Clinical Interviews

  Clinical interviews are a standard component of almost any psychological assessment, including a comprehensive behavioral assessment. The behavioral interview is designed to provide information needed to generate a behavioral case conceptualization, including possible target behaviors, behavioral antecedents, and consequences.

Information from the interview is used to understand both the form and the function of relevant behaviors. For example, with a client suffering from a fear of driving, a therapist might ask questions about fear triggers (e.g., situations in which the fear occurs, variables that affect the intensity of the driving fear), relevant behaviors (e.g., patterns of avoidance, use of safety behaviors), and contextual variables (e.g., accommodation by family members, deficits in driving skills). The clinician would also likely ask about other variables of interest, including the severity of the problem, its development and course, whether criteria are met for a DSM–IV–TR diagnosis, treatment history, medical history, client strengths, and other relevant factors. Unstructured interviews are typically used for the purpose of behavioral assessment. Witt and Elliott (1983) suggested an organizational structure for an initial unstructured behavioral interview, including these nine steps:

1. The interview agenda is discussed, and the rationale for problem identification is introduced.

2. A list of problem behaviors is collaboratively generated.

3. The frequency, intensity, and duration of each problem behavior is reviewed.

4. Antecedents and consequences of problem behaviors are identified.

5. Treatment goals are generated, and a timeline for reaching each goal is established.

6. Client strengths are identified.

7. A plan for recording behaviors is developed.

8. Methods for measuring treatment outcome are discussed.

9. The session content is reviewed, and the client agrees to the plan.

  Ideally, interviews should occur with the identified client and, when appropriate, other individuals (e.g., teachers, parents, spouses, friends, colleagues) who know the client well and are familiar with the behaviors of interest. Client responses to interview questions can be used in two ways (O’Brien et al., 2005): as an indication or as a sample (e.g., tone, volume) of the client’s behavior.

Despite their popularity, clinical interviews do have disadvantages: The quality of the information obtained is likely to be influenced by the clinician’s interviewing skills, the client’s level of awareness and understanding of factors relevant to his or her presenting problem, the client’s interpretive biases and ability to recall details accurately, and many other factors.

Behavioral Observation

  Direct observation of a client’s behavior is the hallmark of behavioral assessment (Ollendick et al., 2004). For example, a therapist might observe a teenager interacting with his or her parents to evaluate family patterns of communication. Similarly, for someone suffering from depression, a therapist might ask the client’s spouse to observe the client in social settings to evaluate the extent to which the client behaves in a withdrawn manner.

A common example of behavioral observation occurs in the context of the behavioral approach test, which is often included in the assessment of individuals with anxiety disorders. In a typical behavioral approach test, clients are asked to approach a feared object or situation, and their behavior in the situation is observed and monitored. For example, a client who is fearful of spiders might be asked to approach a spider as closely as possible while the therapist observes the client’s behavior. Throughout the procedure, the client would typically provide fear ratings using a subjective units of discomfort scale ranging from 0 (no fear or discomfort) to 100 (maximum fear or discomfort). The behavioral approach test can also be used to test hypotheses about the environmental contingencies that maintain the target behavior. For example, the clinician might conduct behavioral experiments by manipulating relevant variables.

Behavioral observation has the advantage of occurring in real time, as behavior is occurring. When planning to collect data through behavioral observation, it is important to first decide what information is to be collected. Depending on the type of target behavior and the hypothesized contingencies, it might be important to sample the occurrence of events (e.g., the number of times a child cries), the duration of events (e.g., how long the child cries), the intensity of events (e.g., how loudly the child cries), the context of the events (e.g., the situations in which the child cries), or some combination of these factors. One potential problem with behavioral observation is the possibility of reactivity, which occurs when the process of assessment influences the behavior that is being assessed.

Ideally, the client should be observed in his or her natural environment, which is referred to as naturalistic observation. However, sometimes naturalistic observation is impractical, impossible, or unethical. In such cases, analogue observation may be a possibility. For example, with a client who is fearful of interviewing for a job, it may not be possible to observe the client in an actual job interview. Instead, the clinician may choose to set up a simulated interview and have the client role play the interaction. Although analogue observation may not provide information that generalizes perfectly to the real-life situation, the data obtained can still be helpful.

In some cases, the clinician directly observes the client’s behavior. In other cases, someone else (e.g., a teacher, a spouse) might be assigned to the role of observer. The type of observer (participant vs. nonparticipant) can influence the type of information obtained during the assessment (O’Brien et al., 2005). Participant observers are individuals who observe the client’s behavior while interacting with the client in some other capacity. Nonparticipant observers are individuals whose full attention is devoted to observing the client’s behavior.

Many clinically relevant behaviors also occur naturally in the course of therapy, so that the therapist can unobtrusively observe these behaviors in the course of conducting an assessment. For instance, a client who describes frequent hostile responses in interpersonal relationships is likely to respond with hostility to the therapist at some point. The therapist can initially observe this behavior and the antecedents and consequences associated with it and use that information to inform the developing functional analysis. Later in therapy, this will provide an opportunity for intervention in the therapeutic relationship.