what makes it hard to use well. Every domain supports a narrow inference, and blocks a wider one. Slow, quiet speech with long pauses records altered speech production. It does not tell you the reason. That could be mood, medication, fatigue, or caution. And a reported perceptual experience is recorded, not diagnosed. Such experiences occur in many contexts, including bereavement and sleep transitions. Nearly every error here is the same one. Treating a description as a conclusion.
Observation
Three Settings, One Trade-Off
Behavioral observation is the direct recording of what a person does. Rather than what they or others report about it. It reaches behavior the person has not noticed, or describes differently from how it occurs. With children, it supplies information from someone who cannot yet give a verbal account. Three settings are distinguished, and they sit on a single trade-off. Naturalistic observation takes place where the behavior ordinarily occurs, with nothing arranged. Structured observation is also in a real setting, but a situation is deliberately set up. Analogue observation is in a clinic, arranged to resemble the situation of interest. The naturalistic setting gives the most realistic behavior. And the least control over whether the behavior happens at all. Coding and open narrative trade off the same way. Comparable data, or everything.
Reactivity
It Runs in Both Directions
Reactivity is change in behavior produced by being observed. It is a well-documented effect, not a theoretical worry. And it runs in both directions, which is often forgotten. Behavior the person regards as undesirable typically decreases under observation. So a difficulty may be substantially under-represented in what you observe. Behavior they regard as desirable typically increases. Self-monitoring is reactive by design. Simply recording a behavior often changes its frequency. Which is why self-monitoring appears in treatment as well as in assessment. Reactivity is mitigated by extending the observation period, so early adaptation dilutes. By making the observer's presence routine. And by corroborating against other sources.
Sources Of Error
None of These Produces a Bad-Feeling Interview
Several sources of error are worth naming, and they share a dangerous property. Interviewer expectancy is an expectation formed early shaping what gets asked. The conclusion then reflects the expectation rather than the presentation. And it looks well-supported, because the supporting questions were the ones asked. Leading questions supply the answer's content, and the person assents rather than reports. Recall limitations mean dates, durations and sequences are systematically unreliable. Impression management is the person presenting as the situation seems to reward. And the halo effect is one strong impression coloring judgments across unrelated domains. Now the property they share, and it explains why these errors persist. In almost every case the wrong conclusion looks well-supported from the inside. None of them produces an interview that feels as though it went badly.
Suggestibility
What Is Asked Shapes What Is Recalled
Suggestibility is reported recollection being altered by how a question is asked. Leading inquiry can change what people subsequently report remembering. And they may report the altered version with full confidence. It is associated particularly with Elizabeth Loftus's work, from the nineteen seventies onward. Two contexts make it especially consequential. Children are more suggestible than adults, and more inclined to defer to an adult questioner. They are also more likely to read a repeated question as a sign the first answer was wrong. Which is why interviewing children is a specialist competence with its own protocols. And in forensic contexts, an account altered by the interviewing can affect a legal outcome. What is asked shapes what is recalled. So the record should preserve what the person said, before it records what they agreed to.
Documentation
An Inference Written as an Observation Becomes a Fact
What is recorded becomes what is known. Subsequent clinicians will read the note rather than re-interview the person. So the central discipline is separating observation from inference. Observation is what was seen or heard. Inference is what you concluded from it. Sat with arms folded and gave brief answers. That is an observation. Was hostile and defensive. That is an inference. Now watch what happens when the second is recorded as though it were the first. It becomes an established fact for everyone who reads it afterwards. The evidence for it is no longer visible, and no longer open to a different reading. A good record contains both, marked as what they are. Writing with that in view is not defensive practice. It produces more accurate notes.
Two Composites
A Smooth Interview, and a Careful Note
The referral read, query generalized anxiety, please assess. Karim is forty-one, with constant worry, irritability, poor sleep and poor concentration. About eight months of it. Now look at what was never asked. Nothing about physical health or medication. Karim had begun a new medication nine months earlier, and had not connected the two. Nothing about alcohol, which had increased over the same period. He had been placed on a performance process at work seven months previously. Two errors operated together. Anchoring set the area before the interview began. And here is the dangerous feature. The interview went smoothly. The second composite is a note rather than an interview. Lena arrived eleven minutes late, wore a coat in a warm room, and sat facing the door. All of that is observation, and recorded plainly it can be read again by someone else. Write guarded and ambivalent instead, and you have carried the conclusion without the evidence.
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